excellencies, distinguished guests, friends and colleagues, ladies and gentlemen.
here today to pledge the commitment of the World Health Organization to reproductive
health - a health priority into a new century.
I am here to lend our support to those committed women, men and constituencies who
speak out for the right of all people to lead a healthy reproductive life.
I am here to share with you our impatience. Cairo was a crossroads. A lot has happened
since 1994, but there is still a long way to go.
Today, a broader understanding of reproductive health is gaining ground. Reproductive
health deals with intimate and highly valued aspects of our lives. It reflects health in
childhood and adolescence. It sets the stage for health beyond the reproductive years for
both men and women.
It is about relationships, with its positive dimensions - closeness, fulfilment, the
opportunity to have a desired child. But there are the negative ones - disease,
abuse, exploitation, unwanted pregnancy and even death.
Why did it take us so long to understand the full importance of reproductive health?
Partly because these highly personal aspects of life are difficult to talk about openly.
But also because there have been cultural taboos - and because women have been denied
access to political, social and economic decision-shaping and decision-making.
Cairo was significant because it changed a lot of that. Our discussions there resonated
around the world. Since Cairo, a more open debate has been possible on adolescent
sexuality, on HIV/AIDS and on unsafe abortion.
Unless we can talk about the real challenges that we face - pandemics of sexually
transmitted diseases, adolescent pregnancies, sexual abuse, rape, and pregnancy-related
deaths and disabilities - we will never be able to address them, or to change the
Let there be no doubt. We will need decades of continued advocacy and action. WHO for
its part will speak out more strongly.
When we take stock of progress since 1994, there are positive changes - such as
the paradigm shift from population control to reproductive health and rights. There are
negative trends - such as a failing will to implement the Plan of Action and, not
least, the tragic lack of resources. And there are still needs crying out for urgent
attention - such as the challenge of adolescent sexuality and the tragedy of maternal
Let us consider the good things first. Cairo was a turning point because it placed
sexual and reproductive health within an ethical framework.
I want to be clear about this. Failure to address people's reproductive health needs is
a matter of human rights and social justice. People have a right to make free and informed
decisions about their reproductive lives. They have a right to information and care that
will enable them to protect their health and that of their loved ones. They have a right
to benefit from scientific progress in health care.
We must never forget the right to equality and nondiscrimination on grounds such as
sex, marital status, race, age and class. People have a right to privacy and to freedom
from sexual violence and coercion. Defining reproductive ill- health as not only a health
issue but as a matter of social justice provides a legal and political basis for
governments to act.
We know what happens when they do not act - when people's sexual and reproductive
rights are denied.
- Every year, at least 120 million women who do not want to become pregnant do not
have the means to prevent it.
- Every year, 20 million women put their health and lives at risk because they seek
- Every year, there are more than 330 million new cases of curable sexually
transmitted diseases and one in 20 adolescents become infected.
- Every year, the HIV virus infects 5.2 million people, over half of them young
people below 24 years old.
- Every year, there are 450 000 new cases of cancer of the cervix.
Between 5% and 15% of the global burden of disease is associated with failures to
address reproductive health needs. This burden hits people - particularly
women - in the prime of life, it hits when their potential, responsibilities, and
productivity are at their highest. Globally, among women of reproductive age, more than
20% of total years of healthy life lost are due to three main groups of reproductive
health conditions - sexually transmitted diseases including HIV/AIDS, maternal
mortality and morbidity, and reproductive tract cancers. A further 10% of healthy years of
life are lost due to conditions affecting the newborn.
These figures are alarming in themselves - but they are still only the tip of the
iceberg. The total burden remains inadequately documented and measured. Reproductive tract
infections cause a huge toll of needless suffering. We are becoming aware of the
importance of the mental and physical ill-health associated with violence, the harmful
practice of female genital mutilation and sexual abuse.
Since Cairo, increasing attention has been given to these neglected issues, and let us
pay a particular tribute to the NGO community for having pioneered effective efforts in
The Programme of Action from Cairo was not a blueprint. Countries have different needs
and varying social and economic contexts, and will find different ways of fulfilling the
agenda of Cairo.
Governments and civil society need to develop a public health approach to reproductive
health that is cost-effective and has the maximum impact. There are lessons to be learned
from 20 years of experience with Primary Health Care, looking beyond the customary
boundaries of curative and preventive medicine and addressing the underlying social causes
of poverty, hunger and ill-health.
It is not a job for the traditional health sector alone. The agenda is as much about
social justice as it is about health care. We need to clarify concepts and to define the
division of labour among sectors and professions.
Let me move on to the issue of declining real resources.
In Cairo we were aware of the growing problem of aid fatigue. Since then things have
become worse. Developed countries have committed to contributing 0.7% of their GDP to
development assistance. I know that is no small commitment, having fought the case as
Prime Minister for Norway to have close to 1%. The sombre global average today is 0.2% and
it is declining.
Global resources for public health interventions in reproductive health have also
failed to keep up with increasing demand. As a result, there is a tendency to move away
from the comprehensive definition of reproductive health that we developed at Cairo. We
know who will pay the price. The most vulnerable - and above all millions of women
We cannot bow our heads. We need to speak out with commitment and with convincing
Needless suffering and death are sufficient cause for action in themselves, but there
are also significant social and economic considerations. Reproductive ill-health affects
young people with family responsibilities, women and men in the prime of their lives.
