| | Fifteen years after the International Conference on Population and Development: What have we achieved and how do we move forward? published online 22 June 2009. Abstract This article surveys the current situation and prospects for attaining the goals set by the International Conference on Population and Development (ICPD) held in 1994, and the health-related Millennium Development Goals (MDGs), set in 2000. Encouraging changes in the policy environment are highlighted, but the available resources do not yet match needs. Global maternal mortality figures, at over 500 000 a year, have not changed since 1990, and morbidity is about 20 million. Some countries have made progress with low-cost, high-yield interventions such as family planning, skilled birth attendants, access to emergency obstetric and neonatal care, management of sexually transmitted infections, and HIV prevention. However, progress in many low-income countries has been slow, and few are on track to meet the goals. There are wide inequities in care among and within countries. Suggestions for priority attention are offered, such as a “continuum of care” approach, integrated services, and comprehensive policies on human resources for health. 1. The current situation  Fifteen years after governments adopted the International Conference on Population and Development (ICPD) Programme of Action [1], countries have embraced the concept and practice of reproductive health as an essential component of poverty reduction, which is critical to reducing high fertility and mortality and the spread of HIV and other sexually transmitted infections (STIs). Many governments have broadened programs to reach people in need of services, and integrated reproductive health within primary health care. This includes services for family planning, pre- and postnatal care, childbirth services, STI and HIV prevention, cervical and breast cancer screening, and referral for treatment where appropriate. There has been an emphasis on improving quality and access of services for underserved groups, including the very poor and people living in remote rural areas. There has also been progress in reproductive rights, with many countries establishing in their policies and laws the basic right of all couples and individuals to decide freely and responsibly the number, spacing, and timing of their children, and to have the information and means to do so; as well as the right to attain the highest standard of sexual and reproductive health, and to make decisions free of discrimination, coercion, or violence. However, scaling up sexual and reproductive health services and realizing reproductive rights remain an urgent challenge, reinforced by the fact that the poorest women have the least access to information and services. Today, sexual and reproductive ill health accounts for an estimated one-third of the global burden of disease and early death in women of reproductive age (15–44 years) [2]. Every year there are an estimated: •180–210 million pregnancies; •80 million unwanted pregnancies; •50 million induced abortions; •20 million unsafe abortions; •536000 deaths from maternal causes, including 68000 deaths from unsafe abortion; •20 million postpartum infections and disabilities; •340 million people infected by sexually transmitted infections; •Over 2 million AIDS deaths. The burden of ill health falls most heavily on women in low- and middle-income countries. Inequalities in accessing services—between rich and poor, urban and rural, the general population and ethnic minorities or other marginalized groups—are greater in sexual and reproductive health than for almost any other health indicator. Among all health measures, maternal mortality indicators show the greatest difference between rich and poor both within and among countries. In fact, 99% of maternal deaths occur in low-resource countries. A woman in Niger faces a 1 in 7 lifetime risk of dying during pregnancy and childbirth compared with a 1 in 8200 risk for a woman in the United Kingdom [3]. In low-income countries women in the richest quintile are 6 times more likely than women in the poorest quintile to have access to medically-trained birth attendants. One-third of pregnant women in low-resource countries have no prenatal care. In Sub-Saharan Africa, where most maternal deaths occur, 70% of women have no contact with health personnel following childbirth. The estimated number of maternal deaths is unchanged since 1990. Maternal mortality has fallen by less than 1% annually between 1990 and 2005, far below the 5.5% annual decline necessary for achieving Millennium Development Goal (MDG) 5. In Sub-Saharan Africa the annual decline has been approximately 0.1%. Unsafe abortions contribute to 13% of maternal deaths. Nearly half (48%) of abortions are unsafe (2003), which is up from 44% in 1995 [4]. Sixty-three percent of women of childbearing age in low-resource countries use a method of family planning, compared with 10% in 1960 [5]. But demand for family planning continues to grow. Some 120–150 million women have an unmet need for family planning. A “woman with unmet need” is a married woman of