Entre Nous: the European magazine for sexual and reproductive health: no. 78: from ICPD to post-2015

THE EUROPEAN MAGAZINE FOR SExUAL AND REPRODUCTIVE HEALTH No.78 - 2013 FRoM ICPD To PoST-2015 2Dr Assia Brandrup- Lukanow Senior Adviser, Danish Center for Health Research and Development Faculty of Life Sciences Ms Vicky Claeys Regional Director, International Planned Parenthood Federation European Network Dr Mihai Horga Senior Advisor, East European Institute for Reproductive Health, Romania THE EntrE nous EDIToRIAL ADvISoRy BoARD Dr Evert Ketting Senior Research Fellow, Radboud University Nijmegen Department of Public Health, Netherlands Dr Manjula Lusti- Narasimhan Scientist, Director’s office HIv and Sexual and Reproductive Health Department of Reproductive Health and Research WHo headquarters, Geneva, Switzerland Prof Ruta Nadisauskiene Head, Department of obstetrics and Gynaecology Lithuanian University of Health Sciences, Kaunas, Lithuania Dr Rita Columbia Reproductive Health Advisor UNFPA Regional office for Eastern Europe and Central Asia CoNTENTS The European Magazine for Sexual and Reproductive Health Entre Nous is published by: Division of Noncommunicable Diseases and Health Promotion Sexual and Reproductive Health (incl. Maternal and newborn health) WHo Regional office for Europe UN City Marmorvej 51 DK-2100 Copenhagen Ø Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 www.euro.who.int/entrenous Chief editor Dr Gunta Lazdane Editor Dr Lisa Avery Editorial assistant Jane Persson Layout Kailow Creative, Denmark. www.kailow.dk Print Kailow Graphic Entre nous is funded by the United Nations Population Fund (UNFPA), Regional office for Eastern Europe and Central Asia, with the assistance of the World Health organization Regional office for Europe, Copenhagen, Denmark. Present distribution figures stand at: 2000 English, 2000 Spanish and 1000 Russian. Entre Nous is produced in: Russian by the WHo Regional office for Europe Rigas, RGH Baltic, Rounborg Grafiske Hus; Spanish by the Instituto de la Mujer, Ministerio de Sanidad, Servicios Sociales e Igualdad, Condesa de venadito, 34, 28027 Madrid, Spain. The Spanish issues are distributed directly through UNFPA repre sentatives and WHo regional offices to Spanish speaking countries in South America. Material from Entre nous may be freely translated into any national language and reprinted in journals, magazines and news- papers or placed on the web provided due acknowledgement is made to Entre nous, UNFPA and the WHo Regional office for Europe. Articles appearing in Entre nous do not necessarily reflect the views of UNFPA or WHO. Please address enquiries to the authors of the signed articles. For information on WHo-supported activi- ties and WHo documents, please contact Dr Gunta Lazdane, Division of Noncom- municable Diseases and Health Promotion, Sexual and Reproductive Health at the address above. Please order WHo publications directly from the WHo sales agent in each country or from Marketing and Dissemination, WHo, CH-1211, Geneva 27, Switzerland ISSN: 1014-8485 © World Health Organization 2013 ICPD Beyond 2014: Shaping a future based on rights, dignity and health for all By Kwabena osei Danquah 3 The ICPD Plan of Action: A Timeless Agenda for a Mutually Supportive Population and Development By Francois Farah 4 Quality health and well-being for all: from the 1994 International Conference on Population and Development to the United Nation’s Post-2015 Development Agenda By nedret Emiroglu and Evis Kasapi 8 Sexual and reproductive health and rights (SRHR) are human rights By Vicky Claeys 12 Taking the Bali Declaration forward: youth and the development agenda By Magnhild Bøgseth and Jakub skrzypczyk 14 The ICPD agenda in Europe two decades after Cairo: progress and remaining gaps By Jens-Hagen Eschenbächer 16 From local to regional – ASTRA as an expert on sexual and reproductive health and rights in central and eastern Europe By Krystyna Kacpura 18 Implementing the ICPD Agenda in Kyrgyzstan: a glass half full By Meder omurzakov, tolgonai Berdi keyeva and ramona Lupu 20 Introducing Beyond the Numbers in the Ukraine: lessons learned By nuzhat Ehsan, Valentina Kolomeychuk, Pavlo Zamostian and Anastasiya Dumcheva 24 The 1994 International Conference on Population and Development (ICPD): past and future from a Finnish/Nordic perspective By Dan Apter and Hilkka V uorenmaa 26 What did Cairo mean to me? By Werner Haug, Gunta Lazdane, Helle Karro, Ingar Brueggemann, Meri Khachikyan and tomris türmen 28 Resources By Lisa Avery 30 ,, 3 No.78 - 2013 ICPD BEyoND 2014: SHAPING A FUTURE BASED oN RIGHTS, DIGNITy AND HEALTH FoR ALL At the Cairo International Confer-ence on Population and Develop-ment (ICPD) in 1994, the global community reached a consensus on how to address challenging population issues. They agreed that population is not about numbers, but about people. They placed human well-being and the rights and empowerment of women at the very heart of development. They recognized and affirmed that sexual and reproduc- tive health and reproductive rights are fundamental to the ability to access all human rights and to sustained economic growth and the achievement of sustain- able development. As well as asserting that every pregnancy should be wanted, every childbirth safe and that every young person’s potential be fulfilled, world leaders argued that these actions – including the protection of basic human rights-- would help to create a world that could sustainably meet the needs of current and future genera- tions. Through the past two decades, we have seen real progress: families are getting smaller, even as more children are surviv- ing. More girls are getting educated and women are taking on more influential roles in society. Young people, who in a large number of countries make up more than half the population and in some cases up to 70% of the population, are connected as never before and have be- come powerful agents of change. Human rights institutions have proliferated in every part of the world and are addressing gender discrimination. Yet challenges remain; in every region of the world economic inequalities persist, leaving a billion people mired in poverty, with women and the marginalized receiv- ing the smallest share of the pie. A thou- sand women die still die each day from preventable complications of pregnancy and childbirth. 67 million girls are mar- ried before they reach the age of eighteen, even when governments have put in place laws to prevent early marriage. In every region of the world, countries struggle to address the causes and consequences of youth unemployment and millions of young people are frustrated by lack of education and job opportunities. Migra- tion both to cities and to countries that holds the promise of greater opportuni- ties is rising, yet inadequate pro-active planning, including inequitable access to services, results in considerable cost to individual rights and well-being. And as our climate changes, natural disasters disrupt lives on an unprecedented scale. Responding to the needs of all 7 billion of us – and future generations – requires promoting human rights, including: ensuring the right of individuals and couples to decide freely on the number, timing and spacing for having children; investing in all people; and enabling in- novation for a green economy to change unsustainable consumption patterns that result in environmental debacles, as well as, a cleaner world for mankind. These actions reaffirm the agreements made in Cairo nearly 20 years ago. The ICPD Beyond 2014 review, led by the United Nations Population Fund (UNFPA) on behalf of the United Nations (UN), will provide the most comprehen- sive overview of progress towards the goals of the Cairo conference and the way forward. In the context of a wider UN effort to determine a new global devel- opment agenda, the review provides a clarion call to governments, civil society and UN partners to address themselves to the unfinished ICPD agenda and to put the sexual and reproductive health and rights of women, girls and marginalized groups at the heart of future development goals. The Regional Population Conference taking place in Geneva July 1-2 2013, provides eastern Europe and central Asia with an opportunity to respond compre- hensively to the emerging population and development issues. The conference also provides an opportunity to strengthen Regional consensus and commitment to putting human rights at the centre of development, reinvigorating the ICPD Programme of Action, contributing to the UN Secretary General Report and influencing the post-2015 development agenda to deliver a better future for all. Kwabena Osei Danquah, Executive Coordinator ICPD Beyond 2014 Secretariat Kwabena Osei Danquah 4 The implementation of the recommendations contained in the Programme of Action is the sovereign right of each country, consistent with national laws and development priorities, with full respect for the various religious and ethical values and cultural backgrounds of its people, and in conformity with universally recognized international human rights. International cooperation and universal solidarity, guided by the principles of the Charter of the United Nations, and in a spirit of partnership, are crucial in order to improve the quality of life of the peoples of the world. In addressing the mandate of the Inter- national Conference on Population and Development and its overall theme, the inter- relationships between population, sustained economic growth and sustainable develop- ment, and in their deliberations, the partici- pants were and will continue to be guided by the following set of principles: Principle 1 All human beings are born free and equal in dignity and rights. Everyone is entitled to all the rights and freedoms set forth in the Uni- versal Declaration of Human Rights, without distinction of any kind, such as race, colour, sex, language, religion, political or other opin- ion, national or social origin, property, birth or other status. Everyone has the right to life, liberty and security of person. Principle 2 Human beings are at the centre of concerns for sustainable development. They are entitled to a healthy and productive life in harmony with nature. People are the most important and valuable resource of any nation. Countries should ensure that all individuals are given the opportunity to make the most of their potential. They have the right to an adequate standard of living for themselves and their families, including adequate food, clothing, housing, water and sanitation. Principle 3 The right to development is a universal and inalienable right and an integral part of funda- mental human rights, and the human person is the central subject of development. While development facilitates the enjoyment of all human rights, the lack of development may not be invoked to justify the abridgement of internationally recognized human rights. The right to development must be fulfilled so as to equitably meet the population, development and environment needs of present and future generations. Principle 4 Advancing gender equality and equity and the empowerment of women, and the elimi- nation of all kinds of violence against women, and ensuring women’s ability to control their own fertility, are cornerstones of population and development- related programmes. The human rights of women and the girl child are an inalienable, integral and indivisible part of universal human rights. The full and equal participation of women in civil, cultural, eco- nomic, political and social life, at the national, regional and international levels, and the eradication of all forms of discrimination on grounds of sex, are priority objectives of the international community. Principle 5 Population-related goals and policies are integral parts of cultural, economic and social development, the principal aim of which is to improve the quality of life of all people. Principle 6 Sustainable development as a means to ensure human well-being, equitably shared by all people today and in the future, requires that the interrelationships between popula- tion, resources, the environment and develop- ment should be fully recognized, properly managed and brought into harmo nious, dynamic balance. To achieve sustainable development and a higher quality of life for all people, States should reduce and eliminate unsustainable patterns of production and consumption and promote appropriate poli- cies, including population-related policies, in order to meet the needs of current genera- tions without compromising the ability of future generations to meet their own needs. Principle 7 All States and all people shall cooperate in the essential task of eradicating poverty as an indispensable requirement for sustain- able development, in order to decrease the disparities in standards of living and better meet the needs of the majority of the people of the world. The special situation and needs of developing countries, particularly the least developed, shall be given special priority. Countries with economies in transition, as well as all other countries, need to be fully integrated into the world economy. Text Box 1. Principles of the 1994 PoA. THE ICPD PLAN oF ACTIoN: A TIMELESS AGENDA FoR A MUTUALLy SUPPoRTIvE PoPULATIoN AND DEvELoPMENT “The empowerment of women and the improvement of their political, social and health status is a highly important end in itself. In addition, it is essential for sustainable development.... Experience shows that population and development programmes are most effective when steps have simultaneously been taken to improve the status of women.” ICPD Programme of Action, 1994 Unlike the earlier two World Population Conferences of Bucharest (1974) and Mexico (1984) the Programme of Action (PoA) of the International Conference on Population and Development (ICPD) which was endorsed in 1994 by 179 countries in Cairo, redefined demograph- ics and population issues primarily from a people’s empowerment and human rights development perspective (see textbox 1). Prior to the ICPD, women’s sexuality and sexual health were largely linked to mere human reproduction, as a social function often subject to imbalanced, adverse and discriminative gender practices which had been hardly questioned. As to women’s fertility it was mostly associated with de- mographic targets as the sole responsibil- ity of governments, many of whom found in population control the one policy item to counter the galloping population growth. The ICPD marked a significant shift, a paradigm shift indeed, at the individual/ micro level mostly in terms of reproduc- tive health, reproductive rights, women’s empowerment and well being; and at the No.73 - 2011 5 8 3 Francois Farah Principle 8 Everyone has the right to the enjoyment of the highest attainable standard of physical and mental health. States should take all appropriate measures to ensure, on a basis of equality of men and women, universal access to health-care services, including those related to reproductive health care, which includes family planning and sexual health. Reproductive health-care programmes should provide the widest range of services without any form of coercion. All couples and individu- als have the basic right to decide freely and responsibly the number and spacing of their children and to have the