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for the follow-up to

the Programme of Action
of the International Conference of
Population and Development Beyond 2014
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Rob, Hamed Saber, Mark Sontak, sistak.
Framework of Actions for the follow-up
to the Programme of Action of the
International Conference on Population
and Development Beyond 2014
Report of the Secretary-General

United Nations A/69/62

Distr.: General
12 February 2014
Original: English

ISBN: 978-1-61800-020-0
Executive summary Our greatest shared challenge is that our very
accomplishments, reflected in ever-greater
human consumption and extraction of the
The present report has been prepared pursuant Earth’s resources, are increasingly inequitably
to General Assembly resolution 65/234, in which distributed, threatening inclusive development,
the Assembly, responding to new challenges and the environ-ment and our common future.
to the changing development environment, and
reinforcing the integration of the population and The evidence of 2014 overwhelmingly supports
development agenda in global processes related the consensus of the International Conference
to development, called for an operational review that respect, protection, promotion and fulfilment
of the implementation of the Programme of of human rights are necessary preconditions for
Action on the basis of the highest-quality data improving the dignity and well-being of women
and analysis of the state of population and and adolescent girls and for empowering them
develop-ment, taking into account the need for a to exercise their reproductive rights, and that
system-atic, comprehensive and integrated sexual and reproductive health and rights and
approach to population and development issues. under-standing the implications of population
dynamics are foundational to sustainable
The Programme of Action of the International
development. Safeguarding the rights of young
Conference on Population and Development,
people and investing in their quality education,
adopted in 1994, represented a remarkable
decent em-ployment opportunities, effective
consensus among 179 Governments that
livelihood skills and access to sexual and
individual human rights and dignity, including the
reproductive health and comprehensive
equal rights of women and girls and universal
sexuality education strengthen young people’s
access to sexual and reproductive health and
individual resilience and create the conditions
rights, are a neces-sary precondition for
under which they can achieve their full potential.
sustainable development, and set forth objectives
and actions to accelerate such development by
The path to sustainability, outlined in the present
2015. Achievements over the ensuing 20 years
framework, will demand better leadership and
have been remarkable, including gains in women’s
greater innovation to address critical needs: to
equality, population health and life expectancy,
extend human rights and protect all persons from
educational attainment and human rights
discrimination and violence, in order that all
protection systems, with an estimated 1 bil-lion
persons have the opportunity to contribute to and
people moving out of extreme poverty. Fears of
benefit from development; invest in the capabili-ties
population growth, which were already abating in
and creativity of the world’s young people to assure
1994, have continued to ease, and the expansion
future growth and innovation; strengthen health
of human capability and opportunity, especially for
women, which has led to economic development, systems to provide universal access to sexual and
has been accompanied by a continued decline reproductive health to enable all women to thrive
in the population growth rate from 1.52 per cent and all children to grow in a nurturing environment;
per year from 1990 to 1995 to 1.15 from 2010 to build sustainable cities that enrich urban and rural
2015. Today, national demographic trajectories are lives alike; and transform the global economy to one
more diverse than in 1994, as wealthy countries of that will sustain the future of the planet and ensure
Europe, Asia and the Americas face rapid popula-
a common future of dignity and well-being for all
tion ageing while Africa and some countries in Asia
prepare for the largest cohort of young people the
world has ever seen, and the 49 poorest countries,
particularly in sub-Saharan Africa, continue to face
premature mortality and high fertility.

ICPD BEYOND 2014 iii

A. The realization of human rights......................................................................................................................7
B. Methodology, data sources and structure of the report...............................................................................9

2. DIGNITY AND HUMAN RIGHTS......................................................................................................................15

A. The many dimensions of poverty.................................................................................................................16
B. Women’s empowerment and gender equality............................................................................................20
C. Adolescents and youth.................................................................................................................................35
D. Older persons...............................................................................................................................................49
E. Persons with disabilities...............................................................................................................................56
F. Indigenous peoples.......................................................................................................................................59
G. Non-discrimination applies to all persons....................................................................................................61
H. The social cost of discrimination................................................................................................................. 66
I. Dignity and human rights: key areas for future action...............................................................................68