reproductive age at risk of pregnancy who would like to postpone or stop childbearing now or prior to her last birth, but is not using/did not use a method of contraception (Fig. 1). Family planning currently prevents 187 million unintended pregnancies per annum, including 60 million unplanned births and 105 million abortions [6]. It saves 140000–150000 lives a year, and averts 15 million injuries and disabilities related to pregnancy and childbirth. Improved access to family planning could avert one-third of maternal mortality and 10% of child mortality. Analyses for the Countdown to 2015 (http://www.countdown2015mnch.org/) countries suggest a return on investment of between 3:1 and 4:1, assuming satisfaction of current unmet need by 2015. Adding family planning to services for preventing mother-to-child transmission of HIV can also save many lives [7]. Currently, programs do not sufficiently address women's needs for family planning information and services at critical points, for example after puberty, sexual initiation, pregnancy and prenatal care, a healthy birth, and STI infection including HIV/AIDS [8]. Meeting the unmet need for family planning is critical as increasing numbers of adolescents and young people are entering their reproductive years. Young people in almost all regions of the world find it harder than other age groups to access reproductive health services. Girls under 18 years are at considerably greater risk of obstetric injury or infection than their older counterparts. The continuing practice of child and very early adult marriage puts young women at heightened risk of maternal mortality and morbidity, including obstetric fistula and other birth injuries. According to recent reports from Countdown to 2015, only 16 of 68 priority countries are on track to achieve MDGs 4 and 5. Other countries have stalled or in some cases actually regressed [9]. 2. The policy environment 15 years after ICPD Despite these tremendous challenges, there have been encouraging changes in the policy environment which can accelerate progress toward universal access to reproductive health. The global consensus of 1994 recognized that empowerment of the individual with access to information and services for reproductive health, including voluntary family planning, was essential for sustainable development. The ICPD agenda stressed the importance of advancing human rights, gender equality and the empowerment of women, and eliminating all kinds of violence against women. The consensus reconciled the reproductive rights of individuals and couples, and particularly women's rights, with overall development goals. ICPD adopted a detailed Programme of Action [1] with goals for 2015. Many of the ICPD goals, including universal primary education and reductions in maternal and child mortality, are reflected in the MDGs, which were elaborated after the 2000 Millennium Summit and have become the guiding framework for development. However, despite extensive civil society pressure, the ICPD goal of universal access to reproductive health by 2015 was left out of the MDGs. It was added in 2005 in the outcome document of the World Summit and subsequently included as a target in the monitoring of the MDGs, which paves the way for faster progress. The targets for MDG 5 are to reduce the maternal mortality ratio by three-quarters between 1990 and 2015, and achieve universal access to reproductive health by 2015. Indicators for the targets are: •maternal mortality ratio; •proportion of births attended by skilled health personnel; •contraceptive prevalence rate; •adolescent birth rate; •prenatal care coverage (at least 1 visit and at least 4 visits)1; •unmet need for family planning. In recent years, there has been increasing national and global attention paid to the “health MDGs” (MDGs 4, 5, and 6: reducing infant mortality, improving maternal health, and rolling back HIV and AIDS). National governments and development partners, including private foundations, are working together much more closely and are guided by the principle of national ownership to strengthen national health systems to achieve the health MDGs. Growing commitment has emerged to pursue comprehensive and integrated health planning and the need for a full “continuum of care,” i.e., the access to a full range of services in different settings at different times of life. This is notably witnessed in the July 2008 summit declaration of the G8 countries, which called for reproductive health to be “widely accessible,” for closer links between HIV/AIDS and family planning programs, and for strengthening health systems. The concerted effort to strengthen health systems constitutes a major source of optimism for the improvement of reproductive health, especially maternal health. A functioning health system that can deliver to women when women are ready to deliver can also respond to other health concerns and emergencies. The new global policy environment has led to increased coordination and harmonization of approaches at the country level. Government leadership is essential and health sector reform is leading to sector-wide approaches and direct budget funding. Development partners are coming together to provide the technical and financial support governments need. This provides an opportunity to factor comprehensive approaches to reproductive, maternal, newborn, and child health into broader sectoral plans. However, there is a need to intensify interventions and investments that promote comprehensive sexual and reproductive health services. 