information, educa- tion and means to do so. Principle 9 The family is the basic unit of society and as such should be strengthened. It is entitled to receive comprehensive protection and support. In different cultural, political and social systems, various forms of the family exist. Marriage must be entered into with the free consent of the intending spouses, and husband and wife should be equal partners. Principle 10 Everyone has the right to education, which shall be directed to the full development of human resources, and human dignity and potential, with particular attention to women and the girl child. Education should be de- signed to strengthen respect for human rights and fundamental freedoms, including those relating to population and development. The best interests of the child shall be the guiding principle of those responsible for his or her education and guidance; that responsibility lies in the first place with the parents. Principle 11 All States and families should give the highest possible priority to children. The child has the right to standards of living adequate for its well-being and the right to the highest attainable standards of health, and the right to education. The child has the right to be cared for, guided and supported by parents, families and society and to be protected by appropriate legislative, administrative, social and educational measures from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sale, trafficking, sexual abuse, and trafficking in its organs. Principle 12 Countries receiving documented migrants should provide proper treatment and ad- equate social welfare services for them and their families, and should ensure their physical safety and security, bearing in mind the special circumstances and needs of countries, in particular developing countries, attempting to meet these objectives or requirements with regard to undocumented migrants, in con- formity with the provisions of relevant con- ventions and international instruments and documents. Countries should guarantee to all migrants all basic human rights as included in the Universal Declaration of Human Rights. Principle 13 Everyone has the right to seek and to enjoy in other countries asylum from persecution. States have responsibilities with respect to refugees as set forth in the Geneva Conven- tion on the Status of Refugees and its 1967 Protocol. Principle 14 In considering the population and develop- ment needs of indigenous people, States should recognize and support their identity, culture and interests, and enable them to participate fully in the economic, political and social life of the country, particularly where their health, education and well-being are affected. Principle 15 Sustained economic growth, in the context of sustainable development, and social pro- gress require that growth be broadly based, offering equal opportunities to all people. All countries should recognize their common but differentiated responsibilities. The developed countries acknowledge the responsibility that they bear in the international pursuit of sus- tainable development, and should continue to improve their efforts to promote sustained economic growth and to narrow imbalances in a manner that can benefit all countries, particularly the developing countries. community/national/macro level in terms of fully integrating demographics and population dynamics issues into a broader economic and social policy, human rights, gender equality and choice driven development. As a result, women were no longer “reproducing individuals” whose exces- sive fertility ought to be regulated. The ICPD shift did recast reproduction in the context of the couple, putting emphasis on the responsibility of both spouses in the reproductive decision-making, timing and outcome, in an equal opportunity environment and in a negotiated, dignify- ing and complementary division of roles and responsibilities. On the other hand, it made public policies, governments but also civil society organizations, parlia- mentarians, interest groups, opinion and cultural leaders and a range of other social partners responsible and enablers for an empowering, equitable and sustain- able human development for both men and women and for the young people, including female adolescents and the girl child in a life cycle approach. Emerging Issues Since the ICPD Demographics and development experi- ences over the last two decades or so have generated a range of population realities and profiles in the world. While fertility expressed by the average number of live children per woman throughout her life has remained rather high in a number of developing and least developed countries, it has fallen below two children (a level required to replace outgoing genera- tions) in a large number of emerging and middle income countries. The world today registers an unmatched number of youth with a potential yet to be realized and fast growing generations of older people. It faces unparalleled pressures on the environment and growing disparities within and across countries in terms of access to basic health and social services, including reproductive health informa- tion and quality services and equal access to economic and social opportunities. Patterns of family formation, hu- man sexuality, relating to the opposite 6 UNFPA Executive Director Babatunde Osotimehin pledging continued assistance for reproductive health and voluntary family planning in the Phillipines. © UNFPA. Source: By Choice, Not by Chance. Family Planning, Human Rights and Development. State of the World Population 2012. New York: UNFPA, 2012. Source: By Choice, Not by Chance. Family Planning, Human Rights and Development. State of the World Population 2012. New York: UNFPA, 2012. THE ICPD PLAN oF ACTIoN: A TIMELESS AGENDA FoR A MUTUALLy SUPPoRTIvE PoPULATIoN AND DEvELoPMENT (ContInuED) sex and evolving geographic and social mobility have also significantly changed in a world where the potential of using communication and access to real time information and social services has not been materialized, particularly in favour of most vulnerable and marginalized groups, including the bottom 20% across countries. A large body of evidence suggests that what came out of Cairo then and what continues to be of extreme relevance today, particularly now that the world community prepares to define the priori- ties of the development agenda after 2015, can be found in the following premises: a) The wholeness, integrity of person- hood and the sacredness of human rights, for every person of all ages and for every human being, whether a man or a woman, a female adoles- cent or a girl child; b) The responsibility of society through its diverse social, economic, cultural, political and judiciary institutions to devise the right policy, programme and law enforce- ment instruments to uphold the above rights and to ensure equality of access to basic health and social services with particular responsibili- ties to reach the underserved; and c) The responsibility of society to ensure that reproductive rights are upheld, promoted and protected and abuses, including gender- based violence and violence against women of all sorts, are kept under check and sanctioned properly. Population Issues in Redefining Development Priorities After 2015 As the UN system carries out a global re- view of the progress made in implement- ing the ICPD PoA, the world community will also proceed to assess the perfor- mance and delivery of the Millennium Development Goals framework in view of defining a meaningful development agenda for the next twenty years or so. This offers an unprecedented opportunity for us to reposition population issues in the broader post 2015 development agenda context. This is critical to move towards a mutually supportive, human rights and equality based and sustainable development agenda. It is in this particular context that the PoA provisions and population and reproductive health issues become central and should be considered an integral part of and of paramount policy significance to the post-2015 development agenda. Such issues should be considered from a two-pronged policy perspective: a) Understanding evolving popula- tion dynamics, including changing population structures, population movement and distribution; and addressing the development needs of special age groups such as youth and the older people, as they have No.73 - 2011 7 8 3 British Prime Minister David Cameron and Melinda Gates talk about family planning issues and volunteering with young people at the London Summit on Family Planning. © Russell Watkins/UK Department for International Development. Source: By Choice, Not by Chance. Family Planning, Human Rights and Development. State of the World Population 2012. New York: UNFPA, 2012. tremendous bearing on macro social and economic development and sustainability processes and outcomes, and b) Bridging disparities and ensuring access to reproductive health and protection of reproductive rights, within a gender equality perspective as they represent a critical chal- lenge for achieving dignified human development and wellbeing for all. Issues related to sexuality, reproduction and gender roles are at the roots of many practices, which continue to constitute widespread violations of human rights of women and the girl child. Practices and attitudes related to women’s reproduc- tive health such as honour crimes, sexual coercion and violence, female genital cut- ting, pre-birth sex selection, rape, restric- tions on women’s mobility, forced/child marriages and others continue to exist in many societies. This concerns a number of institutions at the local, national or international levels such as the state, faith based institutions, the educational system, the media, the market at large, the legal, the criminal and the law enforcement system and the community. A post-2015 development agenda should therefore consider adopting meas- urable targets regarding achieving better education, sustainable job creation, the removal of barriers to accessing repro- ductive health services for improving women’s and young people’s opportuni- ties and their wellbeing and for maximiz- ing their contributions to society. A human rights-based approach to sexual and reproductive health promotes a paradigm shift in which women, couples and female adolescents, particularly those in situations of marginalization and vulnerability, are no longer excluded from services or just considered passive recipi- ents of goods and commodities, but are instead fully empowered agents of their own development and their own destiny! Francois Farah, UNFPA Executive Advisor on ICPD Beyond 2014 and Post 2015 Development Agenda, UNFPA, farah@unfpa.org 8 “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being.” WHO Constitution I. WHY IS THIS A PRIORITY FOR THE FUTURE? Health, including the domain of sexual and reproductive health (SRH), is central to sustainable development: it is a ben- eficiary of development, a contributor to development and a key indicator of what people-centred, rights-based, inclusive, and equitable development seeks to achieve. Health is important as an end in itself and as an integral part of human well-being, which includes material, psychological, social, cultural, educa- tional, work, environmental, political, and security dimensions. These dimensions of well-being are interrelated and interde- pendent. The 1994 International Conference on Population and Development (ICPD) in Cairo was instrumental in increasing awareness that health, including positive SRH, is essential to the broader develop- ment context. A strong social and economic case for change Good health underpins social and economic development and strengthens policies across all sectors. For example: • The costs of not acting to reduce inequities in health are high. Recent studies relevant to Member States of the European Union (EU) estimate that the monetary value of health- inequity-related welfare losses is €980 billion per year or 9.4% of GDP (1). A similar pattern of inequity costs is mirrored in lower-income and transi- tion economies as well. • Good health benefits all sectors and the whole of society –health contrib- utes to increased productivity, a more efficient workforce, healthier ageing and less expenditure on sickness and social benefits. • What makes societies prosper and flourish also makes people healthy – policies that ensure access to educa- tion, good work, decent housing and income all support health. The health and well-being of the population are best achieved if the whole of govern- ment works together to address the social and individual determinants of health. Good health can support economic recovery and development. • Using resources efficiently within the health sector can contain overall pub- lic expenditure and health care costs. Reconfiguring health services around primary health care and community care, people and patient empower- ment, health financing reforms, skill mix and better use of health technol- ogy assessment can provide better value for money. Health systems, like other sectors, need to reform and adapt to change. • In a globalized world, countries are increasingly required to work together to solve many key health challenges. This requires cooperation across borders. A development agenda focused on health and well-being The 1994 ICPD was a milestone in the history of population and development, as well as in the history of women’s rights. It’s Programme of Action set out to: • Provide universal access to family planning and SRH services and repro- ductive rights; • Deliver gender equality, empower- ment of women and equal access to education for girls; • Address the individual, social and economic impact of urbanization and migration; and • Support sustainable development and address environmental issues associ- ated with population changes. 