3. HEALTH.............................................................................................................................................................75
A. A human rights-based approach to health..................................................................................................76
B. Child survival.................................................................................................................................................76
C. Sexual and reproductive health and rights................................................................................................. 78
D. Sexual and reproductive health and rights and lifelong health for young people ....................................82
E. Non-communicable diseases......................................................................................................................119
F. Changing patterns of life expectancy..........................................................................................................121
G. Unfinished agenda of health system strengthening.................................................................................122
H. Health: Key areas for future action............................................................................................................132

4. PLACE AND MOBILITY..................................................................................................................................141

A. The changing structure of households.......................................................................................................142
B. Internal migration and urbanization............................................................................................................148
C. International migration................................................................................................................................156
D. Insecurity of place.......................................................................................................................................162
E. Place and mobility: key areas for future action.........................................................................................168

5. GOVERNANCE AND ACCOUNTABILITY.....................................................................................................173

A. Establishment of government institutions related to the Programme of Action......................................175
B. Strengthening the knowledge sector related to the Programme of Action..............................................178
C. Creating enabling legal and policy environments for participation and accountability .......................... 186
D. Collaboration, partnerships and coherence...............................................................................................191
E. Financial resource flows............................................................................................................................. 196
F. The beyond 2014 monitoring framework....................................................................................................199
G. Governance and accountability: key areas for action..............................................................................199
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६ ᪇᪇᪇᪇᪇᪇᪇᪇᪇ Àᆂ㬒᪇᪇᪇᪇᪇᪇᪇᪇᪇Á撎㑙᪇᪇᪇᪇᪇᪇᪇᪇᪇Â㌜㫟᪇᪇᪇᪇᪇᪇᪇᪇᪇Ã᪇䴈᪇᪇᪇᪇᪇᪇᪇᪇᪇Ä묺櫲᪇᪇᪇᪇᪇᪇᪇᪇᪇Å᪇䠛᪇᪇᪇᪇᪇᪇᪇᪇᪇
6. SUSTAINABILITY...........................................................................................................................................203

A. The heterogeneity of population dynamics..............................................................................................204
B. The drivers and threats of climate change...............................................................................................205
C. The cost of inequality in achieving sustainable development.................................................................207
D. Paths to sustainability: population and development beyond 2014.......................................................209
E. Beyond 2014................................................................................................................................................214

1. Measures of legal abortion where reporting is relatively complete, 2001-2006 ........................................100
2. Estimated critical shortages of doctors, nurses and midwives by region, 2006 ........................................123
3. Trends and projections in urban-rural population by development group, 1950-2050 .............................149
4. Situation assessments conducted by theme, region and coverage...........................................................184
5. Percentage of Governments addressing political participation, by population group ...............................188
6. Estimates of global domestic expenditures for four components of the
Programme of Action, 2011...........................................................................................................................198

1. Thematic pillars of population and development.............................................................................................4
2. The global wealth pyramid...............................................................................................................................18
3. Distribution of global absolute gains in income by population ventile, 1988-2008 ......................................19
4. Proportion of own-account and contributing family workers in total
employment by region, 1991-2012................................................................................................................22
5. Support for gender equality in university education, business executives
and political leaders and women’s equal right to employment by region, 2004-2009 ...............................25
6. Trends in men’s attitudes towards “wife beating”......................................................................................... 29
7. Percentage of girls and women aged 15-49 who have undergone female
genital mutilation/cutting by country...............................................................................................................33
8. Trends and projections in the proportion of young people (10-24 years),
worldwide and by region, 1950-2050............................................................................................................36
9. Adolescent fertility rate and net secondary education female enrolment rate
by region, 2005-2010.......................................................................................................................................41
10. Adjusted net enrolment rate for primary education by region, 1999-2009 .................................................42
11. Primary completion rates by region and by gender, 1999-2009..................................................................43
12. Youth employment-to-population ratio by region, 1991-2011.......................................................................47
13. Trends and projections in the proportion of older persons (over 60 years),
worldwide and by region, 1950-2050............................................................................................................50
14. Labour force participation of older persons as a proportion of total population
aged 65 and over by region, 1980-2009.......................................................................................................53
15. Global labour force participation age 65 and over by sex, 1980-2020....................................................... 54
16. Public tolerance towards selected population groups by region, 2004-2009 .............................................65