2.1. Resources for sexual and reproductive health After encouraging increases for several years, total overseas development assistance decreased from $106.8 billion in 2005 to $103.9 billion in 2006. Population assistance, which includes sexual and reproductive health, was close to 6% of the total. Between 1995 and 2006 support for family planning fell as a proportion of total population assistance while the proportion going to HIV/AIDS treatment, care, and support increased. Low-income countries mobilized an estimated $23.1 billion in 2006 for population activities, mostly in Asia. Estimates for 2007 and 2008 are $24.8 and $26.8 billion [10]. The health sector has seen a dramatic increase in external funding, almost doubling, from $6.8 billion in 2000 to nearly S$17 billion in 2006, with a significant increase in funding from global health partners. External aid now averages approximately 7% of health sector spending in low-income countries, however, this figure varies between countries and regions [11]. At the regional level, African governments agreed in the 2001 “Abuja commitment” to devote 15% of domestic expenditure to health, to be supported by debt relief and donors' commitment of 0.7% of GDP to development assistance. In 2006, African ministers of health and finance adopted targets and budget requirements in reproductive health, but there has been limited follow-up. To address resource gaps in national health plans, a global high-level task force on innovative international financing for health systems has been established. Increased resources are urgently needed to expand sexual and reproductive health services. The total package for sexual and reproductive health, including family planning, prenatal care, delivery care, obstetric complications care, newborn interventions, reproductive organ cancer screening and treatment, as well as other maternal care interventions, is estimated to be US$ 23.5 billion in 2009, peaking at US$ 33.3 billion in 2014 and decrease slightly to $33 billion in 2015. The costing estimates for family planning assume that the current unmet need will be satisfied in 2015 although there is likely to be greater demand for family planning as people become more aware of the options [12]. It is expected that 10 % shortfall in funding for family planning of the projected total estimates based on ICPD goals, may result in an additional 1.8 million unsafe abortions and 19,000 maternal deaths. 3. Pathways to better sexual and reproductive health To ensure greater progress, each country needs a comprehensive policy on human resources for health, and a plan that addresses needs for recruitment, training, and retention to ensure geographic coverage and a balanced skill mix. There is a direct relationship between the ratio of health workers to population and maternal and newborn survival [13]. Given the shortage of financial and human resources, midwives constitute a cost-effective workforce for delivering maternal and newborn health, family planning, and HIV prevention services. Obstetricians and gynecologists play a critical role as physicians and also as trainers, monitors, and advocates for midwifery. Poor working and living conditions, and inadequate equipment, drugs, supplies, and supervision make it difficult to deploy, motivate, and retain skilled birth attendants close to the community. Africa is particularly affected and has lost skilled health workers to AIDS and emigration. Africa needs an additional 700000 midwives and 167000 doctors by 2015 to attain the MDG maternal and newborn health targets. An increasing number of countries are addressing the shortage of human resources by shifting tasks to health workers with shorter training and fewer qualifications. For example, maternal health teams can include nonmedical health providers trained in essential surgery, anesthesiology, and resuscitation. Several countries, particularly middle-income countries, have reduced maternal mortality by strengthening health systems and investing in midwifery skills, logistics, infrastructure, emergency obstetric and neonatal care, and health information systems [14]. 