179 governments reached consensus that the equality and empowerment of women is a global priority not only from the perspective of universal human rights, but also as an essential step towards eradi- cating poverty and stabilizing population growth. A woman’s ability to access repro- ductive health and rights is the corner- stone of her empowerment and also a key to sustainable development. Today, achieving the highest qual- ity health and maximizing healthy life expectancy requires accelerating progress on the Millennium Development Goals (MDGs); addressing the challenges posed by noncommunicable diseases (NCDs), mental health and SRH; and ensuring universal health coverage and access, with equity and human rights built in as a cross-cutting theme. The pursue of these goals beyond 2015 calls for a new agenda, based on greater synergies between health and other sectors and with goals framed in such a way that their attainment requires policy coherence and shared solutions across multiple sectors: what is needed is a whole–of–government and whole–of–so- ciety approach. This vision is captured in “Health 2020: the European policy for health and well-being,” which has been endorsed by all 53 Member States of the WHO European Region. Health 2020, moves the development agenda forward and estab- lishes four priority areas for policy action: • investing in health through a life- course approach and greater empow- erment of citizens; • tackling the Region’s major health challenges of NCDs and communica- ble diseases; • strengthening people-centred health systems, public health capacity and emergency preparedness, surveillance and response; and • creating resilient communities and supportive environments. II. THE STORY OF THE REGION Inequities in experiencing the human right to health constitute a health divide across the Region, which is unfair and unjust Across Europe and central Asia as a whole, health has greatly improved QUALITy HEALTH AND WELL-BEING FoR ALL: FRoM THE 1994 INTERNATIoNAL CoNFERENCE oN PoPULATIoN AND DEvELoPMENT To THE UNITED NATIoN’S PoST-2015 DEvELoPMENT AGENDA No.78 - 2013 9 in recent decades, However, there are significant health inequities between and within countries. As a key indicator of this situation, the lowest and highest life expectancy rates at birth in the Region differ by 16 years, with marked gender differences (2). Increasing evidence shows that this health divide is caused by differences in conditions of life, based on the mecha- nisms by which power, money and re- sources are distributed in society. Many groups and areas have been left behind and, as economies have faltered, in many instances, health inequities have grown within and between countries. Ethnic mi- norities, some migrant communities and groups of travellers, such as the Roma, continue to suffer disproportionately. The rapid growth of NCDs, disabilities and mental disorders, a lack of social cohesion, unemployment, environmental threats and financial uncertainty, all make improving health even more difficult and threaten the sustainability of health and welfare systems. Mixed results in the achievement of the health-related MDGs The Member States of the WHO Euro- pean Region have made significant ad- vances towards the MDGs. Areas remain, however, in which action has stagnated and inequities in progress persist between and within countries. Child and maternal health - Most coun- tries in the Region have made important progress towards MDG 4 – reducing child and infant mortality. The average reported infant mortality rate in 2010 was 7.3 per 1000 live births: a 53% reduction over three decades (2). However countries report strikingly different rates, ranging from more than 50% below to more than 60% above the Regional average. Data on the probability of a child’s dying before the age of 5 years reveal a very similar pattern. Every year more than 160 000 children in the European Region die before the age of five, 40% in the first month of life (2). Two-thirds of these childhood deaths could have been prevented through universal coverage of a few key effective and affordable public health interventions. The Regional average maternal mortality has decreased from 44 per 100 000 live births in 1990 to 13 in 2010 (2). However, despite the progress, the average decline of 3.8% is short of the 5.5% needed to reach the MDG 5 target. In addition, there are big discrepancies between countries, with rates ranging from more than 75% above to more than 60% below the Regional average (2). In many countries of eastern Europe and central Asia, universal access to SRH is of concern– particularly the lack of unified and reliable information; unmet needs on family planning and low rates of modern, effective methods of contra- ception usage (3). Maternal mortality is further influenced by the socioeconomic status of women, including their level of education. This highlights the impor- tance of addressing gender norms and other social determinants of health in policies and interventions and of taking a human rights-based approach to provid- ing the services needed. HIV/AIDS - The European Region is facing considerable challenges in meeting the MDG 6 target of halting the spread of HIV/AIDS; the eastern part of the Region has the fastest-growing HIV epidemic in the world. In 2011, an estimated 2.3 million people were living with HIV and more than 121 000 new cases were reported, the majority from eastern Europe and central Asia (2). Numbers of both diagnosed AIDS cases and AIDS- related deaths have declined in central and western Europe, however in eastern Europe and central Asia AIDS diagnoses quintupled in 2004–2011 and deaths continue to increase (2). The eastern part of the Region has also some of the lowest global rates of coverage of antiretroviral therapy for people who need treatment (less than 20%) (2). Tuberculosis (TB) - TB accounts for over 40% of all mortality from communicable diseases and is the most common cause of death among people living with HIV/ AIDS in the Region (2). The Region is on track in meeting the target of reversing TB incidence; however the TB mortality reduction target will most probably not be achieved. The burden of TB also varies between and within the countries of the Region, with an incidence of less than 1 to above 200 per 100 000 population (2). 86% of all TB cases and more than 98% of all multidrug-resistant TB (MDR- TB) cases are concentrated in eighteen countries; fifteen of which are among the highest MDR-TB burden countries in the world. Even though the treatment cover- age for MDR-TB increased to 96% in 2011, only 25% have access to the WHO recommended treatment regimen, result- ing in low treatment success rates (48%) (2). Even in western European countries there are major gaps in terms of compli- ance with best practices; access to early diagnosis and treatment, including for children, migrants and other vulnerable populations; and adequate mechanisms of patient support for improving treat- ment adherence. With 2015 approaching, scaled up commitment and action are clearly need- ed if we are to achieve the MDG targets. At the same time it is imperative to start thinking about post-2015 development goals. We must therefore continue: • to ensure progress is made towards the current goals; • to back national efforts to sustain the necessary political commitment and financial support; and, crucially, • to maintain levels of investment in national and international systems for tracking resources and results. III. WHAT’S NExT? Actions required for combating health inequities include: • Addressing the social gradient in health by designing policies that cut across the whole gradient while producing faster results for those at the bottom and those who are most exposed to risks. • Taking a life-course approach to increase equity in health, begin- Evis Kasapi Nedret Emiroglu 10 EUR/RC62/9 Health 2020: a European policy framework supporting action across government and society for health and well-being. Available in English, French, Russian and German at: http://www.euro.who.int/en/what-we-do/health-topics/health-policy/health-2020 ning with early life – pregnancy and early childhood development – and continuing with school, the transi- tion to reproductive age, working life, employment and working conditions and circumstances affecting older people. • Addressing the processes of exclusion by changing the structural factors which produce exclusion rather than focusing simply on addressing particular characteristics of excluded groups. • Intervening to prevent the trans- mission of disadvantage and health inequity across generations by em- phasizing the importance of assessing the impact of actions and policies for inequities on future generations and mitigating associated risks. • Putting in place policies that remove gender differences in health and social and economic opportunities. Gender relations affect health in all societies to varying degrees and should shape the actions taken to reduce inequities. • Strengthening national health infor- mation systems, civil registration, and vital statistics, down to the district level and below, as a prerequisite for measuring and improving equity. Addressing the growing burden of NCDs and mental health NCDs – such as cardiovascular diseases, diabetes, cancer and chronic obstructive pulmonary diseases - pose one of the foremost challenges to social, economic, and sustainable development in the 21st century, as affirmed by the UN Political Declaration in 2011. NCDs account for 80% of deaths in the European Region (2). Among broad groups of diseases, all- age mortality from cardiovascular disease accounts for nearly 50% of all deaths (2). Other noncommunicable conditions, such as mental disorders, are the second largest contributor to the burden of disease and the most important cause of disability. Violence and injury add to the burden, with child maltreatment being also associated with chronic mental and physical illness in adulthood. The risks and burden of NCDs and mental health in the Region cluster in the poorest and most vulnerable in society, with devastating health consequences, including adverse SRH, for individuals, families and communities. They threaten to overwhelm the health systems in many countries. Addressing the high prevalence of NCDs requires taking a life-course approach; addressing early childhood exposures and conventional risk factor prevention, investing in cost-effective clinical services at the primary care level, providing palliative care where needed and promoting healthy ageing. A greater focus is also needed on promoting health literacy and patient empowerment, with greater attention to disabilities caused by chronic disease. Advancing universal health coverage Universal Health Coverage (UHC) combines two fundamental components: QUALITy HEALTH AND WELL-BEING FoR ALL: FRoM THE 1994 INTERNATIoNAL CoNFERENCE oN PoPULATIoN AND DEvELoPMENT To THE UNITED NATIoN’S PoST-2015 DEvELoPMENT AGENDA (ContInuED) No.78 - 2013 11 access to health services (promotion, prevention, treatment and rehabilita- tion), as well as, living conditions needed to achieve good health and financial protection to prevent ill health leading to poverty. UHC is a dynamic process. It is not about a fixed minimum package, it is about making progress on several fronts: i) the range of services that are avail- able to people, including those related to NCDs, mental health, infectious diseases, and SRH; ii) the proportion of the costs of those services that are covered; and iii) the proportion of the population that is covered. Few countries reach the ideal, but all – rich and poor – can make pro- gress. It is thus relevant to all countries. Moving towards UHC requires strong efficient health systems that can respond to the full range of health determinants and deliver quality services on a broad range of country health priorities. Health financing systems are required that can raise sufficient funds for health, and also provide access to essential medicines and other supplies and equipment; good governance and health information; peo- ple centred services; and a well-trained and motivated workforce. Health 2020 puts forward a vision to improve health system performance through innovative approaches that strengthen core health system functions with renewed efforts to implement people-centered solutions, whilst remaining resilient to economic downturns. IV. CLOSING The principles and Programme of Action from the 1994 ICPD were instrumental in placing the global community on the path towards and building momentum for the development agenda of overall well-being for all. Health 2020 shares this vision, and moves the development agenda forward with commitment to implementing and scaling up a holistic and synergistic hu- man rights and equity based approach to health that will benefit everyone. Nedret Emiroglu, MD, PhD, Deputy Director, Division of Communicable Diseases, Health Security and Environment and Special Representative of the Regional Director on Millennium Development Goals and governance, WHo Regional office for Europe, nem@euro.who.int Evis Kasapi, Technical officer, Division of Communicable Diseases, Health Security and Environment, WHo Regional office for Europe, eka@euro.who.int References 1. Mackenback JP, Meerding WJ, Kunst AE. Economic implications of socio- economic inequalities in health in the European Union. Brussels: European Communities Health and Consumer Protection Directorate General, 2007: 4–5. 2. European Health for All database [online database]. Copenhagen: WHO Regional Office for Europe, 2012(http://data.euro.who.int/hfadb). 3. By Choice, Not by Chance. Family Planning, Human Rights and Develop- ment. State of the World Population Report. New York: UNFPA, 2012. 12 SExUAL AND REPRoDUCTIvE HEALTH AND RIGHTS (SRHR) ARE HUMAN RIGHTS Introduction In 2014 it will be 20 years since the world has agreed on the Programme of Action of the International Conference on Population and development (ICPD, 1994, Cairo) which was meant to be fully implemented by now. Nothing could be further from the truth. The international community has recognized that there is still a lot of unfinished business and subsequently it was agreed that there will no longer be an end date for implemen- tation. On the one hand this is good because it allows us to keep advocating for its full implementation. On the other hand it also bears the risk that govern- ments will put implementation onto the long haul and, therefore, will not respond sufficiently and promptly enough to the needs of women and couples, or young people, while we know that at this mo- ment the world has the largest number of young people ever. Another concern, as we move towards the post 2015 development agenda, is the place SRHR will hold within the future development goals which will replace the Millennium Development Goals (MDGs). The SRHR community is in its highest state of alert because we don’t want to make the same mistake as in 2000 when the MDGs were developed and where one of the supreme goals of ICPD, ensuring universal access to reproductive health, was missing. It took the whole com- munity seven years to have it formulated as MDG 5B. All the time lost and the inferior positioning of MDG 5B has also contributed significantly to the fact that this MDG has made the least progress of all. The ICPD, SRHR and the International Planned Parenthood Federation (IPPF) In 1994, the ICPD entailed a major shift from discussing and worrying about the growing population to the recogni- tion that individuals should have the right themselves to have or not to have children, when and how many and with whom. The IPPF was already, long before that time, pleading that SRHR was and is a human right. In 1984, at the Population Conference in Mexico City, the then IPPF President, Mrs. Avabai B. Wadia, was lead- ing the IPPF delegation of 25 Member Association representatives that were part of their country’s delegation. In one of her speeches she already mentioned then the strong belief that planned parenthood is a basic human right and a guiding principle for IPPF. In 1990, four years before the ICPD, the IPPF Central Council confirmed its commitment to population and environ- ment, women’s empowerment, quality of care and expressed its concern about SRHR being an unrecognized human right. One year before the ICPD, IPPF formulated its new mission statement which clearly stated that IPPF would defend the right of women and men, including young people, to decide freely the number and spacing of their children and the right to the highest possible level of sexual and reproductive health. In anticipation of the ICPD, IPPF launched its Vision 2000 which was the agenda for the forthcoming years. Expertise on the link between SRHR and