Thanks very much for sending the draft strategy paper. I read it with interest and congratulate you on the content.  I think it's a very strong statement and very reassuring to all of us in the SRHR community.  We especially appreciate the mention of IPPF and our inclusion in the Danish Government's strategic plan.  I attach a copy with some editorial suggestions - mostly in the first part of the paper. In addition, I did want to say that we hope you might include a few more references to IPPF in your discussion of the Thematic Actions, particularly the sections on young people and on linking SRHR and HIV/AIDS activities. Considering that these subjects, along with access (including RH commodity security), lie at the heart of the "5 A's" and that IPPF has been playing a leading advocacy and services role, I thought a mention of how well IPPF's priorities and strategies line up with Denmark's might be possible.  Also, you mention in several places Denmark's expectations regarding UNFPA leadership. I believe IPPF plays a comparable role on the NGO side and that we are willing and able to take on hard issues (e.g., youth services and abortion) that UNFPA won't touch.  Indeed, the best reason to support us is that we can do what UNFPA, working mostly with and through governments, can not.  That creates great synergy between UNFPA and IPPF and makes a strong case for continuing to work closely with us both. Again, congratulations on a very nice job.  I hope the present version survives the review process more or less intact and that it isn't watered down. Warm regards, Steve Steven W Sinding Director General International Planned Parenthood Federation 4 Newhams Row London SE1 3UZ phone (dl): +44 (0)20 7939 8250 fax: +44 (0) 20 7939 8330 email: [email protected]

Strategy for the Promotion of Sexual and Reproductive Health and Rights -- 24-01-200620-01-200618-01-200618-01-200605-01- 200604-01-200620-12-2005 ii Draft The Promotion of Sexual and Reproductive   Health and Rights Strategy for Denmark’s Support  

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft i Foreword.................................................................................................ii 1.    Summary .......................................................................................... 1 2.    The ICPD Programme of Action ................................................. 332 3.    Promoting Social Development ................................................... 554 A Rights-Based Approach .............................................................................................554 Sexual and Reproductive Health and Rights...............................................................554 HIV/AIDS .....................................................................................................................665 Gender Equality .............................................................................................................665 Education ........................................................................................................................776 Children and Young People  .........................................................................................776 4.    Strategic actions at International and National Level ................. 998 Danish International Cooperation – strategic actions ...............................................998 Country Level – strategic actions........................................................................... 111110 5.    Thematic actions......................................................................131312 Promoting Gender Equality and Empowering Women – MDG 3................... 131312 Improving Sexual and Reproductive Health – MDG 5...................................... 141413 Young people: Access to information and services............................................. 181817 Linking the Response to HIV/AIDS with SRHR/MDG 6 .............................. 212120 Research for Planning and Action......................................................................... 232322 6.    Achieving Results - from Words to Action..............................242423 Annex 1: ICPD Goals and Millennium Development Goals..................................................262625 Annex 2: Selected Current and Proposed MDG Indicators....................................................282827 Annex 3: International organisations mandated to promote SRHR ......................................292928 Box 1: The Eight Millennium Development Goals............................................................................ 1 Box 2: Reproductive Health...............................................................................................................332 Box 3: Sexual and Reproductive Rights............................................................................................554 Box 4: Women’s Empowerment .......................................................................................................776 Box 5: Human Sexuality and Gender Relations ........................................................................131312 Box 6: The Size of the Problem...................................................................................................171716 Box 7: The Situation of Young People.......................................................................................191918 Box 8: Geracao Biz........................................................................................................................202019 Box 9: Ways of Linking SRH and HIV/AIDS..........................................................................232322

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft ii Foreword People’s   sexual   and   reproductive   health   and   rights   are   fundamental   for   promoting development,  fighting  poverty  and,  thus  for  achieving  the  Millennium  Development  Goals (MDGs). At  the  September  2005  World  Summit,  heads  of  government  committed  themselves  to achieving  the  goal  of  universal  access  to  reproductive  health  by  2015.  They  committed themselves to integrating this goal into strategies to attain the MDGs, including those aimed at improving maternal health, promoting gender equality, reducing maternal and child mortality, combating HIV/AIDS and eradicating poverty.   This commitment is not new. In 1994, 179 governments agreed to achieve the goal of universal access  to  reproductive  health  by  2015  at  the  International  Conference  on  Population  and Development (ICPD) in Cairo. But it the reaffirmation at the World Summit wasis crucial. It has rightly mainstreameds the ICPD-goal into the global consensus on how to reach the MDGs – a linkage widely neglected when the MDGs were introduced in 2000.    The commitment also  paves the way for including the key ICPD  goal of universal access to reproductive   health   information   and   services   (contraception)   in   the   MDG   targets   and indicators, and emphasizes the need to further strengthen implementation efforts if the goal of sexual and reproductive health and rights for all is to be reached by 2015.   Population issues and sexual and reproductive health and rights will remain high on Denmark’s Development agenda. We will draw on the 2005 World Summit momentum to advance the implementation of the ICPD Programme of Action and the principles and the rights it stands for. Only by empowering people to claim these rights will they emerge out of poverty.  

