A marriage between social and medical sciences. (Reproductive Health).

The memorable day was 13 September 1994, in Cairo, Egypt. Representatives from 180 nations, among them thousands of women of every race and creed, jubilant for having won more than they had dared hope for. The world had publicly acknowledged that health and well-being, and equity and equality, for women are important ends in themselves. They had agreed that finding the balance between resources and population, development and sustainability, concerns people, not numbers. This is the Cairo Programme of Action, which has set the course for the next twenty years following the declaration focusing on people and their needs.

This was the beginning of the paradigm shift--from maternal and child health to reproductive health. Many issues can be encompassed within reproductive health concerns. Yet, the diversity and breadth of issues mean that even if a single, universally applicable, all-encompassing definition of reproductive health is ever agreed, it will be almost impossible to operationalize.

I have defined reproductive health as a marriage between social sciences and medical sciences, because it affects everybody. It reflects health in childhood and sets the stage for health even beyond the reproductive years for both women and men. It affects and is affected by the broader context of peoples' lives, their economic circumstances, education, employment, living conditions, family environment, social and gender relationships, and traditional and legal structures within which they live. For example, gender discrimination in intra-household allocation of food may lead to stunted growth and anaemia in girls by the time they reach adolescence. In later life, they may experience obstructed labour due to contracted pelvises, or increased infections or contraceptive contra-indications from anaemia. Reproductive health also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted disea ses (STDs).

The five core areas of reproductive health are healthy childbearing, fertility regulation, maintenance of a healthy reproductive system, sexuality and sexual behaviour, and the social-cultural context within which reproductive behaviour and ill-health takes place. Cost-effective, service-based strategies for preventing or treating reproductive health problems exist for many of the leading issues in this field. Preventive approaches, in the form of family planning, safer sex, immunizations and breast-feeding promotion programmes, are at the heart of efforts to combat unwanted and unplanned pregnancy, STDs, HIV/AIDS, induced abortion, maternal morbidity and mortality, and general ill-health.

All nations accepted that the aims of the International Conference on Population and Development (ICPD) Programme of Action were realistic and achievable because it responds to people's needs, involves the participation of communities, has the greatest impact for most of the people, and is affordable and sustainable, based on existing infrastructures, with revitalization, reorganization and integration, and it implies real location of resources.

Many Governments, however, especially in the developing world, burdened by more than a decade of declining per capita food production and stagnating per capita incomes, face difficult challenges to expanding health care services. High infection rates for HIV/AIDS and other sexually transmitted infections add to the burden. While there has been notable progress in implementing the actions called for in Cairo, international donor support for reproductive health programmes is far below what is needed. In 1994, Governments agreed that $17 billion would be needed annually for reproductive health services by the year 2000, climbing to nearly $22 billion by 2015--two thirds would come from developing countries and one third from the developed. This commitment went against the trend. And since 1995, with a few exceptions, donors have been reducing rather than increasing support. The indirect effects could be even worse. Failure to meet the commitment of Cairo will spill over into many other areas of development, plac ing enormous stress on education, health care, housing, water, sanitation and all the other linkages involving economic development. For some countries, it will mean the difference between development and stagnation. For many individuals, it will mean the difference between life and death. The $22 billion needed yearly is less than one week of world expenditure on armaments. It is relatively a small investment, but if we do not make it, the effects will be felt for generations to come.

RELATED ARTICLE: Since the 1994 ICPD, countries have been making changes in how reproductive health is implemented, and there has been some real progress:

* Over the past thirty years, the development of modern contraceptive methods has given people more freedom and ability to plan their families. This is crucial because up to a third of maternal mortality and morbidity could be avoided if all women had access to a range of modern, safe and effective family planning services that would enable them to avoid unwanted pregnancies.

* Contraceptive use has increased from less than 10 per cent of couples thirty years ago to some 60 per cent today.

* Family size has fallen from an average of six children in the 1960s to less than three.

Kwasi Odoi-Agyarko, Executive Director of Rural Help Integrated, a nongovernmental organization in Ghana, received the 2002 United Nations Population Award for outstanding leadership and achievement in the field of reproductive health in Ghana.