human rights was being built up and in 1996 the IPPF launched its Charter on Sexual and Repro- ductive Health and Rights which was the first document that looked at internation- ally agreed human rights conventions and derived from there what we believed were also to be included as sexual and repro- ductive rights. For instance, the right to education also includes that young people should receive sexuality education and the right to live also includes the right of the woman to be saved in case of preg- nancy related complications. Approximately 10 years later, the IPPF was ready to go one step further and launched Sexual rights: an IPPF Declara- tion. The document was developed by a panel that included internationally renowned experts in SRHR and was grounded in core international human rights treaties and other instruments. It states: “Universal, interrelated, interde- pendent and indivisible, sexual rights are a component of human rights. They are an evolving set of entitlements that contribute to the freedom, equality and dignity of all people.” Sexual rights go beyond a narrow definition of sexuality focused exclusively on sexual orienta- tion and gender identity. They are closely related to reproductive rights but are distinct. Reproductive rights relate to fer- tility, reproduction, reproductive health and parenthood. Sexual rights span a lifetime but are an integral factor in most reproductive decision-making. The IPPF Declaration was universally accepted by the 152 IPPF Member Asso- ciations which was, and still is, a remark- able achievement because sexual rights are not universally recognized. The WHO only has a working definition which means there is no internationally accepted definition (see text box 1). While repro- ductive rights are widely accepted, sexual rights remain more controversial because they include the concept that sexuality is an integral part of well-being and that all human beings are sexual beings. In addition it recognizes the sexual rights of women, young people, people living with HIV, lesbians and gays, transsexuals and other minority groups-all groups to whom the IPPF is highly committed. In recent years the IPPF has taken a step further and started using existing human rights instruments, such as the Universal Periodic Review of the Hu- man Rights Council, to bring forward anomalies in legislation, as in the case of Ireland where the government has been asked by other governments to review its abortion legislation because it violates certain human rights. Another avenue is the European Court of Justice where a number of women, also from Ireland, were assisted in bringing their case before the Court. More recently the IPPF European Network is using its status with the Council of Europe as an NGO able to file complaints using the European Social Charter. We made the case against the government of Italy for the extensive use of conscientious objection by health professionals to deny women access to abortion while abortion is legal under certain circumstances. At the time of its 60th Anniversary No.73 - 2011 13 8 3 Vicky Claeys “The fulfilment of sexual health is tied to the extent to which human rights are respected, protected and fulfilled. Sexual rights embrace certain human rights that are already recognized in international and regional human rights documents and other consensus documents and in national laws. Rights critical to the realization of sexual health include: • Rights critical to the realization of sexual health include: • the rights to equality and non-discrimination, • the right to be free from torture or to cruel, inhumane or degrading treatment or punishment, • the right to privacy, • the rights to the highest attainable standard of health (including sexual health) and social security, • the right to marry and to found a family and enter into marriage with the free and full consent of the intending spouses, and to equality in and at the dissolution of marriage, • the right to decide the number and spacing of one’s children, • the rights to information, as well as education, • the rights to freedom of opinion and expression, and • the right to an effective remedy for violations of fundamental rights. The responsible exercise of human rights requires that all persons respect the rights of others. The application of existing human rights to sexuality and sexual health constitute sexual rights. Sexual rights protect all people’s rights to fulfil and express their sexuality and enjoy sexual health, with due regard for the rights of others and within a framework of protection against discrimination.” (WHo, 2006a, updated 2010) Text Box 1. WHO Working Definition on Sexual Rights ** ** It should be noted that this definition does not represent an official WHo position and should not be used or quoted as such. It is offered instead as a contribution to ongoing discussion about sexual health. celebrations, we can state clearly that the IPPF, throughout the Federation has renewed its energy and has, besides being a service provider, educator and advocate, also learned to be brave and angry when it comes to using all the existing legal means to defend the case that SRHR are human rights and that they should be at the centre of any new global mechanism that is meant to build a sustainable world. At the moment the SRHR community is totally engaged in the negotiations taking place at national, regional and international level which will ultimately result in a new global framework. There is a lot at stake and a number of different interests are present. Climate change, environmental degradations, water short- age, the upcoming economies, ecological footprints, political instability and war- zones are all extremely important politi- cal priorities. Addressing SRHR in such a complicated environment is certainly not easy and requires re-education of quite a number of SRHR advocates. The IPPF and others believe strongly that SRHR, gender equality and human rights should drive any outcome. To help achieve this the IPPF has launched its Vision 2020 which has 10 concrete “asks” to all govern ments in the world. They are: 1. Secure sexual and reproductive health as a development goal; 2. Close the gap between those who can and can’t access health and rights; 3. Eliminate all forms of discrimination against women and girls; 4. Recognize SRHR as human rights; 5. Ensure young people are involved in all policy decisions that affect them; 6. Integrate sexual and reproductive health, and HIV services, into health systems; 7. Halve the unmet need for contracep- tives; 8. Make comprehensive sexuality educa- tion available to all; 9. Reduce maternal mortality due to unsafe abortion by 75%; and 10. Ensure governments invest the re- sources to achieve these targets. In closing Vision 2020 (More information at www.ippf.org/vision2020) is the IPPF’s global programme and is meant to inspire the Federation and all other organizations that are working towards a fair and just world. It is our hope that these 10 con- crete action points will be reflected in the international dialogue and any outcome documents that will steer further devel- opment action and we therefore invite others to join us in this endeavour. Vicky Claeys, Regional Director, IPPF EN, vclaeys@ippfen.org 14 How did it start? Should young people have a say in the processes concerning their bodies and futures? The answer seems obvious. In spite of that, young people have rarely had the opportunity or support they need to actually take part in national, regional or international policy conversations. In December 2012 a big step was taken for ensuring that young people’s concerns, needs and rights are put on the agenda, when 130 United Nations Member States, 80 youth organizations and networks, 300 individual youth participants, 50 non- governmental organizations (NGOs), 2500 online delegates, 40 private sector institutions, 50 representatives of the United Nations (UN) and other stake- holders met at the Global Youth Forum (GYF) in Bali, which was co-hosted by the Government of Indonesia and the United Nations Population Fund (UNFPA) (see image 1). For the first time ever young people had a space for setting the agenda of what is important for them - and how priorities need to be set for this to actually happen. A key outcome of the meeting was the development of the Bali Declaration, a historic set of recommen- dations for youth and development (the entire document can be read at: (http://unfpa.org/webdav/site/global/ shared/documents/events/2012/Bali%20 Global%20youth%20Forum%20Declara- tion%20FINAL-1.pdf). Bigger picture The Bali Declaration wouldn’t have been such an extraordinary document if it wasn’t a part of a bigger picture and an integral part of the review process for the International Conference on Population and Development (ICPD).The review process measures progress made on the commitments made by 179 states in the Programme of Action agreed to at the ICPD conference in Cairo in 1994. Of the three phases of the ICPD review process, the second and third will feed directly into the making of the new development agenda. This will happen with the report on the implementation of the ICPD by the Secretary General and will feed directly into the High Level Meeting on the Millennium Development Goals (MDGs) in 2013 and the MDGs Summit in 2015. The ICPD beyond 2014 is identified as a source for setting key priorities in the Post-2015 UN develop- ment agenda. The two processes are therefore closely interlinked throughout the different phases, which is a strength as the Bali Declaration is a crucial tool for putting young peoples’ rights at the heart of development. Bali Declaration outcomes The participants at the GYF in Bali worked in subgroups on the 5 different topic areas (see below) and produced sets of recommendations by discussion leading to consensus. The results from the thematic sessions were compiled into the final declaration, which contains 70 recommendations and cuts into 5 differ- ent sections, which are: • Staying Healthy, • Comprehensive Education, • Families, Youth Rights, Well-Being and Sexuality, • The right to decent work, and • Leadership and Meaningful Youth Participation. First of all, the document recognizes that young people have full autonomy over their own bodies, pleasures and desires, emphasizing a positive approach to sexuality. This means that no cultural and religious barriers should prevent access to family planning, safe and legal abortion or other sexual and reproductive health services. While abortion is still illegal in many countries, including in Europe, the huge coalition of young people in Bali urged governments to decriminalize abortion and ensure safe pre- and post- abortion services for young people. We put a strong emphasis on univer- sal access to comprehensive education, including comprehensive sexuality educa- tion (CSE), at all levels. CSE should be provided in a non-discriminatory, non- judgmental, rights-based, age appropriate and gender-sensitive way through part- nerships between governments, NGOs, private sector and civil society, and through equal partnership with young people in the development, implementa- tion and evaluation of programmes. We also created a definition of a modern family that is evolving, inclusive and ensures the right of everyone to form a family, regardless of sexual orientation and gender identity, free from stigma and discrimination. This particular issue regards people in many European coun- tries, who cannot today register their civil partnership or marriage. Another important recommendation is the necessity of involving the most mar- ginalized and vulnerable youth, includ- ing people living with HIV and Lesbian, Gay, Bisexual, Transgender, Queer or Questioning and Intersex individuals, alongside other marginalized groups, in the decision-making processes. Next steps For a new development framework to succeed, sexual and reproductive health and rights (SRHR) need to be crosscut- ting in all other fields of work. Denial of SRHR is affecting the most vulnerable people in all aspects of life and creates a barrier to their ability to contribute to development. Poverty alleviation and sustainable development require a solid sexual and reproductive rights framework which reaffirms the indivisible human rights of all people. The Bali declaration is a great road map for the way we have ahead of us. The priorities in the Bali Declaration are clear. We as young people specified what needs to be done to fulfill our needs. The responsibility of delivering on the needs stated in the Bali Declaration lies not only on the UN but also all national states. We need for them to understand the impor- tance of meaningfully including young people in every aspect of development. We also need for them to understand that for this to happen, all young people need to access our SRHR. Along with governments taking action, we as young people need to realize the importance of demanding our rights. We must put our foot down and let decision TAKING THE BALI DECLARATIoN FoRWARD: yoUTH AND THE DEvELoPMENT AGENDA No.73 - 2011 15 8 3 Jakub Skrzypczyk Magnhild Bøgseth makers know which issues are important for us, and that our rights need to be fulfilled. The Bali Declaration was revolutionary in several ways. It was the first real inclu- sion of young people in the ICPD review process, both because young people took part in all stages of the event itself and be- cause young people for the first time had their proper space in the ICPD process. At the same time we as young people need to be careful in believing that our voices have been heard by the GYF being organ- ized - and that this is good enough. We must not take our rights for granted. Yes, we do have them written in a document - and this is for sure an important step. To keep going, we need to make sure that the Bali Declaration is in- cluded in ongoing processes. We need to present it to media and decision makers and we need to make sure they follow up their commitments and promises. We also need to make sure that the young people that were not at Bali - the people who we as youth delegates were representing - are aware of the result and feel ownership and commitment of taking it forward to their peers and authorities at all levels. We must bear in mind that having one youth conference is not enough. It is a good start, but it can never be a substitute for having young people involved in a meaningful way in ongoing processes at every stage. Our opinions are not only words from a wrinkle-free face, but a voice to be respected and listened to - which is what young people’s meaningful involvement should be. What now? The GYF was the first conference ever in the history of the UN processes, where young people, having ownership over the meeting, agreed upon a vision of how the world leaders should shape the international development agenda in order to fulfill young peoples’ most important needs. Young people must always have the opportunities to speak independently about their needs, not only in the international processes, but on a regular basis, where we can provide input and shape policies at all levels. The GYF can serve as an excellent example of how young people can be meaningfully engaged in decision-making processes. The Bali Declaration must not become another document in the bottom of the pile. We are now at the point where the new development agenda for the years to come is being set. We must make sure that our rights are made a priority - taking the Bali Declaration forward is the best way to make it happen. Magnhild Bøgseth, GyF Delegate, magbogseth@gmail.com Jakub Skrzypczyk, GyF Delegate, jskrzypczyk@hotmail.com Image 1. Global Youth Forum in Bali. Photo: Ivens Reis Reyner 16 Source: By Choice, Not by Chance. Family Planning, Human Rights and Development. State of the World Population 2012. New York: UNFPA, 2012. THE ICPD AGENDA IN EURoPE TWo DECADES AFTER CAIRo: PRoGRESS AND REMAINING GAPS Two decades after the International Conference on Population and Development (ICPD) adopted an ambitious Programme of Action in Cairo in 1994, it is time to take stock of what has been achieved and identify areas where further work needs to be done. In the sub-region comprising Europe, central Asia and North America, the United Nations Population Fund (UNF- PA) and the United Nations Economic Commission for Europe (UNECE) have led a comprehensive process of consulta- tions, debates, data collection, research and analysis.