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 1 1.   Summary   Denmark is firmly committed to promoting sexual and reproductive health and rights for all.    Sexual and reproductive health is a human right, which is essential to good health and human development. For  Denmark, the rights issue is key. People should be able to  take their own decisions about their sexual and reproductive lives and have the means to do so. This includes access  to  reproductive  health  services  and  information  and  to  safe  and  to  legal  abortion. Enabling people to have fewer children, if they want to, helps to stimulate development and reduce poverty, both at the individual and the macro - economic level. Danish policy, support and cooperation within the field of population is based on the twenty- year Programme of Action (PoA) adopted by the International Conference on Population and Development  (ICPD)  in  Cairo,  1994  and  the  additional  goals  and  indicators  adopted  at  the Special Session of the United Nations General Assembly in 1999 (ICPD+5).   The full implementation of the ICPD PoA and ICPD+5 is central to the achievement of the Millennium Development Goals (MDGs), and thus to poverty reduction, which is the overall objective of Danish development assistance.   Box 1: The Eight Millennium Development Goals Goal 1: Eradicate extreme poverty and hunger Goal 2: Achieve universal primary education Goal 3: Promote gender equality and empower women Goal 4: Reduce child mortality    Goal 5: Improve maternal health   Goal 6: Combat HIV/AIDS, malaria and other diseases Goal 7: Ensure environmental sustainability Goal 8: Develop a global partnership for development The MDGs have a total of 18 targets and 48 indicators. The overall goal of this strategy is to contribute to the ICPD goal of universal access to sexual and  reproductive  health  and  rights,  including  for  youth.  With  the  MDGs  as  the  common framework   for   poverty   reduction   and   the   driving   force   for   international   development cooperation, the focus will be on contributing directly towards achieving MDG3, MDG5 and MDG6, as well as contributing indirectly to the achievement of MDGs 1, 2, 4 and 7 . Denmark will continue to cooperate with and support international organisations, governments and partners to promote and defend everyone’s right to sexual and reproductive health and to ensure   that   all   governments   and   other   partners   remain   committed   to   realizing   the internationally agreed goals and targets on sexual and reproductive health and rights.   This  strategy  recommends  actions  for  Danish  support  and  cooperation  at  the  International level and at country level, as well as strategic actions for Danish efforts within the following four thematic areas: Promoting gender equality and empowering women; Improving sexual and

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 2 reproductive  health;  Young  peoples’  access  to  information  and  services;  and  Linking  the response to HIV/AIDS and SRHR.  

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 3 2.   The ICPD Programme of Action The   1994   International   Conference   on   Population   and   Development   in   Cairo   moved population  policies  and  programmes  away  from  a  focus  on  human  numbers  to  a  focus  on human lives. It placed emphasis on improving the lives of individuals and increasing respect for their human rights. The twenty-year Programme of Action underlined the integral and mutually reinforcing linkages between population and development.   ICPD established a new agenda with three main themes: human rights, women’s empowerment and  sexual  and  reproductive  health  and  rights.  The  strength  of  the  new  agenda  was  in  its emphasis  on  the  empowerment  of  women  and  the  improvement  of  their  political,  social, economic,  and  health  status  as  a  highly  important  end  in  itself  as  well  as  essential  for  the achievement of sustainable development. It established that women’s rights are human rights. The ICPD objectives and goals are  sustained  economic growth in the context of  sustainable development; education, especially for girls; gender equity and equality; the reduction of infant, child  and  maternal  mortality;  and  the  provision  of  universal  access  to  reproductive  health services, including family planning and sexual health. Box 2: Reproductive Health Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide, if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health- care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. (ICPD Programme of Action Para. 7.2) A special session of the United Nations General Assembly (ICPD+5) was held in June 1999 to discuss progress and challenges in  the first five years  of implementing  the Cairo  Agreement. The  ICPD+5  document  gave  high  priority  to  reproductive  and  sexual  health  in  the  broader context  of  health  sector  reform.  It  stressed  the  need  for  involving  men,  making  sexually transmitted diseases, including HIV/AIDS, an integral component of SRH programmes at the primary health care level, and addressing the needs and rights of adolescents. New benchmark indicators were introduced for education and literacy, reproductive health care and unmet need for contraception, maternal mortality reduction and HIV/AIDS. In 2004, halfway through the ICPD Programme of Action, several international meetings were held  on  to  review  progress  and  challenges.  Progress  in  meeting  the  ICPD  goals  had  been considerable in some countries while there had been little or no change in others, especially in Africa. There were improvements in areas such as child mortality and girls’ access to education, but  other  areas  such  as  maternal  mortality  and  adolescents’  sexuality  had  not  received  the attention they deserved other than on paper. However, the general picture masked huge intra-

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 4 country  differences  between  regions,  districts  and  population  groups,  with  the  poor  and vulnerable being most disadvantaged with respect to their health status and rights.   Abortion  was  one  of  the  most  controversial  issues  at  Cairo  and  threatened  to  block  the consensus, but a compromise was reached by making it a matter for national decision-making. Unmarried  young  couples  or  individuals’  access  to  reproductive  health  services  including contraception and sexuality education and information were also controversial issues together with  acceptance  of  modern  family  patterns  and  the  resistance  to  public  interference  (vs. parental rights) in SRH matters and practice.   Growing  international  pressure  has  weakened  political  and  financial  support  for  sexual  and reproductive  health  and  rights.  Some  countries  are  reluctant  to  reconfirm  the  commitments they made in Cairo in 1994. This has made it difficult to move the political agenda on sexual and  reproductive  health  and  rights  forward  and  to  accelerate  progress  towards  the  full implementation of the ICPD PoA. Especially within the field of HIV/AIDS prevention, where condom  use  is  a  key  issue,  the  focus  on  abstinence  and  the  opposition  to  young  unmarried peoples’ access to condoms has lead to a backlash which threatens some of the hard-won gains of the ICPD and the Beijing Platform of Action.