Just imagine the costs, to the individual and to society, of the 600 000 women
dying every year due to maternal causes, and the 7.6 million perinatal deaths. Not to
mention the 2 million little girls subjected to female genital mutilation. Think of the
costs of failing to ensure that young people - our common future - have the
knowledge, skills and services they need to help them make healthy choices in their sexual
and reproductive lives. Investment in reproductive health is an investment in future
health and development. This message must be brought more convincingly to decision-makers.
WHO will increase its gathering of evidence and its ability to bring it clearly across.
We know what needs to be done to reduce maternal mortality. We know how to prevent and
treat many sexually transmitted diseases. We know how to increase people's choices
regarding the number and spacing of their children. We know the kinds of interventions
needed to promote breastfeeding.
We still have a lot to learn about how to prevent sexual abuse and violence, how to
care for people with HIV infection, and how best to reach out to the poor and most
disadvantaged. We must continually seek to expand our knowledge of what works. We must
anchor all our activities on a foundation of sound scientific evidence.
The evidence base is important because it enables us to assess what needs to be
done, guides us in determining what can been done in our health systems and health
programmes. Evidence-based approaches help us to allocate and use our resources wisely. In
WHO we have created a separate cluster on Evidence and Information for Policy. This too is
a global public good - available for countries to access and learn from.
Looking ahead - five years after Cairo, I see two issues that demand our urgent
and undivided attention. As the end of the twentieth century approaches, we must deal with
the unfinished agenda in maternal health and we must address the emerging
challenge of adolescent sexual and reproductive health.
Look at the tragedy of maternal mortality, an area where there has been little
sign of progress. In parts of Africa, women face a one in 16 risk of death because they do
not receive the care they need when they get pregnant. By contrast, in most of Europe and
North America, such a tragedy will hit only one woman in 4000. No other indicator so
starkly reflects the disparities between rich and poor, between the haves and have nots,
between the developed and developing worlds.
Every death is a tragedy. The death of a young woman, who may have other children who
depend on her, is a multiple tragedy. The inexcusable fact is that so many of these deaths
are preventable. They are preventable with simple and cost-effective interventions.
Pregnant women must have access to skilled care. They must be able to reach a functioning
health care facility when complications arise.
These interventions are feasible, measurable and effective. Why have we not made more
Part of the answer lies in piecemeal approaches. Health care providers have been
trained, women have been informed about the risks of pregnancy and childbirth,
micronutrients have been distributed, antenatal care programmes have been established,
family planning information and services have been made available. But not enough effort
and resources have been directed into strengthening the health system.
WHO will address this challenge. We interpret the high levels of maternal mortality not
only in terms of what they mean for women and children, not only in terms of their disease
burden, but in terms of what they tell us about the failure of health systems, policies
and programmes to address the essential needs of women.
We cannot address maternal mortality without a functioning health care system. A
well-run health sector is designed to reduce inequity of access, focus on quality of
health outcomes, both at clinical level and for public health programmes, and use scarce
funds as effectively and efficiently as possible. It is responsive, and allows people a
voice in setting priorities and in holding providers accountable for their performance.
The health sector cannot function without strong links to other parts of government, to
the private sector and civil society. We will offer reliable and effective support to
countries as they reform and restructure their health sector, making sure that people -
particularly poor people - get a better deal from their health system.
At WHO we will give special priority to this - as we invite our Member States to join
in a Partnership for Health Sector Development.
The second urgent issue that we must address is adolescent sexual and reproductive
There is often a deep-seated discomfort in dealing with adolescent sexuality. We need
to change this. Adolescents - in developed and developing countries alike - are
vulnerable - because of a variety of biological, psychological and social factors.
Every year, one in 20 adolescents contracts a sexually transmitted disease and one in
four unsafe abortions occurs in adolescence. We have an ethical duty to do what is
necessary to prevent this suffering and devastation.
Young people need adult assistance to deal with the thoughts, feelings and experiences
that accompany physical maturity. By providing this help, we are not encouraging
irresponsible lifestyles. Evidence from around the world has clearly shown that providing
information and building skills on human sexuality and human relationships helps avert
health problems, and creates more mature and responsible attitudes.
Looking ahead, we need to make strategic alliances. The broad reproductive health
agenda is too big and complex for any single agency. We can be more effective when we link
with others, agree on a division of labour, and create real partnerships to achieve real
This message goes to all those committed to international health and development. It is
vital that we work together. We must not give mixed messages. We must avoid overlap and
duplication. Let us share commitments as we look towards the next millennium. Let us work
with countries, help them to mobilize their collective wisdom, knowledge and action and
share experiences in carrying out reproductive health strategies. Let us pay more
attention to reducing the disparity between the health outcomes of the poor and the better
off. Let us promote increased access to a package of services that addresses people's
needs in family planning, in prevention and management of sexually transmitted diseases
and pregnancy care.
Cairo was a pledge for action. In the weeks and months leading up to July, let us renew
the pledge. Let us generate and share our new knowledge. Let us build and strengthen a
broad alliance for the key survival issues. WHO is committed to putting health at the core
of the development agenda. That is where it belongs. Reproductive health is part and
parcel of that commitment.