Contents (continued)

17. Percentage of governments addressing discrimination against migrants,

disabled persons, older persons and pregnant girls....................................................................................68
18. Global under-five, infant and neonatal mortality rates, 1990-2010..............................................................77
19. Total disability-adjusted life years attributed to sexual and reproductive health
conditions among males and females (all ages), worldwide and by region, 1990-2010 ...........................78
20. Mortality (per 100,000) among young people from maternity-related causes,
communicable and non-communicable diseases and injury.......................................................................83
21. Trends in the percentage of never married women aged 15-24 using a condom at last sex ...................84
22. Trends in the percentage of never married young men aged 15-24 using a condom at last sex .............85
23. Trends in modern contraceptive prevalence rate in Northern and Western Africa,
by household wealth quintile...........................................................................................................................91
24. Trends in modern contraceptive prevalence rate in Eastern, Middle and
Southern Africa, by household wealth quintile..............................................................................................92
25. Trends in modern contraceptive prevalence rate in the Americas, by household wealth quintile .............94
26. Trends in modern contraceptive prevalence rate in Asia, by household wealth quintile ............................96
27. Percentage distribution of women aged 15-49, according to contraceptive method use,
highlighting single-method dominance in selected countries......................................................................96
28. Rates of voluntary termination of pregnancy and use of oral contraceptives
among women of reproductive age, Italy, 1978-2002..................................................................................98
29. Abortions per 1,000 women aged 15-44 years, weighted regional estimates,
1995, 2003 and 2008......................................................................................................................................99
30. Abortions per 1,000 women aged 15-44 years in selected European countries
where abortion is legally available, 1996 and 2003.....................................................................................99
31. Maternal mortality ratio by country, 2010.....................................................................................................104
32. Trends in skilled attendance at birth in the Americas, by household wealth quintiles ...............................106
33. Trends in skilled attendance at birth in Asia, by household wealth quintiles ............................................. 108
34. Trends in skilled attendance at birth in Eastern, Middle and Southern Western Africa, by household
wealth quintiles...............................................................................................................................................110
35. Trends in skilled attendance at birth in Eastern, Middle and Southern Africa,
by household wealth quintiles........................................................................................................................112
36. Association between emergency obstetric care facility density per 20,000 births
and maternal mortality....................................................................................................................................112
37. Estimated coverage of women with access to management of post-partum
haemorrhage, urban-rural, selected African countries, 2005......................................................................115
38. Estimated coverage of women with access to management of post-partum
haemorrhage, urban-rural, selected Asian countries, 2005.........................................................................115
39. Estimated coverage of women with access to management of post-partum haemorrhage,
urban-rural, selected Latin American and Caribbean countries, 2005....................................................... 115
40. Percentage of antenatal care attendees tested for syphilis at first visit, latest available data since 2005
41. Prevalence of obesity, ages 20 and over, age standardized, both sexes, 2008 .......................................120
42. Density of physicians, nurses and midwives, urban-rural, selected countries, 2005 ................................124


43. Percentage of births assisted by professionals, selected regions, 2000, 2005 and 2015 (projected) .....125

44. Trends in the proportion of one-person households, by region ...................................................................143
45. Trends in the proportion of one-person households, by age category ....................................................... 144
46. Singulate mean age at marriage by sex, 1970-2005...................................................................................145
47. Trends in the proportion of children (0-14 years old) living in single-parent
households, by region....................................................................................................................................148
48. Distribution of world urban population by city size class, 1970-2025 .........................................................150
49. International migrants by major area of origin and destination, 2013 ........................................................ 158
50. Persons displaced internally owing to armed conflict, violence or human
rights violations, 1989-2011...........................................................................................................................167
51. Establishment of institutions to address population, sustained economic
growth and sustained development, by country income group and year of establishment .....................176
52. Establishment of institutions to address the needs of adolescents and youth,
by country income group and year of establishment...................................................................................176
53. Establishment of institutions to address gender equality and women’s empowerment,
by country income group and year of establishment...................................................................................176
54. Establishment of institutions to address education, by country income group
and year of establishment.............................................................................................................................176
55. Donor expenditures for four components of the Programme of Action, 1997-2011 ..................................196