* The ultimate aim of this process is to identify, and build consensus around, key priorities to be addressed in the Region in the years and decades to come. What has emerged from the process so far is that the big picture, by and large, is positive. People generally live longer, healthier lives and have higher levels of education than past generations. Many countries in the eastern part of the Re- gion have struggled with the consequenc- es of often painful transition processes af- ter the collapse of communism. However following a sharp decline in the 1990s, key indicators such as life expectancy and fertility have stabilized and even show a modest upward trend again. Fertility levels overall have remained low in most countries of the Region, with a few notable exceptions such as Turkey, Cyprus and central Asia. Yet even in countries with high levels of fertility, a trend towards smaller families can be observed. As a result of increasing longev- ity and low birth rates, populations are ageing across the Region, in some cases rapidly. A number of countries see their populations shrinking. Increasingly com- plex migration movements have helped mitigate some of the effects of ageing in countries of destination, but exacerbated these effects in countries of origin, in par- ticular in eastern Europe and central Asia. Low fertility levels, ageing societies and immigration are often presented as threats in the public discourse, raising fears of economic decline and instability. Yet experts speaking during the consulta- tion process agreed that such fears are largely unfounded. With proper prepa- ration for the anticipated population dynamics, societies can prosper despite negative population growth and larger proportions of older persons or migrants. Two aspects are key in this regard, the experts said: 1) investing in “human capital,” i.e. in the education, health, work opportunities and productivity potential of all people in society and 2) putting human rights and respect for the repro- ductive choices of the individual at the centre of policy development. Pronatalist policies ignoring these principles are not only problematic in light of human rights standards, but are also likely to lead to costly failure. For much of the past two decades, inequalities have been shrinking in most of the countries of the Region. There are indications that this trend has been reversed in some countries, following the economic and financial crisis that has af- fected the Region since 2008. As many in- dicators reflect national averages, the true extent of poverty often remains hidden in the statistics, in particular with regard to disadvantaged population groups such as children, youth, older women and some ethnic minorities. Economic inequality is compounded by social exclusion and discrimination in many countries, affecting groups such as migrants and ethnic minorities such as Roma. Although legal frameworks have been improved significantly, in practice gender stereotypes still prevent women from equal participation in society and perpetuate violence and other malprac- tices such as child marriage in some areas. A key area affected by the negative consequences of inequality and social exclusion is access to sexual and repro- ductive health. Although now gener- ally well-regulated in laws and policies across the Region, there remain political, cultural and social barriers to universal access to sexual and reproductive health, in particular for young people and for disadvantaged groups such as Roma. Maternal mortality has generally declined over the past two decades, in particular in the new EU member states. For example, Estonia has achieved a decrease from 48 to 5 deaths per 100 000 live births (1). Mortality rates are still high in the Caucasus and central Asia, but they are falling in these sub-regions as well. The United States was one of the few countries in the Region with an increase between 2000 and 2010 (1). The number of teenage pregnan- cies is also on the decline in the Region, although differences are still significant (with a rate in Switzerland of less than 1 percent, and more than 10 percent in Bulgaria, Romania, Azerbaijan and Georgia) (1). In the eastern part of the Region, where the decrease has been most No.73 - 2011 17 8 3 Jens-Hagen Eschen- bächer High school students in Bucharest, Romania, read a leaflet about condoms. ©Panos/Peter Barker. Source: By Choice, Not by Chance. Family Planning, Human Rights and Development. State of the World Population 2012. New York: UNFPA, 2012. significant, this is likely to be a result of a more efficient and more frequent use of contraceptives, as statistics show that abortion rates among teenagers have not increased. In fact, abortion rates have been declin- ing significantly in the Region, although they remain high in a number of coun- tries in eastern Europe. In the Russian Federation, for example, there are almost 600 abortions for every 1000 live births (down from 1550 in 2000) (1). One of the most troubling negative trends in the Region is the increase in HIV prevalence rates. Over the past two decades HIV prevalence nearly doubled from 0.25 to 0.41, making this the only world region where HIV is still on the rise (1). Injecting drug users, men having sex with men and young people below 24 years of age, as well as their partners, are at particular risk in the Region. Participants in the consultation meet- ings agreed that achieving universal access to sexual and reproductive health must remain a top priority in the Region. Following the 1-2 July Geneva confer- ence, the results of the regional ICPD Be- yond 2014 process, including recommen- dations on how to address the remaining gaps, will be conveyed as input for the UN Secretary General’s global report to be delivered at a Special Session of the UN General Assembly in 2014. They will also feed into the process of developing a new development agenda for the time after the Millennium Development Goals (MDGs) expire in 2015. In the Region, the ICPD Beyond 2014 and MDG post-2015 processes have already served to galvanize thousands of people who have used this once-in-a- lifetime opportunity to contribute their views and ideas on how they wish their societies to look like in the future. It is now up to the governments in the Region to take the emerging updated population and development agenda forward and reflect it in legal frameworks, policies and programmes in line with the principles agreed on two decades ago in Cairo – towards a Region where every pregnancy is wanted, every child birth is safe, and every young person’s potential is fulfilled. * The “ICPD Beyond 2014” process in the Region consisted of consultations in several countries of the Region, three Regional expert meetings, Regional forums involving youth representa- tives and parliamentarians, a Regional high-level conference (to be held in Geneva on 1-2 July 2013), as well as two major studies: “Population Trends and Policy Responses in the UNECE Region: Outcomes, Policies and Possibilities”, UNFPA and Wittgenstein Centre for Demographic and Global Human Capital, 2014 (forthcoming), and “ICPD Beyond 2014: The UNECE Region’s Perspective”, UNECE and UNFPA, 2014 (forthcoming). Jens-Hagen Eschenbächer, Regional Communications Advisor UNFPA, Istanbul, Turkey, eschenbaecher@unfpa.org References 1. Population Trends and Policy Respons- es in the UNECE Region: Outcomes, Policies and Possibilities. UNFPA and Wittgenstein Centre for Demographic and Global Human Capital, 2014 (forthcoming). 18 FRoM LoCAL To REGIoNAL – ASTRA AS AN ExPERT oN SExUAL AND REPRoDUCTIvE HEALTH AND RIGHTS IN CENTRAL AND EASTERN EURoPE Our history ASTRA – the central and eastern Eu- ropean Women’s Network for Sexual and Reproductive Health and Rights is a regional network created in 1999 in Warsaw, by 10 NGOs from central and eastern Europe (CEE). The idea to start a regional network came from experi- ences at the UN where women from CEE countries felt that their issues were not sufficiently recognized or addressed. The network’s initial aim was to develop a regional strategy and organize advocates and activists around common goals, noting the importance of civil society in raising awareness, both in the public and political sphere, and the need to link the women’s reproductive rights movements throughout the Region. Subsequent strategy sessions have taken place over the years and membership has grown from the original 10 to 31 organizations from 19 CEE countries including Caucasus and Balkan countries in 2013. Central and eastern Europe today ASTRA sits at the intersection of two critical issues: sexual and reproduc- tive health and rights (SRHR) and the uniquely challenging political, economic and social situation in the Region, which in the last 22 years has been affected by political and economic transition, ethnic conflicts, revival of nationalism and growing religious fundamentalism. Coun- tries in the Region have also experienced the resurgence of conservatism with tra- ditional visions of societies, families and gender roles. All of these trends produce a hostile environment for and towards SRHR alongside gender inequities and inequalities. Furthermore, the Region does not gar- ner much international attention, leaving many of the issues unheard and over- looked. As economies move forward and more countries accede to the European Union (EU), it is an absolutely critical issue that SRHR are respected, promoted and advanced in all EU Member States and accession countries, as well as, neigh- boring countries. Status of SRHR in CEE countries The current status of reproductive health across the Region varies widely, though the aforementioned adverse factors tend to be more uniform across borders. In many countries, access to information, education and services is so limited that many women use abortion as a method of family planning. Yet in other countries, the influence of religion and tradition is slowly but surely chipping away at wom- en’s rights, putting restrictions on abor- tion or making it inaccessible even when liberal laws exist. The use of modern contraception remains low, due largely to the lack of education and availability (including price). Comprehensive sexual- ity education and services for adolescents are substantially restricted and the Region has some of the highest rates of teenage pregnancy, teenage abortion and sexually transmitted infections (STIs), including HIV, among young people. Crumbling health care systems as a result of political transition led to both privatization and increases in costs of services, two insurmountable barriers in access to care for the majority of women. As a result the health inequity gap be- tween the rich and the poor is growing, just as it is between western Europe and eastern Europe. The Women’s movement in CEE Civil society organizations, including the women’s movement, are still very few in this Region as organizing within civil so- ciety was not tolerated until the collapse of communism. Women’s groups still need to be strengthened in order to adjust to the ever changing political and eco- nomic climate. Currently many of these groups are non-sustainable, lacking skills, knowledge, experience and resources. Engaging at the national, regional, and international levels with a collective voice provides opportunities for change and sends a message to political leaders and health care providers that the right to health is essential to the fulfillment of other human rights, that SRHR are fun- damental human rights and that restrict- ing access is a violation of these rights. As a network of NGOs from the Region, ASTRA is uniquely positioned to strive for these goals with an acute un- derstanding of CEE’s political, economic, and social context. ASTRA’s Mission “Sexual and reproductive health and rights constitute fundamental human rights, form a vital aspect of women’s empowerment and are key to the achievement of gender equality”. Strategies The principle of “think globally; act lo- cally” is ASTRA’s natural way of working. The strategies include: • public education about sexual and reproductive issues (especially good practices in international medical and human rights standards) to which women should have access; • advocacy for the improvement of national policies regarding SRHR, including governments obligations and international commitments; and • informing governments, international institutions and societies about the status of women’s reproductive health in the Region, including reporting discriminatory laws and policies. Fourteen years from ASTRA’s incep- tion, thank to its events, conferences, numerous publications, position papers and other forms of regular advocacy, the network has been recognized by many international institutions such as the European Parliament, the European Commission, many UN bodies and agen- cies including the WHO, UNFPA, UNDP and other civil society partners. ASTRA’s role in the International Conference on Population and Development (ICPD)+20 process The ASTRA Network’s overall objective is to ensure that SRHR is meaningfully included in the post-2015 development framework. The Region has failed to use the ICPD as a framework to build a sustainable architecture to promote and protect women’s SRHR. The social and economic upheaval that took place in No.73 - 2011 19 ` 8 3 Krystyna Kacpura CEE in the 1990s has brought declin- ing economic conditions and increasing inequality throughout the Region. As a result, 20 years after Cairo, women die unnecessarily due to unsafe abortion, pregnancy, or childbirth and many more women suffer due to the lack of access to quality health services including family planning and modern contraception methods. The ASTRA Network is currently en- gaged in the ICPD Beyond 2014 process that is crucial for the assessment and the future implementation of the ICPD Pro- gramme of Action in the new develop- ment agenda. Key activities have included: • Together with 5 international net- works ASTRA was engaged in the preparation of the ICPD+20 Global Report on the Status of Sexual and Reproductive Health and Rights in the Global South. The Network also published its Regional Report, “Status of Sexual and Reproductive