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 5 3.  Promoting Social Development   A Rights-Based Approach   Danish  efforts  within  the  field  of  sexual  and  reproductive  health  is  based  on  a  rights-based approach,  which  views  citizens  not  as  passive  receivers  of  services  or  beneficiaries  of programmes  but  as  active  rights-holders.  States  have  obligations  to  respect  these  rights  and protect their citizens against violations. Fulfilling the right to sexual and reproductive health will require  the  building  of  responsive,  equitable  health  education  and  legal  systems,  as  well  as addressing underlying determinants of SRH. It implies that states, policymakers and others are accountable to their people. It is recognised that fulfilling these rights will require time, money, commitment and action.1 Box 3: Sexual and Reproductive Rights Reproductive rights embrace certain human rights that are already recognised in national laws, international human rights documents and other relevant United Nations documents. These rights rest on the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents. (ICPD Programme of Action. Para. 7.3) The Rights-based approach was reaffirmed and extended by the Fourth Conference on Women in Beijing in 1995: “human rights  of  women  include  their  right  to  have  control  over  and  decide  freely  and  responsibly  on  matters  related  to  their sexuality …”. This paragraph is regarded as setting forth a definition of sexual rights. (Beijing Declaration and Platform for Action. Para 96) International Legal Framework: 1.    Universal Declaration of Human Rights 1948 2.    The International Covenant on Economic, Social and Cultural Rights 1976 3.    The Convention on the Elimination of all Forms of Discrimination Against Women 1979 4.    The Convention of the Rights of the Child 1989   5.    UN Commission on Human Rights 2004 Sexual and Reproductive Health and Rights Promoting sexual and reproductive health and rights has high priority in Danish development assistance. It is an integral part of Danish multilateral and bilateral policy dialogue and support. Denmark  considers  it  an  important  –  and  necessary  -  task  to  actively  promote,  defend  and protect these rights. It is crucial for Denmark that the international commitments made and goals and targets set in the twenty-year Programme of Action (PoA) and at the Special Session of the United Nations General Assembly in 1999 (ICPD+5) as well as in the Beijing Platform for Action (1995) are under  no  circumstances  evaded,  renounced  or  in  any  other  way  weakened.  Danish  policy, support and cooperation within the field of population are based on these documents. There has  been  many  attempts  to  undermine  international  commitments  since  1994,  and  it  is foreseen, that also in coming years, there will be a continuous need to ensure that the Cairo- agenda, and the principles and rights it stand for, is actively confirmed and promoted as central and necessary element in fighting poverty and achieving the MDGs.  

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 6 Denmark  deliberately  uses  the  term  “sexual”  together  with  reproductive  to  underline  that sexuality  and  the  purpose  of  sexual  activity/relations  is  not  limited  to  reproduction.  This approach  is  rooted  in  the  belief  that  sexual  health  care  and  human  sexuality  are  also contributing  to  the  quality  of  life  and  well-being  –  both  mentally  and  physically  and  are enhancing personal relations.   Denmark  is  convinced  that  women  should  have  access  to  safe  and  legal  abortion  and  post abortion care. Without access to safe and legal abortions, women are not fully able to decide freely  on  matters  related  to  their  sexual  and  reproductive  health  and,  thus,  not  able  to  fully enjoy their human rights. Abortion should not be promoted as a method of family planning. Denmark  believes  that  the  best  way  to  avoid  abortions  is  through  improved  access  to reproductive health services and information and the empowerment of women.    In accordance with the ICPD-agenda, sexual and reproductive health and rights are promoted through  an  integrated  approach.  Sexual  and  reproductive  health  is  affected  by  the  socio- economic, cultural and political environment, and related to individual and collective rights and responsibilities.   Sexual   and   reproductive   health   and   rights   are   closely   interlinked   with promoting gender equality and fighting  HIV/AIDS. Increased understanding and acceptance of  this  will  serve   to  improve   synergies  and  impact  both  in  international  development cooperation and at country level. Danish  efforts  will  involve  broader  development  interventions  through  a  number  of  sectors that  impact  women  and  adolescent  girls’  health  –  not  least  education  of  girls.²  The  health sector, however, is the prime provider of the essential sexual and reproductive health services. It  is  essential  that  the  sector  has  the  capacity  to  meet  the  peoples’  needs  qualitatively  and quantitatively,   especially   with   respect   to   gender   and   protection   against   coercion   and discrimination.  Health  staff  has  a  proactive  role  in  informing  users  about  their  rights  and options in relation to reproductive health, fertility regulation, sexual abuse and violence, all of which are human rights issues. HIV/AIDS ³ Combating HIV/AIDS is a strategic priority for Danish development assistance, with special focus on Sub-Saharan Africa. The HIV/AIDS strategy of April 2005 aims to strengthen and focus  Denmark’s  contribution  towards  reaching  the  internationally  agreed  HIV  and  AIDS targets through its multilateral and bilateral development cooperation. Denmark supports the development  of  comprehensive  global  and  national  strategies  that  address  HIV/AIDS  in  a balanced  way,  inte-grating  prevention,  care  and  treatment  interventions.  Priority  areas  of intervention include addressing the specific needs of women and girls, adolescents and young people,   children   and   orphans   and   people   in   conflict   situations.   Integrating   sexual   and reproductive health and HIV/AIDS efforts, and fighting stigma and discrimination are other priorities. Gender Equality ⁴ Gender equality is a key crosscutting issue in Danish development assistance. The strategy on gender equality in Danish development assistance (2004) highlights three overall entry points to working with gender equality: promotion of equal rights, women’s access to resources and