3.1. Continuum of care Combining primary health care, district hospital and referral hospitals, and a community-based approach offers optimal management of sexual and reproductive health care over the life cycle. Access to essential obstetric interventions, in particular emergency obstetric and neonatal care, is critical. Easily accessible basic emergency obstetric and neonatal care at the community level, and referral to comprehensive care as needed, can deal with complications before they become life threatening. Community-based approaches allow more equitable access to technology and resources, and can encourage behavior change. Service delivery through community-based groups, including faith-based organizations, can help to mobilize demand for services among hard-to-reach groups, generate pressure for policy change, improve governance, and ensure sustainable resource mobilization [15]. When resources are scarce, a national health information system to account for outcomes and monitor results against resources becomes even more important [16]. Health systems must be able to factor in and respond promptly to demand for vital drugs, supplies, and services, including contraception, voluntary HIV and AIDS counseling and testing, and maternal and newborn health supplies. Integration of HIV/AIDS prevention programs and other reproductive health services is critical. 3.2. Role of obstetricians and gynecologists Together with other partners, obstetricians and gynecologists, and their professional societies, are of inestimable value in helping countries reach the ICPD goals and the health MDGs. They can advocate for investment in primary health care and a continuum of care with emphasis on sexual and reproductive health. Their advocacy can influence health legislation, direct public and private investments, and bridge the gaps between a clinical focus and prevention at all levels. They can build technical skills in medical and nursing and midwifery schools, and in in-service programs, and raise the quality of care by establishing norms and accreditation criteria. They can apply and transfer new technologies for STI prevention and management. They can also promote new technologies in expanding contraceptive choices and new low-cost primary care protocols and supplies. 4. Conclusion: prospects for reaching the ICPD goals and MDGs The goals of the ICPD Programme of Action and the health MDGs remain not only within reach but essential for development. The policy environment is encouraging, resources have been identified, and successful approaches and specific measures are well known and affordable. Delivering an essential package of health care that includes family planning, maternal health, adolescent sexual and reproductive health, STI/HIV prevention and care, and mitigation of gender-based violence is an excellent investment from the point of view of both public health savings and basic human rights. New partnerships have come into existence among multilateral agencies, donors, private foundations, health providers, professional associations and research and training institutions. These partnerships endeavor to establish a clear distribution of labor and complementary roles, making the best use of available resources to advance the health MDGs. In addition, a high-level task force on innovative financing for health systems has been established to address resource gaps in national health plans. Success calls for a positive attitude as well as leadership at the highest levels, both in program and donor countries. Governments, the medical professions, civil society, and external partners must come together in a spirit of cooperation that transcends sectoral concerns to achieve universal access to reproductive health by 2015. Acknowledgement The author is grateful for the contribution of Hedia Belhadj. References [1]. [1]International Conference on Population and Development. Summary of the Programme of Action. Available at: http://www.unfpa.org/icpd/summary.cfm. Accessed November 30, 2008. [2]. [2]WHO Statistical Information System. WHO estimates of disability adjusted life years (DALYs) by sex, cause and WHO mortality sub-region. Available at: http://www.who.int/whosis/en/. Accessed November 30, 2008. [3]. [3]WHO, UNICEF, UNFPA, World Bank . Maternal mortality in 2005. Estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva: WHO; 2007;. [4]. [4]Cohen SA. New data on abortion incidence, safety illuminate key aspects of worldwide abortion debate. Guttmacher Policy Rev. 2007;10(4):. 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The global shortage of health workers and its impact. Fact Sheet Number 32, April 2006. Available at: http://www.who.int/mediacentre/factsheets/fs302/en/index.html. Accessed November 30, 2008. [14]. [14]United Nations Millennium Project . In: Investing in development: A practical plan to achieve the Millennium Development Goals. Report to the UN Secrtary-General. London: Earthscan; 2005;. [15]. [15]In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al. editor. Disease Control Priorities in Developing Countries. Chapter 56. Community Health and Nutrition Programs. Disease Control Priorities Project. Second Edition. 2006;. [16]. [16]WHO, UNFPA . National-level monitoring of the achievement of universal access to reproductive health: Conceptual and practical considerations and related indicators. In: Report of a WHO/UNFPA Technical Consultation, 13–15 March 2007, Geneva. Geneva: WHO; 2008;. United Nations Population Fund, New York, USA  United Nations Population Fund, 220 East 42nd Street, New York, NY 11109, USA.
PII: S0020-7292(09)00137-4 doi:10.1016/j.ijgo.2009.03.017 © 2009 Published by Elsevier Inc. | |
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