Health and Rights in Central and Eastern Europe” (available at http://www.astra.org.pl/ pdf/publications/ICPD_20.pdf (1). This report filled a substantial gap as the CEE Region was previously excluded from ICPD review process; • The ASTRA Network prepared the Global South Regional Youth Inter- vention Factsheet on Adolescents and Young People’s access to SRHR in CEE (available at: http://http://www. astra.pl/youth) (2) that will help in shaping youth development policy after 2015; • The Network launched the Warsaw Call to Action (available at: http:// www.astra.org.pl/pdf/wcta.pdf), a document representing CEE coun- tries and NGOs interests and role in shaping development policy after 2015; and • ASTRA was recognized as a key representative on SRHR of the Region in the international process headed towards shaping the post-2015 devel- opment agenda, including: 1. ASTRA Youth was chosen as a part of the Steering Committee of the Global Youth Forum in Bali; 2. The ASTRA Network joined 2 important initiatives as represent- atives, the Global Interfaith and Secular Alliance for Sexual and Reproductive Rights and health and the Civil Society Platform to Promote SRHR beyond 2015; 3. ASTRA Youth was invited as a Regional expert to the ICPD beyond 2014 civil society and young stakeholders consultation organized by UNFPA in Istanbul, Turkey; 4. The representative of ASTRA Net- work presented the SRHR issues in CEE during the public hearing on SRHR in the European Parlia- ment. The hearing was organized by the European Parliament’s Committee on Women’s Rights and Gender Equality; 5. The ASTRA Network in partner- ship with the Eastern European Alliance for Reproductive Choice was selected by the WHO to take forward a central and eastern European Health Consultation post-2015, as part of a global con- sultation process. The outcome report (available at: http://www. astra.org.pl/pdf/publications/ HealthConsultationReport.pdf) features SRHR as one of the main priorities for any future health goal and target in the post 2015 agenda in CEE; 6. An ASTRA representative partici- pated in the High Level Dialogue on Health - the culmination of the global consultations on health held in Botswana - to ensure that SRHR issues were included in the final document; 7. An ASTRA representative partici- pated in the Global Civil Society Consultations at the UN High Level Panel meeting in Bali, pre- senting a statement (available at: http://www.astra.org.pl/pdf/state- ments.pdf) during the roundta- ble discussion on women’s rights and the post 2015 development framework; 8. An ASTRA representative at- tended the second UNFPA and UNECE Thematic Meeting “Inequalities, Social Inclusion and Rights” in Belgrade as a SRHR expert and was asked to present the outcome of that meeting at the upcoming Regional Confer- ence in Geneva (1-2 July 2013); 9. An ASTRA representative at- tended the 3rd UNFPA and UN- ECE Thematic Meeting “Families, Sexual and Reproductive Health over Life Course” in Bucharest; 10. At the Women Deliver Confer- ence in Kuala Lumpur, Malay- sia, ASTRA was invited to be a speaker at the European Regional Caucus; and 11. An ASTRA Coordinator was selected to serve on the reference group for the preparations of the ICPD Beyond International Thematic Conference on Human Rights (the Netherlands, 7 – 10 July 2013). Conclusion ASTRA’s strong and active engagement with the ICPD Beyond 2014 process on every stage at both the regional and international levels will help ensure that the ICPD Beyond 2014 agenda and the broader post-2015 development agenda advance the realization of women’s SRHR without discrimination in CEE Region. Krystyna Kacpura, Executive Director, ASTRA Network, Warsaw, Poland krystyna_k@astra.org.pl References 1. Reclaiming & Redefining Rights - ICPD+20 Report: Status of Sexual and Reproductive Health and Rights in Central and Eastern Europe. Warsaw: ASTRA, 2012. 2. Eastern Europe Region Fact Sheet: Set- ting the Adolescent and young people SRHR Agenda Beyond ICPD+20. Warsaw: ASTRA, 2012. 20 IMPLEMENTING THE ICPD AGENDA IN KyRGyzSTAN: A GLASS HALF FULL Photo 1. Validation workshop. 19 years ago, along with 179 other states, Kyrgyzstan adopted the ICPD Pro- gramme of Action (PoA) and agreed to put human rights at the heart of any efforts to improve the quality of lives of all individuals and achieve sustained economic growth and development. The adopted PoA gave renewed promi- nence to education, particularly of girls, as an agent of change. It stressed the importance of reproductive health, gen- der equality and women’s empowerment. And it gave wide and systematic recogni- tion to the role of non-governmental organizations. As we approach the target date of 2014, progress on key human rights elements of the ICPD agenda in the Kyrgyz Republic has shown a steady growth of 5.1 percent per annum in recent years (2003-2008), but poverty remains widespread as more than 31.7 percent of the population lives below the poverty line and the govern- ment remains challenged in delivering basic services, particularly in rural areas (1). The unstable situation in global markets and the lack of sustainability in the development of some sectors of Kyr- gyzstan’s economy jeopardize the progress that has been achieved. Serious concerns exist with respect to the health sector. Infant and child mortality have been declining, but at a rate slower than needed and there has been a worrisome increase in the number of deaths among newborns due to lack of medical as- sistance and low quality of care (25 cases per thousand) (1). However, insufficient resources have been made available to implement the national Reproductive Health strategy 2006 – 2015 and there are no mechanisms for integrated sexual and reproductive health (SRH) and HIV plan- ning at the operational level. These shortcomings are also based on a general political instability as Kyrgyzstan experienced significant political changes with government turnovers in March 2005 and April 2010. The Ruling coali- tion has been re-established three times since parliamentary elections in 2010. Since 2010 the Cabinet of Ministers has changed four times. The structure and function of the government has changed at least five times. The latest changes in the function and structure of the govern- ment took place on March 5, 2013. The adoption of a wide range of laws and programmes highlight the govern- ment’s aim to achieve the ICPD goals in Kyrgyzstan. Yet, the constant political turnover has had a direct impact on the implementation of the existing legislation and many important international com- mitments (including in the area of ICPD 21 No.78 - 2013 Ramona Lupu Tolgonai Berdi- keyeva Meder Omurza- kov Photo 2. Validation workshop. issues) that have not been able to be put into practice. In addition to the above outstanding challenges, the compounding effects of economic and other crises have brought to the surface important new challenges in making young people in Kyrgyzstan a priority and meeting their needs in terms of health, education and employment. Moreover, emerging issues stemming from critical population dynamics such as urbanization, ageing and migration, also have had an impact on the country’s sustainable development. The government approved a national youth policy in 2012; however raising youth issues at the national level did not automatically translate into real commit- ment and support as youth participation in the decision making remains limited. Women are represented in the Parlia- ment based on a 30% quota system. However, actual representation of women in the Parliament is 21%. The major problems in the area of women’s political participation include that women con- tinue to have limited legislative, execu- tive and administrative powers. They are under-represented in decision-making bodies, there is a lack of women’s issues in the country’s policies, lack of political leadership capacity development op- portunities for women, a lack of training possibilities for women to strengthen their leadership capacity and a lack of financing. Kyrgyzstan: ‘ICPD BEYOND 2014’ Review Process Background and rationale In December 2010, the UN General As- sembly extended the ICPD PoA beyond its 20-year deadline of 2014 and called for a comprehensive global review of its achievements since inception. The review involved a formal and systematic Global Survey underway in 194 countries. As mandated by the UN General As- sembly, the United Nations Population Fund (UNFPA), in cooperation with relevant UN and international organiza- tions, institutions, and experts – conduct- ed a Global Review of the 1994 ICPD PoA in Kyrgyzstan. The results of the Review provided a robust report of what worked and where gaps remain in how the coun- try can best focus efforts and move faster to a world where everyone enjoys a better quality of life with dignity. In order to present the current state of Kyrgyzstan’s population (5.6 million peo- ple) and its development, progress made, gaps and challenges and priorities for the future – the UNFPA Country Office provided the Government of Kyrgyzstan with technical support in completing the ICPD review process in 2012. The UNFPA Kyrgyzstan Country Office’s objectives were twofold: 1) to support the government in ensuring wide participation of national stakeholders in the ICPD review and timely submission of a consolidated national response to the regional commission; and 2) to help as- sess national progress on implementation of the ICPD PoA. Process In June 2012, the UNFPA Country Of- fice informed the government of the upcoming ICPD review and discussed the establishment of a national mechanism for filling out the questionnaire. At the same time, in order to ensure a wider participation, the review process also involved interviews and focus group meetings with national experts, non- governmental organizations (NGOs) and youth organizations on pertinent sections. The UNFPA helped identify na- tional experts, NGOs and youth organi- zations in different fields using its own partners and partners of other develop- ment agencies. A half-day national validation work- shop took place on the 23 October 2012. All respondents and other key individu- als who could contribute to validating national responses were invited to attend. Participants were divided into seven working groups, which corresponded roughly to the thematic structure of the questionnaire (see photos 1-3). Challenges and results Just days after the final version of the questionnaire was made available in Rus- sian and ready to be implemented, a new government came into power following the break-up of the majority coalition in Parliament. A major challenge was garnering the commitment of the new government officials for the ICPD review process in a very short period of time. Although the incoming government officials were not new to the issues under 22 IMPLEMENTING THE ICPD AGENDA IN KyRGyzSTAN: A GLASS HALF FULL (ContInuED) Photo 3. Validation workshop. discussion, many of them were unaware of their relationship to the ICPD. Thus, the process served as an important advo- cacy effort among the new members of the government. The ICPD questionnaire was complet- ed on schedule despite a very short time frame (2 months), which was regarded as the major challenge. ICPD Beyond 2014 Analysis of the review tools submitted by the governmental partners indicated that they have made considerable efforts to address the ICPD PoA objectives on all themes, as well as the related MDGs. However, given the limited resources and efforts in governance, challenges remain in areas such as poverty and economic development, financial investments in maternal and child health programmes and political commitment. It is apparent that most of the ICPD PoA and MDG objectives are not likely to be achieved by 2014/2015 unless Kyrgyzstan commits itself to renewed efforts in programme implementa- tion. Kyrgyzstan has made remarkable achievements in the ICPD PoA and MDG objectives in terms of policy formulation, development of appropriate legal frame- works and adoption of relevant interna- tional instruments. These include those derived from UNFPA initiatives (UNFPA supported the development of the ‘Law of the Kyrgyz Republic on Reproductive Rights’. Adopted in 2001, this is the first such law in the Commonwealth of Inde- pendent States). Since 2004, Kyrgyzstan has moved forward to set up new institutions and strengthen existing ones; and also de- signed national and sectoral programmes and plans to address the various dimen- sions of population – poverty, gender, youth, access to health and SRH services, family planning, education, etc. Overall, the ICPD review also notes the wide gap that exists in Kyrgyzstan, between population-related policies and their actual implementation. Barely two years to the end of the ICPD and MDG programme cycles (2014 and 2015, respectively), the prognosis for achieving the objectives of the ICPD and the targets of the MDGs is generally not reassur- ing (see image 1). Time is limited and population issues are generally difficult to turn around in the short term. However, strategic or targeted planning, coupled with financial commitment, could still achieve much within a short time. While national conditions vary, the outcome of this review suggests that renewed focus by the Kyrgyz Government could galvanize the country’s lackluster move toward 2015. As a follow up, the results of the ICPD review will be used as the basis for pre- paring a National ICPD Report in 2014. Conclusion Participating in the Global IPCD review has been instrumental in highlighting both the positive actions taken by the Government of Kyrgyzstan to implement the ICPD PoA and the gaps and challeng- es that remain. Knowing these gaps is es- sential in order to ensure that Kyrgyzstan is able to position itself appropriately in the post 2015 development agenda to ensure improved health and well-being, including SRH, for all. Meder Omurzakov, MD, Assistant Representative, UNFPA, Kyrgyzstan Ms. Tolgonai Berdikeyeva, National Programme Analyst on Population and Development, UNFPA, Kyrgyzstan Ms. Ramona Lupu, Communication and Resource Mobilization Consultant UNFPA, Kyrgyzstan For correspondence please contact: lupu@unfpa.org.kg References 1. Millennium Development Goal (MDG) Progress Report in the Kyrgyz Republic. Bishek: UNDP Kyrgyzstan, 2011. 23 No.78 - 2013 Based on the ICPD questionnaire that was used to assess progress scores for each area of implementation were developed, on a scale from 1-4. The scoring system is as follows: •   1 - Not enough progress has been made in this area, •   2 - Behind the plan in terms of implementation, •   3 -According to the plan in terms of implementation, and  •   4 - Ahead of the plan in terms of implementation. The image provides an overview of the progress Kyrgyzstan has made in implementing the PoA from Cairo in select areas. Image 1. 