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 7 equal influence. Empowerment is a key condition for enabling women to demand and make use of equal rights, resources and inJuence and thus for gender equality. Box 4: Women’s Empowerment Empowerment is a key condition for enabling women to demand and make use of equal rights, resources and influence and thus for gender equality. The concept implies that each individual acquires the ability to think and to act freely, to take decisions and to fulfil his or her own potential as a full and equal member of society. International  efforts  in  the  Keld  of  gender  equality  focus  in  particular  on  violence  against women during peacetime and situations of armed con Jicts, sexual and reproductive rights in relation   to   health,   HIV   and   AIDS,   and   access   to   resources.   The   strategy   emphasises mainstreaming  of  gender  equality  in  sector  support  and  in  national  Poverty  Reduction Strategies, and in the support for human rights, democratisation and good governance.   Promoting gender equality demands changes to existing power structures, the status and role of women and men. Men’s responsibility for supporting women’s SRHR is vast – as a decision maker,  father,  husband,  lover,  brother  and  son.  Men’s  participation  in  changing  women’s SRHR  is  far  more  important  than  previous  policies  have  reflected.  Violence  against  women, family planning, prevention of STI and respecting women’s rights are all related to how men and women interact. Women’s SRHR is highly related to the prevailing perceptions of women’s roles and rights in society and in the family, the more gender inequalities the poorer the SRHR of women. Education ⁵ It is well documented that girls’ education is a key instrument for empowering girls and women and for improving their SRHR, including the prevention of HIV/AIDS. Being in schools, even in schools of poor quality, is protective from a reproductive health standpoint – delaying sexual initiation, increasing chances of condom use, and decreasing forced sex.   At  the  same  time,  education  is  an  opportunity  to  teach  adolescents  girls  and  boys  life  skills including population, reproductive psychology and physiology issues. Denmark promotes life skills  education  as  part  of  the  standard  national  teaching  curricula  for  pupils  and  teachers. Danish  efforts  to  promote  girls  education  are  based  on  Education  for  All  -  The  Dakar Framework for Action and the United Nations Girls Initiative. Children and Young People ⁶ To  further  develop  its  assistance  to  children  and  young  people,  Danida  has  developed guidelines  to  secure  inclusion  of  children  and  young  people  the  various  sector  programmes when  appropriate.  They  list  the  main  priorities,  structured  according  to  the  Millennium Development  Goals  -  six  of  the  MDGs  refer  specifically  to  children,  as  they  point  to safeguarding the rights of children to health, education, protection and equality - and provide a course of action for follow-up and review. The guidelines also include a chapter about Children and  young  people  in  crisis,  conflict  and  injustice.  These  situations  make  children  and  young people  more  vulnerable  towards  sexual  violations  and  unsafe  sex.    UNICEF,  UNFPA  and Danish NGO’s are central partners for Denmark.  

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 8 In accordance with the guidelines, the terms youth and young people will be used for persons aged 10-24.

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 9 4.  Strategic actions at International and National Level Danish International Cooperation – strategic actions SRHR and the full implementation of the ICPD PoA will be promoted in international fora, agreements  and  resolutions.  Denmark  will  seek  to  influence  international  organisations  at  all levels and will fund work carried out by international organisations.   The   UN   Economic   and   Social   Council,   the   Commission   on   Human   Rights,   the   UN Commission on Population and Development, and the Commission on the Status of Women set political norms with respect to human rights and gender equality. WHO and UNESCO are standard setting organisations for health and education respectively, with a specific mandate to promote and monitor global norms and standards, and they also provide technical assistance to support   this   normative   function.   Influencing   these   political   and   technical   norm-setting organisations and fora to further promote SRHR and the implementation of the ICPD PoA is central to this strategy. The EU plays a vital role in promoting SRHR at the political level. Since Cairo, the EU has demonstrated strong political commitment to realising people’s SRHR. This commitment has been  supported  by  substantial  financially  contributions.  The  EU  has  been  influencing  the population agenda internationally and plays an important role in stemming ICPD-opposition. Not  least  at  the  2005 UN  World  Summit,  the  EU  played  an  active role  in  ensuring  that  the ICPD-goal  of  sexual  and  reproductive  health  and  rights  was  integrated  into  the  global consensus on how to reach the MDGs.  The Joint Statement on the European Consensus on Development,  adopted  in  November  2005,  fully  reflects  EU’s  strong  commitment  to  SRHR and the Cairo-Agenda, both as part of the common EU vision of Development and as part of the  EC  Development  policy.  EU’s  political  leadership  will  continue  to  be  crucial  for  the promotion of SRHR.   The major international organisations whose work contribute to promoting the Cairo Agenda and   the   implementation   of   the   ICPD   PoA   are   UNFPA,   WHO,   UNICEF,   UNAIDS, UNIFEM,  UNESCO,  EU  and  WB.  Important  international  non-governmental  organisations include  International  Planned  Parenthood  Federation,  Family  Care  International,  Population Council,  HIV/AIDS  Alliance,  Ipas  and  International  Women’s  Health  Coalition.  Also  a number  of  Danish  non-governmental  organisations  are  active  partners.  Annex  3  lists  central partners for Danish support and cooperation within the field of SRHR. Being responsible for monitoring the implementation of the ICPD PoA and being the world’s largest  international  source  of  funding  for  population  and  reproductive  health  programmes, UNFPA  is  a  strategic  partner  for  Denmark  in  the  implementation  of  this  strategy  –  at international and country level. UNFPA is an influential advocate for gender equality, women’s empowerment and reproductive rights together with prevention of HIV/AIDS among girls and women  and  prevention  of  the  mother  to  child  HIV-transmission.  In  addition,  an  important area  is  UNFPA’s  continued  efforts  to  build  national  capacity  to  manage  reproductive  health commodity security, with a long-term focus on building national capacity to take over this task.

