1 The Reproductive Health and Poverty Cycle The Situation in Less Developed Countries
2 Reproductive Health and the MDGsIn this brief session we shall be looking at the relationship between poverty reduction or rather the attack on poverty and the role of reproductive health in a developing country context. When speaking about poverty reduction the all too familiar Millennium Development Goals come to mind.
3 MDGs Goal 1: Eliminate extreme poverty and hungerGoal 2: Achieve universal primary education Goal 3: Promote gender equity and empower women Goal 4: Reduce child mortality Goal 5: Improve maternal health by reducing the Maternal Mortality Ratio (MMR) by ¾ between Goal 6: Combat HIV/AIDS, malaria, and other diseases Goal 7: Ensure Environmental Sustainability Goal 8: Develop Global Partnership for Development Although the MDGs may appear overambitious to some, they still conjure a vision of a much improved world where by 2015: extreme poverty is halved child mortality is reduced gender disparities in primary and secondary education are eliminated women are more empowered, and finally health and environment indicators improve. The first seven goals are mutually reinforcing and are directed at reducing poverty in all its forms. The last goal i.e. “global partnership for development”- concerns the means to achieve the first seven goals. Therefore we can say that RH Care is a proximate determinant for the MDGs
4 UN Secretary General, Kofi Annan“The MDGs, particularly the eradication of extreme poverty and hunger, cannot be achieved if questions of population and reproductive health are not squarely addressed. And that means that stronger efforts to promote women’s rights, and greater investments in education and health, including reproductive health and family planning, are required.” UN Secretary General, Kofi Annan Statement at 5th APPC, 16th Dec. 2002, Bangkok However, there is no linear or defined method of achieving these goals. Poverty is multidimensional, complex, and the causes are highly variable. Therefore attacks on poverty have to be many, and reproductive health is only one (albeit an extremely important) approach. Family planning, safe motherhood and the prevention of HIV/AIDS have much to offer in alleviating the plight of people whose lives are daily plagued by suffering…a downward spiral propelling people deeper into the trap of chronic poverty. In fact as UN Secretary General Mr. Kofi Annan stated: “The MDGs, particularly the eradication of extreme poverty and hunger, cannot be achieved if questions of population and reproductive health are not squarely addressed”.
5 MDGs and Reproductive Health: the linkReproductive Health is central to the achievement of all MDGs Lack of recognition of reproductive rights and access to RH information and services may result in: MDG 1: More poverty resulting from higher population growth MDG 2: Higher pupil-teacher ratios, lower retention rates MDG 3: Lower status of girls and women MDG 4: Higher malnutrition, stunted growth of children MDG 5: Lack of contraceptive choice, births delivered by unskilled persons, more death and pregnancy related complications MDG 6: Increase in STIs and HIV infections MDG 7: Migration to crowded urban slums, environmental deterioration MDG 8: Lack of access to services, medicines, technologies Linkages between women’s empowerment, reproductive health and poverty reduction are inseparable. Development, poverty and population issues are intertwined. Therefore universal access to high quality, voluntary reproductive health services, including family planning, is key to achieving all the MDGs. Consequences of not doing so may well include amongst others: More poverty resulting from higher population growth Higher pupil-teacher ratios Lower status of girls and women Higher malnutrition and stunted growth of children Lack of contraceptive choice, births delivered by unskilled persons, more death and pregnancy related complications Increase in STIs and HIV infections Migration to overcrowded urban slums and environmental deterioration and finally Lack of access to services, medication and technology.
6 Therefore access to reproductive health services providing options and choices to users, have to be in place if we are serious about modifying and breaking the chain of poverty, inequality, and low productivity. Issues such as family size and household poverty, need to be a priority since these constrain resource investments in children’s education, therefore affecting the life chances of the next generations. Within this context, we can therefore see that access to quality reproductive health is pivotal to meeting MDG targets especially those related to poverty reduction, child and maternal mortality, HIV/AIDS, gender and education. The diagram above can better illustrate how reproductive health care can feed into the achievement of all the MDGs. *RTI (Reproductive Tract Infections) *IEC (Information, Education & Communication) *FP (Family Planning)
7 The Poverty-Health CycleWhen addressing poverty and health problems, we can often see that the two are inextricably linked, and are both a cause and consequence. This means that we are confronted with a vicious cycle whereby poverty exacerbates health problems and disease, and health problems and disease in turn result in increased poverty. Mediating between the two is increased discrimination and social exclusion that aggravate the situation.