I. Figures, Tables and Boxes............................................................................................................................ 217
II. Government Priorities...................................................................................................................................238
III. Methodology..................................................................................................................................................260
IV. ICPD Beyond 2014 Monitoring Framework................................................................................................268

ICPD BEYOND 2014 vii


1 Introduction:

A new framework for
population and development

23 Development is the expansion of human oppor- fell by 47 per cent,6 and the global fertility rate fell
tunity and freedom. This definition is inherent in the by 23 per cent.7 The review also makes clear,
commitment made by all States Members of the however, that progress has been unequal and
United Nations to universal human rights and the fragmented, and that new challenges, realities
dignity of all persons. It represents the shared and opportunities have emerged.
aspiration of Governments and citizens to ensure that
all persons are free from want and fear, and are Unequal progress
provided the opportunity and the social arrangements 23 Research suggests a significant
to develop their unique capabilities, participate fully in correlation be-tween the education of girls,
society, and enjoy well-being.1 healthier families and stronger gross domestic
product (GDP) growth.8 The entry of women into
24 The Programme of Action of the International the export manufacturing sector in Eastern and
Conference on Population and Development2 Southern Asia, among other factors, has been a
reflected a remarkable consensus among diverse key driver of economic growth and contributed to a
countries that increasing social, economic and shift in the concentration
political equality, including a comprehensive of global wealth from West to East.9 Gains in
definition of sexual and reproductive health and the educational attainment of girls are also
rights3 that reinforced women’s and girls’ human contrib-uting to the success of Asia and Latin
rights, was and remains the basis for individual America in the knowledge-based economy.10
well-being, lower population growth, sustained
economic growth and sustainable development. 24 Nevertheless, belief in and commitment
to gender equality is not universal,11 and gender-
25 The evidence of the operational review, based discrimination and violence continue to
mandated by the General Assembly in resolution plague most societies.12 Beyond the
65/234, overwhelmingly supports the validity discrimination experienced by women and girls
of that consensus. Between 1990 and 2010 the are persistent inequalities faced by those with
number of people living in extreme poverty in disabilities, indigenous peoples, racial and ethnic
developing countries fell by half as a share of minorities and persons of diverse sexual orien-
the total population (from 47 per cent in 1990 to tation and gender identity, among others. While a
23 per cent in 2010), a reduction of 700 million core message of the International Conference on
people.4 Women gained parity in primary educa- Population and Development was the right of all
tion in a majority of countries,5 maternal mortality persons to development, the rise of the global
middle-class13 has been shadowed by persistent


inequalities both within and between countries. lation crossed the 7 billion mark in late 2011 and
While important gains in health and longevity United Nations medium-variant fertility projections
have been made, they are not equally shared anticipate a population of 8.4 billion by 2030.21
or accessible to many.
23 Population trends today are characterized by
5888 Despite considerable advances in maternal considerable diversity between different regions
and child health and family planning in the past two and countries. Most developed countries, and
decades, 800 women died each day from causes several developing countries, have ageing
related to pregnancy or childbirth in 2010,14 and an populations, with declining proportions of young
estimated 8.7 million young women aged 15 to 24 in people and working-age adults. Even in poor
developing countries underwent unsafe abor-tions in countries, declining fertility rates will eventually
2008.15 The advent of antiretroviral drugs has averted lead to an ageing population, and the high
6.6 million deaths from HIV and AIDS, including 5.5 proportion of older persons that is evident in
million in low- and middle-income countries, but in far Europe and developed countries in Asia today
too many countries the number of new infections will characterize much of the world by 2050.22
continues to rise, or declines have stalled.16 In
general, fewer and fewer gains can be expected from 24 At the opposite extreme, high total fertility rates of
technical “silver bullets” without making serious more than 3.5 children per woman are now confined
improvements to the health systems of poor to just 49 poor countries, mostly in Africa and South
countries17 and addressing structural poverty and Asia, which make up less than 13 per cent of the
human rights violations. world’s population. These and other developing
countries are still characterized by increasing
5889 Many of the estimated 1 billion people proportions of young and working-age persons, a
living situation which, under the right circum-stances
in the 50-60 countries caught in “development (including a decline in fertility), can lead to a
traps” of bad governance, wasted natural temporary “demographic bonus” but which, at the
resource wealth, lack of trading partners or same time, challenges Governments to ensure
conflict have seen only limited gains in health and adequate access to education and employment.23
well-being since 1994, and some are poised to
become poorer as the rest of the global population 25 Declining fertility rates are providing low- and middle-income
anticipates better livelihoods.18 It is in these countries with a window of opportunity for unusually rapid
countries, and among poorer populations within
economic growth because the proportion of the population that
wealthier countries,19 that the status of women,
maternal death, child marriage and many other is in the working age range is historically high, relative to the