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 10 Denmark  will  continue  to  support  and  further  strengthen  UNPFA  in  carrying  out  its  global leadership role in promoting and defending everyone’s right to sexual and reproductive health and  assisting  governments  and  other  partners  in  realizing  the  international  agreed  goals  and targets on sexual and reproductive health and rights - as an end in it self and as precondition for promoting development and fighting poverty, and thus for achieving the MDGs. To this end, it is important that UNFPA strengthens national authoritiesauthorities’ capacity to incorporate reproductive health and gender issues in the development of national PRS, health and   education   sector   programmes,   as   well   as   contributes   to   UN   harmonization   with government   SRHR   strategies   and   work   programmes.       To carrying out its global leadership role and to further advance implementation of the ICPD goal,  it  is  essential  that  UNFPA  cooperates  closely  with  and  is  supported  by  all  relevant partners.  Denmark  will  support  national  leadership  and  ownership  and  promote  cooperation among all partners and initiatives by being an active partner in coordination fora and sharing all relevant information with national and external partners. Furthermore, Denmark will encourage to the efficient and effective participation of multilateral donors in SWAps, harmonisation and in  simplifying  of  rules,  regulations  and  procedures  of  multilateral  organisations  as  well  as optimising  the  effect  of  donor  assistance  in  accordance  with  the  donor  harmonisation recommendations agreed upon in Paris in 2005.  

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 11 Country Level – strategic actions Ensuring universal access to SRH information and services will require strengthening of health, education and legal systems and the recognition by governments of their duties in this regard, including  through  increased  allocation  of  funds  for  these  sectors.⁷  Donors  also  have  a responsibility for supporting governments to do so. Increasing the power of citizens, especially the poor and marginalised, to make claims for education and health care is essential, as is an open   dialogue   on   controversial   issues   such   as   youth   sexuality,   abortion,   and   women’s empowerment in order to bring about real change.    Health and education systems in the developing world are pluralistic, with a variety of service providers in  the  government and non-government sectors.  In  most  developing countries the government  sector is by and large characterised by insufficient resources - financial, physical and human - and weak planning and management structures both at district and central levels, contributing  to  poor  performance.  Inequity  and  gender  inequality  are  major  problems,  with limited access to education and health care services in remote areas, and user fees acting as a barrier  especially  for  the  poor  and  for  women  who  do  not  have  access  to  money.  It  is government’s  responsibility  to  regulate  the  private  sector,  but  this  receives  low  priority.  The quality of services varies greatly both in the private and public sectors.   Changes in staff attitudes can be necessary to ensure that the staff’s own moral codes do not result  in  disrespectful/discriminatory  treatment  (for  example,  towards  orphans,  people  living with  HIV/  AIDS,  street  children,  marginalised  groups),  sexual  exploitation  of  young  people and  especially  girls,  or  denial  of  information  and  services  (such  as  sex  education  in  schools, contraceptives to adolescents and unmarried persons, abortion and post-abortion care).    The  increasing  “brain  drain”  of  qualified  health  and  education  personnel  to  industrialised countries poses a severe threat to developing countries. In Africa, this problem is worsened by the AIDS epidemic as well as the low wage levels, frustrating working conditions and lack of carrier  development  opportunities  in  the  public  sector.  The  “brain  drain”  is  also  related  to changes in industrialised countries, where fewer people find it attractive to work in the public sector. Addressing this problem will require actions both in developing as well as industrialised countries.   Denmark recognised early the need to strengthen public systems, including at the district level, and has supported health and education sector reforms and public sector reforms as part of its development   assistance.   Experience   has   shown   the   need   for   increased   emphasis   on collaboration with multiple partners within and outside the specific sector. Denmark continues to emphasize  the need  for equity,  not just in terms of access but also in terms of improved health and education status for the poor. In this context, it sees information technology as a powerful and as yet untapped resource for human development.

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 12

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 13 5.  Thematic actions Promoting Gender Equality and Empowering Women – MDG 3   MGD3 (gender equality and women’s empowerment) focus on equal access to education, the share of women in wage employment outside agriculture, and seats held by women in national parliaments.  In  addition  to  these,  Danish  assistance  will  also  reflect  the  broader  concerns  of ICPD   with   the   full   involvement   of   women   in   policy-   and   decision-making   processes, eliminating  all  forms  of  violence  against  women  and  ensuring  women  control  over  their fertility.  It  will  advocate  for  the  implementation  of  the  Security  Council  Resolution  1325  on Women, Peace and Security (October 2000), which urges increased participation of women at all  decision-making  levels  in  national,  regional  and  international  institutions  and  mechanisms for  conflict  prevention,  reconciliation  and  reconstruction  and  the  incorporation  of  a  gender perspective into peace-keeping operations.⁹ Discrimination against Women and girls            Women’s rights are human rights, yet women often have less access to food, land, education, employment,   resources   and   influence   than   men.   Though   177   states   have   ratified   the Convention on  the Elimination of All Forms of Discrimination  Against Women (CEDAW), there continues to be a gap between rights and reality in most countries, reinforced by gaps in laws and/or by cultural traditions and social, economic and political structures. Box 5: Human Sexuality and Gender Relations Human sexuality and gender relations are closely interrelated and together affect the ability of men and women to achieve and maintain sexual health and manage their reproductive lives. Equal relationships between men and women in matters of sexual  relations  and  reproduction,  including  full  respect  for  the  physical  integrity  of  the  human  body,  require  mutual respect and willingness to accept responsibility for the consequences of sexual behaviour. Responsible sexual behaviour, sensitivity  and  equity  in  gender  relations,  particularly  when  instilled  during  the  formative  years,  enhance  and  promote respectful and harmonious partnerships between men and women. (ICPD Programme of Action Para. 7.34) Numerous laws, policies and regulations affect sexual and reproductive health, including laws on  the  minimum  legal  age  of  marriage¹⁰,  access  to  contraceptives  and  abortion,  women’s consent  to  marriage and equal rights  to divorce. Women in  many countries do not  have the right to own and inherit land or to take loans and credit. In many countries women cannot seek health care for themselves or their children without the permission of their family (husbands, mothers-in-law, older and senior relatives), either for economic or cultural reasons.     Violence against Women Violence against women takes many forms and includes physical, sexual and emotional abuse by intimate partners, sexual exploitation or rape by close acquaintances (teachers, relatives and people in authority) or strangers, female genital mutilation/cutting, trafficking of women and children, forced prostitution, and sexual assault and rape in situations of armed conflict, civil unrest  and  disaster.  Studies  show  that  between  4%  and  20%  of  women  experience  violence during  pregnancy,  with  consequences  for  themselves  and  their  babies  such  as  miscarriage, premature labour and low birth weight.¹¹ Such violence is seldom officially reported, although one-third of all women in  the  world  experience violence.¹² Violence is  found in all layers of society,   though   aggravated   by   poverty.   Violence   generates   fear,   causes   physical   and