8 Poverty and Reproductive Health Problems form a cycle: Both are a cause and a consequencePoverty leads to Malnutrition Unhealthy living and working environments Lack of access to healthcare Lack of access to education Disease leads to Inability to earn a living Lower productivity at national level Poverty is generally held to be a major cause of impairment, disabilities and health problems such as HIV/AIDS in developing countries, and many kinds of health problems are the result of specific diseases or conditions that are preventable. On the other hand, persons with health problems are likely to become poorer, because the impairments or disabilities resulting from these health problems, place heavy demands on limited resources, reducing access to opportunities for education and a sustainable livelihood. Simply speaking, what this means is that a healthy population is a productive population. At a macro level, poor health means low productivity and consequently low economic development. Although this relationship is a complex one, what is undisputed is the fact that persons with preventable and other diseases and health problems are disproportionately represented among the poor, and are amongst those living in extreme or chronic poverty.
9 Poverty Health ProblemsMortality and Morbidity by income level Poor people are more at risk of suffering from health problems due to a lack of access to adequate nutrition, health care, sanitation, and safe living and working conditions, all of which contribute to the risk of diseases, impairments and disabilities. In fact as the graph indicates, mortality rates (and those related to reproductive health prevail) are disproportionately higher in the lowest income groups.
10 Reproductive Health, Poverty& The Gender Variable Therefore we can safely say that reproductive health problems are a major cause and consequence of poverty, and therefore any serious attempts at attacking poverty, must address reproductive health. Similarly, gender disparities in both poverty status and reproductive health complications, can not be left out of the equation. Efforts at placing women at the forefront of both poverty reduction strategies and reproductive health care are therefore pivotal.
11 Gender and Poverty 1.3 billion people live on less than one dollar a day. The majority of the absolute poor are female. In most societies, women have low social status & limited access to power. Rigidly ascribed socio-cultural norms, beliefs and attitudes based on perceived gender roles, and early marriage restrict the choices of women even further. Women bear a disproportionate burden of poverty. Much of the work women do goes unrecognized and underpaid. Women in many countries are still discriminated against when it comes to ownership of land and property inheritance Reasons for prioritizing women and women’s health are not a luxury but indeed stem from the disadvantaged reality women live. Gender disparities in health, education, access to credit and employment are wider among the poor. In fact : When addressing the gender variable in development work, one often comes across the notion that women are disproportionately disadvantaged both as women and as poor people. In fact, of the 1.3 billion people who live on less than one dollar a day, the majority of the absolute poor are female. Women’s reproductive work is rarely given an economic value, hence work performed by women is often invisible and left unquantified. Intrahousehold inequalities prevail, and hence projects targeted at households rarely reach women. In a large number of LDCs, rigidly ascribed social roles, norms and their limited access to assets, power, education, training, health services, information and other resources essential for their livelihoods, maintain women in a situation of low social status, and low power, and high poverty. This means that although poverty affects households as a whole, women bear a disproportionate burden, attempting to manage household consumption and production under conditions of increasing scarcity.
12 Gender and reproductive healthReproductive health & Women The average maternal mortality ratio is 400 per 1000,000 live births. Women in Africa face 1 in 16 chance of Maternal death; in developed countries this chance is 1 in 2800 In Africa, Asia and Latin America the complications of pregnancies, child birth and illegal abortion constitute the leading cause of death among women of reproductive ages Reproductive health cuts across gender, age, ethnicity even though the means of achieving it are culture and context-specific. Still, much work on reproductive health is unavoidably targeted at women. This is because the denial of reproductive choice and lack of reproductive health care seriously interfere with all women's quality of life and human dignity, and for poor women in low-income countries, a lack of reproductive health care is literally a matter of life and death. Research in fact depicts a very grim picture of the current situation whereby:
13 Pregnancy related complications kill 514,000 women every year 36% of pregnancies in developing countries are unwanted. 20 million illegal abortions held worldwide, most in the developing world.. Every year, 2 million girls and young women undergo Female Genital Mutilation HIV/AIDS & STDs Pregnancy related complications kill 514,000 women every year. 99% of these occur in less developed countries, 95% in Africa and Asia alone. 36% of pregnancies in developing countries are unwanted. Illegal abortions proliferate, standing at 20 million worldwide and killing 80,000 women in the process. Again, most of them in the developing world. Millions more suffer injuries from unsafe abortions which often go untreated. This is a clear indication that making abortion illegal in such circumstances, does not stop them, but only makes them unsafe and life threatening. Finally, every year 2 million girls and young women undergo Female Genital Mutilation often without anesthetic to prevent the pain and antiseptics to prevent infection. But Reproductive health is not complete without addressing AIDS and a host of sexually transmitted diseases again prevalent in underdeveloped countries.