24 Background At the 1994 Conference on Population and Development in Cairo, leaders from 179 countries reached consensus on a group of population and development goals, of which sexual and reproductive health and rights featured prominently. Ukraine was one of the 179 countries that pledged to implement the Cairo Programme of Action, which focused on sustained economic growth in the context of sustainable development; education, especially for girls; gender equality and equity; infant, child and maternal mortality reduction; and the provision of universal access to reproductive health services, including family planning and sexual health. This article highlights the progress made in addressing infant child and maternal mortality reduction in the Ukraine since the Cairo ICPD, through implementation of the National level programme “New Life - New Quality of Mother and Child Health Care,” of which the WHO Beyond the Numbers (BTN) approach is a key component. The legacy of past health care system After collapse of the Soviet Union, the Ukraine inherited a health care system which was overly centralized with a focus on inspections and punitive prac- tices. The area of maternal and child health (MCH) was characterized by over medi- calization of care with numerous manda- tory prenatal visits to doctors, tests, spe- cialist referrals and unnecessary lengthy hospitalizations. Furthermore, lack of adherence and trust in evidence-based medicine with a tendency for “expert” opinions to dominate over scientific facts, as well as, the continuous bureaucratic process of changing regulations and rules, characterized MCH care in the country. As a result despite access to skilled care, key MCH indicators lagged behind those of western Europe. On the positive side, however, there was great interest and commitment of both health care practitioners and managers in improving the MCH situation and in reversing the negative MCH health indicator trends. Transformations in health care for mothers and babies over the last decade Over the last 15 year years several large- scale donor supported programmes have been implemented in the Ukraine. The support and advocacy of the UN Agencies – the WHO, UNICEF and UNFPA- have played a pivotal role in introducing a number of remarkable changes in the outdated MCH health care system. Two key fundamental areas were addressed: 1) to make the system more client and family oriented and 2) to promote care, based on evidence-based medicine. Modern perinatal technologies were widely introduced into practice and many potentially harmfully practices were replaced with those based on evidence. New evidence based clinical guidelines were developed and endorsed by the Ministry of Health (MoH). At the national level positive changes in the area of reproductive health, including MCH care culminated in the adoption by the Government of the Ukraine of “The Reproductive Health of the Nation State Programme (2006-2015).” The Programme set a target of maternal and infant mortality reduction by 20% with antenatal care for pregnant women set for the level of 98%. In 2010 the President of the Ukraine, as part of the Health System Reform initi- ated the National Project “New Life - New Quality of Mother and Child Health Care”. Its main investment focus is to establish a network of well equipped regional peri- natal health care centres to provide high quality care for patients with perinatal risk, especially low birth weight babies. The UN Agencies and development partners (UNDP, UNICEF, UNFPA, Swiss Agency for Development and Coopera- tion (SDC) and WHO) joined the initiative and declared that their priority area of support and contribution would be quality of care improvement, further promotion of knowledge, use of modern perinatal technologies and adherence to evidence based medicine. In this context both the UNFPA and WHO included BTN as part of their com- mitment towards support of the project. They also used the New Life platform to dialogue with the national counterparts on a perinatal reform strategy and to continuously advocate for the need to discontinue punishment-based practices of addressing maternal mortality and morbidity cases. The BTN launch in the Ukraine: slow but promising The BTN methodology was introduced in the Ukraine by the WHO country office at the national BTN workshop held in the Ukraine April 22-25, 2008. At the end of 2010 the BTN implementation process received new impetus when the SDC and the UNFPA joined the initiative. The UNFPA Country office in the Ukraine included implementation of BTN into its new Country Programme for 2012-2016. In September of 2011 a technical workshop was organized on Confidential Enquiries into Maternal Deaths (CEMD) and Near-Miss Case Review (NMCR), with health care practitioners from all over the Ukraine. Great interest in the approach was invoked at this workshop and a number of follow up actions were identified with key milestones, all of which would need to be preceded by an Order (“prikaz”) of the MoH to establish the legal framework for BTN implemen- tation. While the order for NMCR went through, unfortunately, in spite of de- clared commitments, the order on CEMD is still pending approval by the MoH; thus support for implementation of CEMD has been put on hold. NMCR piloting from initiation to mid-term review In September 2011 a technical workshop was held to introduce the BTN methodo- logy. At this meeting it was also agreed to start implementation in four pre-selected pilot maternities: Kiev Perinatal Centre, Lugansk city Maternity, Lviv Perinatal Centre, and Zhytomir Perinatal Centre, INTRoDUCING BEyoND THE NUMBERS IN THE UKRAINE: LESSoNS LEARNED No.78 - 2013 25 Anastasiya Dumcheva Pavlo Zamostian Valentina Kolomey- chuk Nuzhat Ehsan based on their long experience of success- ful implementation of effective perinatal technologies and systematic use of na- tional and local standards and protocols. Through on-site visits of international experts, the teams in these centres were trained to conduct reviews and formulate local clinical standards of case manage- ment and selection criteria for cases. A NMCR mid-term review and super- visory mission occured in November of 2012. The review found that most critical elements of the methodology were captured and well-practiced by the teams. It was noted however, that the teams still needed to improve their practice of detailed analysis of causes of problems in identified deficiencies of care and to formulate effective and feasible solutions and recommendations. Some standards of case management also needed revi- sion. In many cases midwives and nurses were not invited to the meetings. It also emerged that some national protocols (guidelines) of care required revision to be compliant with global evidence based recommendations. NMCR annual review and scaling up plans The annual review took place in May of 2013, led by a team of international and national experts including a national NMCR coordinator. The review identi- fied lessons learned, recommendations for advancement of the NMCR process and its sustainability, as well as, identified facility-based indicators of the effective- ness of NMCR. Following visits to the pilot materni- ties, a one-day review meeting with key personnel from the pilots was organized. Challenges, lessons learned and good practices were discussed. Following this, MoH managers and experts, regional health care authorities and regional peri- natal healthcare centres were invited for a dissemination workshop where results of the one year NMCR piloting experience were shared. At this workshop, through interaction with the teams from the four pilot maternities and with guidance from experts, the next steps required to kick-of the NMCR process in the newly estab- lished perinatal health care centres were jointly defined. First lessons learned from the NMCR piloting process: • The NMCR methodology is not sim- ply a know-how approach; it envisag- es cultural changes in the mindsets of health care managers and providers in the manner that they communicate, analyze, draw conclusions and imple- ment actions. These core features makes it invaluable for strengthening team work, identifying lost opportu- nities and improving quality of care; yet, the requisite cultural changes take time and require much more time than a one-year project implementa- tion; • Piloting is a necessary step for in-country implementation. As recommended by the WHO, NMCR implementation should be started from a piloting process supported by international expertise. Doing so allows the methodology to be adapted to country specific settings and de- monstrates its advantages and useful- ness for further advocacy purposes; • Piloting is a lengthy process and con- tinuous technical support in terms of international expert supervision for greater than 1 year may be required; • Ensuring “political” support and commitment at the national and regional/pilot maternity level was instrumental for the success of the piloting process. Linkage with ambi- tious perinatal health care reform initiated by the top leadership of the Ukraine was used effectively as an advocacy platform to ensure that sup- port was present for both piloting and for scaling up and dissemination of the methodology; • The piloting of the NMCR helped identify numerous issues in the area of MCH care at the facility and national level, such as gaps in national clinical guidelines, gaps in adherence and use of evidence-based effective perinatal technologies, gaps in essen- tial drugs and equipement i.e. blood for urgent transfusions and attempts to hide certain cases/conditions due to continued fear of punishment. Thus, linkage of the NMCR imple- mentation to larger initiatives in sup- port of perinatal health care reform would be beneficial; and • The scaling-up strategy should be considered carefully with realistic esti mates of the international exper- tise required and existing national capacities. Developing national exper- tise to support the scaling-up process are among the most important tasks of the piloting phase and investments in capacity development of national experts should be part of the support project. Conclusion Since the landmark ICDP Conference in Cairo, held nearly 20 years ago, the Ukraine has demonstrated commit- ment to implementing its Programme of Action, especially in the area of MCH. The experience and lessons learned from implementing the BTN approach has been instrumental in helping the Ukraine identify both the successes and challenges that need to be addressed in continuing to work towards sustainable development and health for all. Nuzhat Ehsan, UNFPA Representative for Ukraine, Country Director for Belarus, Valentina Kolomeychuk, Deputy Head of MCH division, Ministry of Health of Ukraine Pavlo Zamostian, Assistant Representative, UNFPA Country office Ukraine Anastasiya Dumcheva, National Programme officer, WHo Country office, Ukraine For correspondence contact: ehsan@unfpa.org 26 Family Federation of Finland’s Sexual Education experts handing out condoms to youth at festivals. THE 1994 INTERNATIoNAL CoNFERENCE oN PoPULATIoN AND DEvELoPMENT (ICPD): PAST AND FUTURE FRoM A FINNISH/NoRDIC PERSPECTIvE Background In 1994, Finland was among the 179 countries that approved the ICPD Pro- gramme of Action. Based on its national experience Finland has long understood the central- ity of gender equality, promotion of the status of women and girls, education, health care services, including sexual and reproductive health and the realization of sexual rights for all, in achieving develop- ment. These issues have been part of the Finnish development policy and coopera- tion long before the ICPD. However, the Finnish government welcomed the ICPD Programme of Action and considered it, in its progressiveness, as a remarkable achievement and took its implementa- tion seriously. In its official ICPD report the Ministry for Foreign Affairs stated: “…. the comprehensive approach of the Programme of Action with its new termi- nology holds also Finland accountable. … After the ICPD we (Finnish government) have emphasized the implementation of the ICPD Programme of Action among inter- governmental organizations, governments and civil society. …. The concrete respon- sibilities set in the Programme of Action for donor countries to reach a certain level of aid for the support of the reproductive health programmes in the development countries are also binding Finland.” The term “sexual and reproductive health and rights (SRHR)” was actively launched in Finnish national and interna- tional policy. The concept of “population” took a major shift towards the context of human rights, individual choice, women’s and girls’ empowerment and the universal right to SRHR. The ICPD and its Pro- gramme of Action were a watershed event and revolutionary document that affected both global development discussions and implementation everywhere, including influencing changes in the Finnish politi- cal and financial commitment towards SRHR. The ICPD, Väestöliitto – Family Federation of Finland and the Finnish government After the ICPD, Väestöliitto – Family Federation of Finland, which is the Inter- national Planned Parenthood Federation (IPPF) Member Association of Finland, started to advocate in a structured way for global SRHR in Finnish development policy and cooperation. In 1995, shortly after the ICPD, The Finnish All-Party Group on Population and Develop- ment was established within the Finnish Par liament on Väestöliitto’s initiative. Väestöliitto has acted as the Group’s ad- viser since then. The relationship between the Ministry for Foreign Affairs and Väestöliitto intensified after the Confer- ence and Väestöliitto has been instru- mental in raising the awareness of the civil servants on the ICPD’s Programme of Action, especially SRHR, and keeping them firmly on the Finnish development agenda. It has also served as an adviser for No.78 - 2013 Hilkka V uorenmaa Dan Apter 27 “Hey, ask me about sex!” – The backs of the Family Federation of Finland’s experts engage the public for a dialogue about safe sex. Picture taken at Provinssirock festival in June 2013. the Ministry for Foreign Affairs on global SRHR issues. The Finnish political commitment for global SRHR has remained strong throughout five successive governments and its funding for SRHR has been steadily increasing. Finland’s support to international SRHR is allocated primarily through the UN system. Most of the sup- port is directed to the UNFPA. In addi- tion Finland has been a steady supporter of the IPPF. On a global level, since the European Union (EU) has enlarged to the present 27 Member States, it has become increas- ingly difficult to find consensus on SRHR issues. For example, many countries, such as Malta and Poland, have opposed the inclusion of sexual rights in EU docu- ments since joining the EU. Among the Nordic countries, Finland, in addition to other likeminded countries, has been pivotal in the fight to keep SRHR on the European and global agendas. This has meant that more often than not the EU has been split in its decision making and no joint agreements have been found where SRHR are concerned. Fortunately, joining forces with likeminded countries outside Europe, especially with those from the Global South, has strengthened and enforced the likeminded front in international negotiations. On the domestic front, in Finnish domestic policy, issues mentioned in the Programme of Action, such as sustainable development, women’s empowerment and gender equality, vulnerable and mar- ginalized group and addressing the needs of adolescents and youth have been very much the focus. For example: • The Ministry of Social Affairs and Health published in 2007 a national action programme for promotion of sexual