concerns of the International Conference have number of children and older working people. Young people can,
seen minimal progress since 1994, and life if provided with education and employment opportunities, sup-
expectancies continue to be unacceptably low.20
port higher economic growth and development. Sub-Saharan
The threats to women’s survival are especially
acute in conditions of structural poverty, owing to Africa will experience a particularly rapid increase in the size of

their lack of access to health services, particularly the population aged 25-59 in the coming decade. 24
sexual and reproductive health services, and the
extreme physical burdens of food, production,
water supply and unpaid labour that fall dispro- 26 Access to mobile phones and the Internet has
portionately on poor women. raised the aspirations of young people today for
lives they could not have imagined previously, and
New challenges, realities and
informed many of them about their human rights
and the inequalities they experience.25 Capi-talizing
23 The dramatic decline in global fertility
on those aspirations will require significant
since the International Conference has led to a
investments in education and reproductive health,
decrease in the rate of population growth;
nevertheless, owing in part to demographic inertia,
the world’s popu-
5888 ICPD BEYOND 2014
enabling young people to delay childbearing and them with access to higher education and the t
acquire the training needed for long, productive labour market while residen- i
lives in a new economy. And because they too will a
eventually be part of an ageing society, they will l
need opportunities for lifelong learning and for
social, economic and political participation i
throughout their lives. They will also need the n
skills to be responsible stewards of the planet and s
the environmental legacy left to them. e
⠀256⤀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀĀȀ⸀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ̀̀ĀȀ⸀ĀᜀĀᜀĀ u
ᜀĀᜀĀᜀĀᜀĀᜀĀᜀ̀̀ЀȀ̀⠀⤀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ㜀ĀȀ⸀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ r
ĀᜀĀᜀ㠀ĀȀ⸀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ We are living in a time of i
relative global peace. Although the world has t
experienced a precipitous decline in inter-State y
warfare since the end of the cold war,26 in the two
decades since 1994 deeply held distinctions based on c
religious and political values have become a
increasingly apparent, with the human rights and n
autonomy of women and girls a frequent touchstone
of ideological difference.27 In no country are women l
fully equal to men in political or economic power. e
However, while most States are progressing — albeit a
slowly — towards gender equality,28 in a number of d
States the rights and autonomy of women are being
curtailed.29 t

ᜀĀᜀĀᜀĀᜀĀᜀĀᜀ̀̀ЀȀ̀⠀⤀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ㜀ĀȀ⸀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ h
ĀᜀĀᜀ㠀ĀȀ⸀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ Internal migration, a common i
response to structural inequality and an integral g
part of the development process, was far smaller in h
scale in 1994, but by 2008 more than half the e
world’s pop-ulation had become urban dwellers, r
and cities and towns are now growing by an
estimated 1.3 million people per week, a result of r
both natural increase and migration. Greater i
mobility, both within and between countries, means s
that people are living in an increasingly
interconnected and interdependent world. The
rapid growth of the urban population is one of the
major demographic transformations of the century,
and international, national and subnational
leadership will be sorely needed if cities are to be
places of innovation, economic growth and well-
being for all inhabi-tants. And while the growing
internal migration of young people to urban areas 32
represents gains in agency, freedom and
opportunity, migrants experience a host of
vulnerabilities, often living in appalling conditions,
without secure housing, social support or access to
justice. Migration also carries particular
opportunities and risks for young women, providing
ks of sexual violence and reproductive ill- leadership on environmental sustainability grows

health.33 more pressing each day.