14 Adults and Children estimated to be living with HIV/AIDSEastern Europe & Central Asia 1.2 million Western Europe North America East Asia & Pacific 1.2 million North Africa & Middle East Caribbean South & South-East Asia 6 million Sub-Saharan Africa 29.4 million Latin America 1.5 million Australia & New Zealand 15 000 An estimated 40 million are infected with the HIV Virus, half of which are women. 95% live in LDCs where expensive treatment is not available. Half of new HIV infections are among young people- making young people a priority for effective reproductive health care. Preventing infection means enabling young people to protect themselves from sexually transmitted diseases through access to reproductive health education and services, contraception, together with the development of adequate life skills. And this should go beyond religious, political and other differences. But HIV/AIDS is not the complete picture, as a further 300 to 400 million people develop a sexually transmitted disease every year. Again the correlation between poverty and ill health is evident, as new cases are concentrated in the poorer countries. Untreated STIs are the cause of chronic pain, damage reproductive and non-reproductive organs, and increase transmission of the HIV virus. Infants born to mothers with an STI can also be affected. Total: 42 million Source: UNAIDS, 2002
15 Reproductive Health problems Propel PovertyTill now, the point we have clearly made is that poverty exacerbates and opens a wide space to various health problems, as evidence from the poorest countries shows us. But the effect of health problems on poverty is also a devastating one, hence the notion that the sick and the disabled constitute the poorest of the poor.
16 Reproductive Health problems are not only an individual problem. Households, families and communities at large are affected by the health problems of one member. Inability to participate in economic and social life by whole communities inhibit economic growth. Reproductive health problems incur costs for treatment etc. aggravating an individual’s level of poverty. Reproductive Health problems are not a marginal issue since problems such as HIV/AIDS are not solely a personal problem. This means that there are a considerable number of persons affected by the health problems of one member e.g. if the household head is the one affected. Family members must absorb extra responsibilities that inhibit their participation in the economic and social life of their communities. And of course, the less productive any citizen is, the less the chances of survival, and less economic growth is possible. Reproductive health problems worsen the lives of already poor people due to their inability to participate in economic activity and also the extra costs incurred on medication, treatment etc. Poverty rates among people with health problems are in fact much higher even if the same poverty lines ( e.g. the $1 a day benchmark) are used that are applied to the general population. Therefore it is clear that the fight against poverty will not succeed without focused efforts to address issues of health and in this case reproductive health, since these people constitute the poorest of the poor. And again, if any poverty reduction strategy is serious, it must target the poorest disenfranchised groups.
17 RH in the fight against PovertyReproductive Health Gender Family Planning Maternal Health HIV/AIDS and STIs Harmful practices, Cancers, infertility In the past decade, organized efforts by those who support reproductive choice around the globe have spurred the international community to recognize that people have a right to reproductive health. At the 1994 International Conference on Population and Development in Cairo, 180 nations signed an agreement called the "Programme of Action". This agreement calls for universal access to reproductive health services and information, and among its provisions are declarations that all people have the following rights: Adolescents and Youth
18 "To attain the highest standard of sexual and reproductive health," "To decide freely and responsibly the number, spacing and timing of their children," "To attain the highest standard of sexual and reproductive health," "To make decisions concerning reproduction free of discrimination, coercion and violence." "To decide freely and responsibly the number, spacing and timing of their children,“ "To attain the highest standard of sexual and reproductive health,“ "To make decisions concerning reproduction free of discrimination, coercion and violence." In practical terms this involves dramatic changes in health care, education, and other social services needed to protect everyone's reproductive health and the right to: make choices for themselves, empower women and improve population, health and social outcomes.