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 14 psychological damage and its specific consequences for sexual and reproductive health include unwanted pregnancy, unsafe abortion, chronic pain syndromes, sexually transmitted infections including  HIV,  and  gynecological disorders.  Gender violence arises  from  historically unequal gender  relations.  Changes  in  women’s  roles  can  be  threatening  to  men  and  it  is  therefore necessary to involve men in changing social perceptions of men’s and women’s roles. Promoting gender equality requires actions in the health as well as in other sectors. The latter are  addressed  in  this  section,  while  actions  in  the  health  sector  are  presented  in  section  5.2. Similarly, issues related to the health of young people are presented in section 5.3. Important  partners  for  promoting  gender  equality  and  women’s  empowerment  are  national governments including ministries of finance, law, education, health and local government, and civil society organisations. International partners are the Commission on Human Rights (CHR), Commission on Population and Development  (CPD), Commission on the Status of Women (CSW),  ECOSOC,  EU,  UNESCO,  UNFPA,  UNIFEM,  UNHCR,  World  Bank,  like-minded donors,  international  and  Danish  NGOs,  and  NATO  and  OSCE  for  peace-keeping  and security operations.   Improving Sexual and Reproductive Health – MDG 5   The fifth MDG is to improve maternal health. In 2005 this was the most off track MDG. The target is to reduce the maternal mortality ratio by three-quarters between 1990 and 2015. The indicators focus  on  maternal  mortality rates and the proportion of births attended by skilled birth personnel, Danish assistance will take a more comprehensive approach and will, thus, also address  abortion,  access  to  contraception  and  emergency  obstetric  care,  and  young  people’s rights to information and services, all of which are part of the ICPD PoA.   Maternal Mortality Pregnancy and childbirth continue to threaten the lives of a majority of the world’s women. Of all  the  human  development  indicators,  those  related  to  maternal  health  show  the  greatest discrepancy between developed and developing countries. Approximately 15% of all pregnant

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 15 women  and  girls  suffer  from  a  life-threatening  complication  which  cannot  be  predicted  or prevented through ante-natal care. Nationally representative surveys in Malawi and Zimbabwe suggest that the risk of pregnancy related death is eight to nine times higher in HIV-positive women.   To reduce maternal mortality, it is necessary to prevent unwanted pregnancy (through effective family  planning  services),  manage  unwanted  pregnancy  safely  (through  abortion,  where  legal, and universal post-abortion services) and prevent deaths from complications of pregnancy or delivery. Improving women’s access to  health  facilities, improving community recognition of obstetric  emergencies,  and  improving  the  ability  of  existing  medical  institutions  to  deliver quality obstetric care, are all necessary. However, services will continue to be under-utilised if they  are  perceived  negatively  by  pregnant  women  and  their  families,  as  the  poor  are  often subjected to rude and discourteous behaviour by staff.   Preventing pregnancy-related deaths requires a skilled attendant at delivery backed up by access to  24-hour  7-day-a-week  emergency  obstetric  care  services,  and  a  functional  referral  system with access to transportation. Evidence from the field has shown that the training of traditional birth attendants (TBAs) did not have a significant impact on the maternal mortality rate. It was also found  that antenatal care could not  predict obstetric complications occurring in  women without high-risk characteristics. The concept of a ‘skilled attendant’¹³ was therefore introduced in 1999 One of the indicators for MDG 5 is the number of births attended by skilled health personnel.   In most countries where maternal mortality is high, there are too staff with midwifery training  and  only  medical  doctors  are  authorised  to  carry  out  surgeries.  The  MDG  5 Task Force recommends changes in “scope of profession” regulations and practice to empower mid-level providers, including skilled birth attendants, to perform life-saving procedures safely and effectively. Poor health of the woman and inadequate care during pregnancy,  childbirth  and  the  postpartum  period  negatively  affects  the  health  and survival of her newborn. Abortion It    is    estimated    that    15%    of    all    recognised    pregnancies    end    in    a    spontaneous abortion/miscarriage, often incomplete and requiring post-abortion care. In many developing countries, abortion is a serious and neglected public health problem. About 45 million women seek abortion each year, 19 million of them in unsafe circumstances, and 40% of these unsafe abortions are performed on young women aged 15 –24 years.¹⁴ An average of 13% of maternal deaths are related to unsafe abortions, though for some areas this figure is as high as 25 – 30%.   Unsafe abortion is also associated with ill-health, such as infection and infertility.   While the unmet need for effective contraception contributes to this problem, it is important to recognise that unintended pregnancies also occur due to human error or contraceptive failure.   Deaths and ill-health due to abortion could be almost totally prevented through the provision of appropriate services. Even in countries where abortion is legal, there is limited awareness of

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 16 this, and access to abortion and post-abortion  care is limited. In countries where abortion is illegal, well-off women in cities are more likely to be able to access safe abortion, while poor rural women are forced to resort to unsafe procedures. Evidence from many countries shows that legalising abortion does not result in increased abortion rates.