and reproductive health 2007-2011. It was a comprehensive document with many good ideas, but the implementation has been rather limited. Saving costs in health care has instead been the dominating theme. A revision of the program for sexual and reproductive health 2013- 2020 is now in preparation; • We have seen both ups and downs in sexuality education. In 2004 sexuality education was renewed and since then comprehensive sexuality has been provided in schools by trained teachers. Among other key indicators, use of contraception has increased and adolescent abortion rates de- clined; and • The population of Finland is aging rapidly, with the largest birth cohorts retiring in 2012-2013. Fertility in the Nordic countries is rather high in European comparison at 1.8-1.9, al- though having children is postponed rather late and many families remain childless. Women’s share of the labor force is equal to that of men’s work and through childcare and other ser- vices it has been possible to combine work and family. In Finland we now have a positive correlation between the income and education of the mother and having children. Thus, while some achievements have been reached since 1994, it is difficult to evalu- ate the possible role and/or contributions the ICPD Programme of Action played in these successes. In closing In 2014 it will have been 20 years since the 1994 ICPD and its landmark Pro- gramme of Action. At the same time, in 2015, the Millennium Development Goals will also reach their deadline for imple- mentation and assessment of progress. The present time thus represents a pivotal opportunity for the international com- munity, including the UN organizations, governments, civil society, foundations, private sector, etc., to take stock of what has been accomplished, what remains to be done and what direction needs to be taken in order to ensure that SRHR remains an integral part of the post 2015 development agenda. Finland will con- tinue to participate in this process to en- sure that the new global framework, while still a work in progress, continues to build on the principles so clearly articulated in the Cairo Programme of Action. We are living in a historical period in time, where big decisions concerning the future of our planet are going to be decided. It is pivotal that no one is left behind! Dan Apter, MD Chief Physician & Director, The Sexual Health Clinic, väestöliitto - Family Federation of Finland Hilkka Vuorenmaa, Senior Advocacy officer, The Sexual Health Clinic, väestöliitto - Family Federation of Finland For correspondence contact: dan.apter@vaestoliitto.fi Werner Haug 28 On these pages are a few quotes from individuals who were present at the 1994 International Conference on Population and Development (ICPD) in Cairo in answer to the question “What did the ICPD in Cairo mean for you personally and professionally?” “Cairo was a watershed in history: countries agreed that development is not about numbers, it is about choice, rights and sustainability.” “The most exciting part of Cairo was the preparatory process of the ICPD Programme of Action which saw the involvement of civil society organizations and women’s move- ments on an unprecedented scale. “ “After Cairo, population policies changed. Instead of fixing quan- titative targets for fertility decline and distribution of contraceptives, they started focusing on the rights of women and girls, education and information, choice and quality of reproductive health services.” Werner Haug, UNFPA Regional Director, Eastern Europe and Central Asia “ICPD in Cairo for me, an obste- trician and gynaecologist, who had just started to understand the importance of public health poli- cies, legal frameworks and diversity of values, was eye opening. In 1994 I was a President of the newly established Latvia’s Association of Family Planning and Sexual Health and as such I was invited to join the governmental delegation of Latvia. It turned out that ICPD was just the beginning, followed by nu- merous activities in my country and globally, such as the Women’s Conference in Beijing, ICPD+5 in the Hague and New York and many others. As a member of a very active non-governmental organiza- tion and as the Chair of Depart- ment of Obstetrics and Gynaecol- ogy in the Riga Stradins University, I tried to accelerate the progress in implementation of the Programme of Action of ICPD in my country. Presently, during the last 10 years as a WHO staff member, I am actively involved in assisting 53 countries of the European Region to monitor progress in achieving universal access to reproductive health, to analyze remaining gaps and to overcome them. Despite the huge progress during these 20 years, some issues are still very topical or have become more obvious. A recent financial crisis has increased sexual and reproductive health inequalities and much more should be done to decrease them.” Gunta Lazdane, MD, PhD, Programme Manager, Sexual and Reproductive Health, Division of Noncommunicable Diseases and Life-course, WHO Regional Office for Europe “It was a very important event for all further development. I did not understand in 1994 why people cannot find consensus in such simple and obvious matters as saving lives of women, but I learned a lot both in Cairo and afterwards. And now I better understand why attitudes towards family planning, fertility regulation and other areas of sexual and reproductive health and rights are so different in differ- ent cultures and groups of people. Good progress has been achieved in decreasing maternal mortality but there remains lack of progress in other areas of sexual and repro- ductive health (SRH,) despite the inclusion of the 5B target in the Millennium Development Goals. Polarization of the attitudes to- wards SRH and rights seems even bigger today. In fact, at times it ap- pears as if nowadays it may be even more difficult to find consensus. The definition of reproductive health of ICPD includes choices – free choice based on information. For me this is very important and crucial. I always start my lectures on reproductive health with an explanation of this definition and reproductive rights. Personally I see reproductive health as part of sexual health, but I do understand that globally cultural traditions cause other approaches and requires us to talk mostly about reproductive health and not sexual health.” Prof.Helle Karro, Head of the Depart- ment of Obstetrics and Gynaecology, Faculty of Medicine, University of Tartu, Estonia – member of the governmental delegation of Estonia WHAT DID CAIRo MEAN To ME? No.78 - 2013 Tomris Türmen Meri Khachi- kyan Ingar Bruegge- mann Helle Karro Gunta Lazdane Werner Haug 29 “As a contemporary witness of the Cairo Conference on Popula- tion and Development 1994, I can say with full confidence that until today - 19 years later - it was the most important conference, I at- tended in my almost three-decades- long work for the WHO, next to the WHO-UNICEF Conference on Pri- mary Health Care in 1978 in Alma Ata. For me, the Cairo Conference created a new consciousness of the subject of Sexual and Reproductive Health and Rights (SRHR). It was important and also courageous to have articulated the “Programme of Action” which has by no means lost its validity. It is the basis for all issues, still relevant for the activities related to the Population Dynamics in the 21st Century. From 1995 to 2002, I was the Director-General of the International Planned Parent- hood Federation in London, an ideal situation to join the Strategic Plan of IPPF with the ICPD Pro- gramme of Action. In the ten years after my retire- ment, the subject continues to play an active role in my voluntary work, in which I concentrate on in- forming youth about their SRHR as well as methods of family planning. I strongly hope that these SRHR programmes and related services, particularly for adolescents, are given high priority in the “post- 2015 agenda”. Ingar Brueggemann, Vice-Chair, Rotarian Action Group for Population and Development “Cairo is a very important step in my life. I have several certificates of participation in different meetings but I only keep one on my wall: this is the certificate of participation in Cairo.…….After Cairo something changed in my personal attitude – I felt responsibility – not only for my family, my clients, but also for peo- ple who are living in my communi- ty, in our country and also around the world. When we returned back from Cairo I realized that we need- ed to do something at country level immediately….that same month together with the Deputy Minister of Health we decided to initiate the National Programme on Reproduc- tive Health for the County……..We proposed this National Programme which was supported by the WHO, UNICEF and UNFPA…..It was the first programme and after this everything started: establishment of family planning cabinets all over the country, research on reproduc- tive health, and then each five years we were repeating this research to look at the dynamics, introduc- tion of a client friendly approach, integration of sexual and repro- ductive health services with HIV/ AIDS services. I think we made a lot of good steps forward towards Cairo, but still many issues are not resolved.” Dr Meri Khachikyan, Member of the Armenian Delegation in 1994, Current Director Pan-Armenian Family Health Association “For me, personally it was an exciting experience because I lived it – I was in the debates with the conservative governments, with the NGOs, so it is as if it is yesterday. Suddenly we had a new paradigm, which is reproductive health, it is not sexuality, not gynaecological disorders but something that really encompassed the whole spectrum of one’s life. So SRH was an eye opener for all of us who knew the issues but at the same time couldn’t articulate it so clearly. So we had this big umbrella: women’s issues, violence against women and the need to invest more in those issues. I think it was a very big step for- ward – it was almost as if we went into an enlightened stage where we could identify individuals rather than seeing them as a big faceless group of people that lived on this planet.” Prof. Dr. Tomris Türmen, Represented the WHO in 1994, Currently President, International Children’s Center, Bilkent, Ankara, Turkey 30 RESoURCES By Choice, Not by Chance. Family Planning , Human Rights and Development, UNFPA, 2012. This report analyzes data and trends to understand who is denied access to family planning and why. Building on the ICPD Programme of Action this report asserts that governments, civil society, health providers and communities have the responsibility to protect the right to family planning for all women, including those who are young or unmarried. Available in English, French, Russian, Arabic and Spanish at: http://www.unfpa.org/public/home/publications/pid/12511 Towards a Post-2015 Development Framework. Position Paper. EuroNGOs, IPPF EN, Countdown 2015 Europe, ASTRA Network, 2013. A position paper developed by the SRHR community, the principles outlined provide a shared vision for how NGOs can work together and individually to ensure that the post 2015 development agenda has a strong and explicit focus on SRHR. Available in English at: http://www.astra.org.pl/publications.html Reclaiming and Redefining the Rights. ICPD+20: Status of Sexual and Reproductive Rights and Health in Central and Eastern Europe, ASTRA Network, 2012. This report reflects on the progress made and the challenges encountered in the implementation of the Cairo ICPD Programme of Action in central and eastern Europe and, based on these, formulates strategic goals for the ICPD’s agenda beyond 2015. Available in English at: http://www.astra.org.pl/publications.html Making Reproductive Rights and Sexual and Reproductive Health a Reality for All, Repro- ductive Rights and Sexual and Reproductive Health Framework, UNFPA, 2011. The framework builds on the goals of the 1994 Cairo ICPD and summarizes progress achieved since then, identifies major remaining gaps and priorities and outlines principles and approaches for programme planning and implementation. Available in English at: http://www.unfpa.org/public/home/publications/pid/7602 Vision 2020 Manifesto, IPPF EN, 2013. IPPF EN’s ten point call to action, this document invites partners in the development community to work together to ensure that SRHR play a central role in the post 2015 development agenda. Available in English at: http://ippf.org/sites/default/files/v2020_manifesto_en_web.pdf Sexual Rights, An IPPF Declaration, IPPF EN. This abridged version, to be used in conjunction with IPPF’s original Sexual Rights Declaration, is grounded in and informed by international agreements. Essential reading for understanding how SRHR relates to all development. Available in English at: http://ippf.org/resource/Sexual-Rights-IPPF-declaration-abridged ICPD at 15 – Report, Looking Back, Moving Forward, UNFPA, 2011. Published following the ICPD +15 review process, this report is a valuable reference source that highlights previous progress and contributes to the discourse on development and rights. Available in English at: http://www.unfpa.org/public/home/publications/pid/7236 31 No.78 - 2013 Lisa Avery Healthy Expectations Celebrating Achievements of the Cairo Consensus and Highlighting the Urgency for Action, UNFPA, 2009. Issued in commemoration of the first 15 years of the 20-year Programme of Action adopted at the ICPD in Cairo, it maps out progress, highlights disparities and calls attention to areas where accelerated action is needed. Available in English at: http://www.unfpa.org/public/home/publications/healthyexpectations World Reaffirms Cairo, Official Outcomes of the ICPD at Ten Review, UNFPA, 2005. This report shares the declarations, resolutions, and action plan from the official reports of the review meetings of the implementation of the Programme of Action of the ICPD at ten years, held between 2002-2004. Available in English at: http://www.unfpa.org/public/home/publications/pid/1347 International Conference on Population and Development - ICPD - Programme of Action A/CONF.171/13/Rev.1 -- Report of the International Conference on Population and Development, UNFPA, 2005. This official document from the 1994 ICPD in Cairo is essential reading and demonstrates how the conference firmly recognized reproductive health and rights, as well as women’s empowerment and gender equality, as cornerstones of population and development programmes. Available in English at: http://www.unfpa.org/public/home/publications/pid/1973 Useful websites ICPD Beyond 2014: www.icpdbeyond2014.org ICPD Global Youth Forum: http://www.icpdyouth.org/ 7Billion Actions: http://7billionactions.org/ Vision 2020: http://ippf.org/vision2020 UNFPA: http://www.unfpa.org/public/ Upcoming Events ICPD Review International Conference on Human Rights, 7-10th July, The Hague http://icpdbeyond2014.org/key-events UNECLAC Regional Population Conference 12 to 15 August 2013, Montevideo, Uruguay http://icpdbeyond2014.org/key-events The European Magazine for Sexual and Reproductive Health WHO Regional Office for Europe Division of Noncommunicable Diseases and Health Promotion Sexual and Reproductive Health (incl. Maternal and newborn health) UN City Marmorvej 51 DK-2100 Copenhagen Ø Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 www.euro.who.int/entrenous