19 Reproductive health and MDG 1: Eradication of Poverty and HungerMDG 1: Eradicate Poverty & Hunger Reproductive illnesses and unintended pregnancies weaken or kill people in their most economically productive years In sub-Saharan Africa, poor reproductive health accounts for nearly two-thirds of disability-adjusted life years lost among women of reproductive age. Smaller family size has contributed to economic opportunities. Every year of education reduces the likelihood that a girl will bear a child in her teens or live in poverty. Until a woman can determine the number and spacing of her children, she cannot participate to the best of her abilities in society. Reproductive health can do much to help in the fight against poverty. Looking at MDG 1 alone, the picture is relatively clear: Reproductive illnesses and unintended pregnancies weaken or kill people in their most economically productive years: Sexual and reproductive health conditions account for nearly one- fifth of the global burden of disease and 32 percent of the burden among women of reproductive age worldwide. Therefore, effective reproductive health is necessary if we are to have a productive workforce, able to sustain their own livelihoods. In sub-Saharan Africa, poor reproductive health accounts for nearly two-thirds of disability-adjusted life years lost among women of reproductive age: In many developing countries, women earn 40 percent to 60 percent of household incomes. This is a significant economic contribution that is lost when a woman dies in pregnancy or is unable to work due to poor reproductive health. Smaller family size has indeed contributed to economic opportunities i.e. through higher ratios of workers to dependent children. This has allowed families and governments to invest more in each child – ensuring access to education and health care – and over time, the ability to save more, invest more productively and ultimately, to stimulate economic growth. Every year of education reduces the likelihood that a girl will bear a child in her teens or live in poverty: Girls who complete their secondary education are between 3 and 13 times less likely to become mothers early in life and tend to have fewer and healthier children. Until a woman can determine the number and spacing of her children, she cannot participate to the best of her abilities in society: In this case, access to RH is a source of empowerment to women, as pregnancies are by choice and there are fewer births and smaller families. Higher female labour force participation leads to increased income, economic growth and reductions in poverty. It decreases population growth, and improves health and social outcomes. Guaranteeing sexual and reproductive health and rights is therefore a necessity.
20 The investment in Adolescent reproductive health to fight Poverty and HIV/AIDSNeglect of programmes targeting young people to avoid unwanted pregnancy, unsafe childbirth and STIs undermine development and spread HIV/AIDS 1.2 billion people (1 in 5) are between ages 10 and 19. One of four live in extreme poverty Some 82 million girls aged 10 to 17 will marry before their 18th birthday, disrupting education and life opportunities to climb out of poverty. 14 million teenagers give birth each year, and 5 million undergo unsafe abortion. Girls aged 15 to 10 are twice as likely as women in their 20s to die in childbirth. Source: UNFP (2003) An important challenge and obligation is to target, specifically young people. Evidence shows that HIV/AIDS has become the disease of the young, again fuelled by serious poverty, gender inequality and lack of information and services for prevention. 1.2 billion people are between ages 10 and 19. And at least a third of new cases of curable STIs occur in young people aged 15 to 24, a large majority of which are still ignorant of how HIV is transmitted. This is a clear indication that there has been some serious navel gazing in the delivery of services and information, and that an emphasis on quantity may have taken over issues of quality. Therefore the challenge here is to provide education that is adequate and effectively targeted at youth, and finally to provide access to youth-friendly reproductive health services.
21 Way Forward Efforts at reaching the MDGs, or any concern about poverty reduction, HIV/AIDS and development MUST ensure that resources are made available for reproductive health services. Generate the necessary human, financial and other resources required to provide sexual and reproductive health services to all who need them Stronger and more consistent sexual and reproductive health language Reproductive health and HIV/AIDS initiatives must support each other Poverty reduction must remain a priority if efforts are to be sustained in improving the quality of life of the world’s poorest. We still have a long way to go, and as we speak today, people are dying, and prospects of climbing out of poverty are grim for many. Work needs to be done if these people are ever to become more than numbers sitting on policy makers’ shelves and desktops. Efforts concerned with achieving the MDGs, poverty reduction, human rights, HIV/AIDS and development – must ensure adequate financial resources for sexual and reproductive health services. Commitment, greater capacity and coordination are needed to generate the necessary human, financial and other resources required to provide sexual and reproductive health services to all who need them: In recent years, reproductive health services have expanded and gender equality integrated in many governments’ development agendas. But access is still far from universal, and thus it is critical to enhance rather than diminish efforts to strengthen women’s rights, improve their status, and to increase access to health care, including contraceptive services. Donor and developing countries are encouraged to employ stronger sexual and reproductive health language –to make visible the important linkages between good sexual and reproductive health and overall development goals. Reproductive health and HIV/AIDS initiatives must be mutually reinforcing to take full advantage of the linkages between the two, as well as linkages between reproductive health and broader health and development issues. Finally, The international community’s commitment to poverty reduction and development must not be diluted. Investments in development – in education, nutrition ,poverty reduction and expanded access to reproductive health programs – play a critical role in improving the quality of life for many individuals and their communities. To achieve the MDGs, promote global peace and security, and ensure human rights, requires a sustained commitment to development, including support for universal access to reproductive health services. All these are necessary in what need to be consistent and complementary attacks on poverty. Finally, and most importantly is that support for local initiatives are necessary, if the poor are to shift from being passive beneficiaries and become the resourceful and empowered change makers they really are.