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 17 Contraceptives Contraceptive services are the primary health intervention for preventing unwanted pregnancies and in the last fifty years there has been a steady rise in the demand for contraceptives both for preventing  pregnancy  and  the  spread  of  HIV/AIDS.  They  have  helped  reduce  the  global fertility  rate  from  5.0  per  women  in  1960  to  2.7  in  2001.  Since  then,  however,  the  ICPD- opposition has severely affected the availability of contraceptives in many developing countries. The Danish government is supporting the promotion of female condoms in its programmes in Africa,  both  for  HIV/AIDS  and  family  planning  and  has  also  increased  its  support  to UNFPA’s global programme to enhance reproductive health commodity security. Sexual and Reproductive Ill-health   There is need for a life-cycle approach to address women’s changing needs at different stages of their lives. Women of all ages suffer from sexual and reproductive ill-health, though the focus of  health  programmes  has  mainly  been  limited  to  certain  aspects  of  women’s  reproductive function. When it was demonstrated that HIV spread much faster in countries where STIs are common, syndromic treatment of sexually transmitted infections was introduced to men and women but had limited success especially in managing vaginal discharge syndromes in women. There  has  been  little  focus  on  other  reproductive  tract  infections,  though  they  are  also important for HIV prevention.   Box 6: The Size of the Problem Maternal mortality and morbidity About 530,000 women die of pregnancy-related causes each year,¹⁵ 99% of them in the developing countries. For every woman who dies, 30 others suffer from acute complications, in total 15 million women per year. The lifetime risk of dying in childbirth is 1 in 20 in Africa, compared to 1 in 2,800 in he developed regions. Sexual and reproductive ill-health Sexual and reproductive health problems account for 18% of the total global burden of disease and 32% of the burden among women in the reproductive age-group (15 – 44 years) worldwide, of which sexually transmitted infections including HIV, account for 16%. Pregnancy and childbirth-related morbidity and mortality for 12%.¹⁶ In sub-Saharan Africa, sexual and reproductive ill-health, including HIV/AIDS account for over 60% of the total burden. Abortion There are 45 million abortions a year, 19 million of them under unsafe conditions and nearly 70,000 deaths (13% of maternal deaths) are related to abortions. In Africa, 1 in every 150 abortions leads to death, compared to 1 in every 85,000 abortions in the developed world.¹⁷ HIV/AIDS HIV/AIDS accounts for 6% of the global burden of disease. There are nearly 40 million people living with HIV/AIDS, of whom 25 million live in sub-Saharan Africa. While worldwide, nearly half of those infected are women, in sub-Saharan Africa 57% are women.¹⁸ It is estimated that in 2003, only 8% of those in need of ART received it (4% in sub-Saharan Africa) and only 8% of pregnant women were offered treatment for preventing mother-to-child transmission.¹⁹ Other Sexually Transmitted Infections20 In addition, there are 340 million new cases of curable STIs each year in the reproductive age-group, many of which are not treated. Untreated infection increases the risk of HIV/AIDS by 10.

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 18 Unmet need for contraception43: 201 million women have an unmet need for effective contraception, including 64 million women who use traditional methods. Female Genital Mutilation/Cutting21 World wide 130 million girls and young women have experienced FGM/FGC. An additional 2 million are at risk every year. Fistula is a devastating problem for over 2 million young women caused by prolonged labour, immature childbearing resulting in incontinence, making them social outcasts. Female genital mutilation (FGM) and poor diet are contributing factors, while violent rape can also result in fistula. FGM is mainly found in Africa, and its long-term complications include infections, chronic pain and excessive growth of scar tissue as well as psychological suffering. Ending this traditional practice will require going beyond the health issues and addressing society’s cultural and social values.   The sexual and reproductive health needs of men received little attention in public health services until the HIV/AIDS epidemic brought them into focus. Men need more information on all aspects of sexual and reproductive health. Strategic Actions for Improving Sexual and Reproductive Health Important partners for improving sexual and reproductive health are national governments including ministries of finance, education, health and local government, and civil society organisations. International partners are EU, UNESCO, UNFPA, UNAIDS, UNICEF, WHO, World Bank, like-minded donors, international and Danish NGOs. Young people: Access to information and services²³ There  are  no  specific  millennium  development  goals  for  youth,  but  there  are  indicators  for primary education, HIV-prevalence among persons 15-24 years of age and their knowledge on

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 19 transmission of HIV/AIDS, proportion of orphans 10-14 years in school, and unemployment rates for male and female youth between 15-24 years.   Box 7: The Situation of Young People²⁴ Nearly half of the world’s population of 6.4 billion is under the age of 25. Some 1.2 billion people are between the ages of 10 and 19, 87% of them live in developing countries.   About 57 million young men and 96 million young women aged 15-24 in developing countries cannot read or write.   Worldwide, an estimated 352 million children between ages 5 and 17 were economically active in 2000, over 246 million of them working illegally and nearly 171 million in hazardous conditions. HIV/AIDS   An estimated 6,000 youth each day become infected with HIV — one every 14 seconds. The majority are young women. At the end of 2001, an estimated 11.8 million young people aged 15-24 were living with HIV/AIDS, of whom 7.3 million were young women. Only a small percentage of these young people know they are HIV-positive. Two-thirds of newly infected youth aged 15-19 in sub-Saharan Africa are female. More than 13 million children under age 15 have lost one or both parents to AIDS. The overwhelming majority of these AIDS orphans live in Africa.   Early marriage and childbearing 82 million girls in developing countries who are now aged 10 to 17 will be married before their 18th birthday. In some countries, the majority of girls still marry before their 18th birthday.   Worldwide, some 14 million women and girls between ages 15 and 19 — both married and unmarried — give birth each year. Pregnancy is a leading cause of death for young women aged 15 to 19 worldwide, with complications of childbirth and unsafe abortion being the major factors. For both physiological and social reasons, girls aged 15 to 19 are twice as likely – and girls under age 15 five times as likely to die in childbirth as those in their twenties.   Living on the margins The number of youth in the world surviving on less than a dollar a day in 2000 was an estimated 238 million, of whom 60 million were in sub-Saharan Africa. Each day, 5,000 children become refugees. (Children of both sexes are especially vulnerable to sexual abuse in conflict and emergency situations.) Global estimates of street children vary from 100 million to 250 million, and their numbers are rapidly increasing. The ICPD PoA was the first international document that recognised adolescents’ reproductive health needs. It was also the first time that governments were obliged “to protect and promote the  rights  of  adolescents  to  reproductive  health  education,  information  and  care  and  greatly reduce the number of adolescent pregnancies.” This was to take place with full participation by adolescents in the “planning, implementation and evaluation” of reproductive and sexual health information and services. To achieve this “countries should, where appropriate, remove legal, regulatory  and  social  barriers  to  reproductive  health  information  and  care  for  adolescents.” (ICPD PoA, Para. 7.45--7.47)

Strategy for the Promotion of Sexual and Reproductive Health and Rights – final draft 20 Yet young people constitute a group whose sexual and reproductive health needs continue to be  largely  ignored,  which  is  reflected  in  the  data  on  HIV/AIDS,  teenage  pregnancies  and deaths.  Adults  in  many  countries,  including  health  staff,  continue  to  disapprove  of  young people’s  sexuality  and  wrongly  believe  that  information  and  education  on  sex  will  promote sexual promiscuity. In addition, conservative forces are again promoting abstinence at the cost of access to information and services. Cross-generational  transactional  sex  (exchange  of  sex  for  gain,  ranging  from  consensual  to coercive relationships), is a growing problem due to poverty and unequal power relations. Married  and  unmarried  female  adolescents  face  different  problems,  with  the  former  being treated  more  like  adults  and  the  latter  as  children  who  should  not  engage  in  sex.  Married adolescents  are  often  isolated,  out  of  school,  and  away  from  familiar  social  networks,  with decisions regarding their health care being made by husbands or mothers-in-law. As they are expected  to  prove  their  fertility,  they  are  exposed  to  unprotected  sex.  Both  married  and unmarried adolescents lack knowledge and access to health services and contraception. Box 8: Geracao Biz In  Mozambique  only  5%  of  the  15-19  years  females  use  modern  contraception  methods.  The  high  rate  of  AIDS  and unwanted pregnancies along with the low rates of literacy threatens Mozambique’s productive capacity. About 85% of all girls have their first child before the reach the age of 19 years. This could continue for several decades if the youth is not targeted now to be change agents of the future.   “Geracao Biz” is a programme for adolescents and young peoples’ SRHR incl. AIDS prevention in and out of schools as well as a youth friendly health programme. UNFPA is coordinating the programme covering about 40% of Mozambique. A 2004 evaluation was positive and recommended the programme to scale up to cover the whole of Mozambique. “Geracao  Biz”  is  training  the  youth  to  perform  dramas  and  conduct  peer  education  with  the  aim  of  promoting  SRHR including  preventing  HIV/AIDS  via  counselling.  It  is  supporting  community  youth  groups,  developing  teaching  and information materials, training school teachers in facilitating SRHR knowledge to the school kids and training and equipping health staff to meet young peoples needs for SRHR services. The programme is implemented by an international NGO in collaboration with the three ministries Health, Education and Gender/Youth and Sport. The Scandinavian countries and Holland support the programme and plans for going to scale are developed. The  provision  of  genuinely  youth-friendly  services  through  designated  clinics  has  shown impressive results, but the problem lies in establishing sufficient numbers of clinics to meet the needs  of  such  a  large  population  group,  given  existing  financial  and  human  resources.    It  is therefore necessary to mainstream access for youth by changing attitudes of new and existing health staff and making all existing services youth-friendly. (This applies not just for youth but also for the poor and disadvantaged.) Young people are not a homogenous group, and programmes will therefore need to be tailored to meet the needs of different groups of youth (15 – 24) and young people (10 – 24). At the same  time,  it  must  be  recognised  that  they  are  both  resourceful  as  well  as  vulnerable.  Their genuine  involvement  in  programming  is  therefore  essential,  keeping  in  mind  the  successes achieved through peer-led programming. Important  partners  for  improving  sexual  and  reproductive  health  are  national  governments including  ministries  of  finance,  education,  health  and  local  government,  and  civil  society organisations, especially youth/young peoples’ organisations. Internationally, the Committee on