0 International migration has become a key feature of Fragmented implementation of

globalization in the twenty-first century. Attracted by the Programme of Action
better living and working conditions and driven by 23 A hallmark of the International Conference was its
economic, social and demographic disparities, conflict inclusiveness, which enabled an un-precedented level of
and violence, some 230 million people — 3 per cent of participation from civil society, both during the preparatory
the world’s population process, the non-governmental organization (NGO) forums
— currently live outside their country of origin. Mi- and the Conference itself, and expanded the range of
grants whose rights are protected are able to live with issues addressed in the outcome document. The
dignity and security and, in turn, are better able to Programme of Action included 16 chapters that defined
contribute to their host societies and countries of objectives and actions for more than
origin, both economically and socially, than those who
are exploited and marginalized. 23 dimensions of population and development,
including the interests of distinct population
1 With global economic growth has come a groups, calls for investments in young women’s
massive increase in greenhouse-gas emissions. In capabilities and concern for the implications of
2013 the concentration of CO2 in the atmosphere demographic phenomena, and recommended
surpassed long-feared milestone of 400 parts per actions to be taken.
million for the first time in 3 million years,34 suggesting
that the chances of keeping global warming of the 23 The range of subjects addressed in the
planet to below 2 degrees Celsius above preindustrial Programme of Action offered the potential for a
levels is fading quickly.35 The need for global comprehensive, integrated agenda. However, in
practice Governments and development agencies


were selective and took a sectoral approach to the General Assembly underscored the need for
implementation. Programmes promoting repro- a systematic, integrated and comprehensive
ductive rights, for example, ignored quality of care approach to population and development, one
and inequalities in access to services. Similarly, that would respond to new challenges relevant
investments in cities failed to effectively take into to population and development and to the
account and embrace urban population growth, changing development environment, as well as
and in doing so left large numbers of the urban reinforce the integration of the population and
poor and other marginalized groups without land, development agenda in global processes related
housing security or access to critical services. In to development. The findings and conclusions of
addition, decades of attention to international mi- the operational review suggest a new framework
gration notwithstanding, large numbers of migrants for population and development beyond 2014
both documented and in an irregular situation, built on five thematic pillars: dignity and human
continue to be excluded from full participation rights; health; place and mobility; governance
in their societies of destination. In numerous and accountability; and sustainability.
examples across multiple sectors, development
efforts continue to fail to ensure universal respect 23 The new framework acknowledges that the
for human rights or consistent investment in the motivations for development are generated by human
capabilities and dignity of disadvantaged individu- aspirations for dignity and human rights, for good
als throughout the life course. health, and for both security of place and mobility.
While these aspirations are interlinked and reaffirm
Foundation for population and one another, they offer distinct organizing thematic
development beyond 2014 pillars for reviewing the numerous prin-ciples,
23 In its resolution 65/234 on the review of the objectives and actions contained within all the
implementation of the Programme of Action of the chapters of the Programme of Action. While the
International Conference on Population and objectives of the International Conference touched on
Development and its follow-up beyond 2014, many different dimensions of well-being across

Thematic pillars of SUSTAINABILITY

population and development




5888 ICPD BEYOND 2014

the life cycle and many domains of population and human rights to all persons. Principle 1 of the Pro-

development, they each contribute, in the main, to gramme of Action affirmed that all human beings
the fulfilment of dignity and human rights, good are born free and equal in dignity and rights and
health, a safe and secure place to live, and are entitled to the human rights and freedoms set
mobility. Because the respect, protection, forth within the Universal Declaration of Human
promotion and fulfilment of human rights are Rights without distinction of any kind. This is
necessary precon-ditions for realizing all of the similarly affirmed and elaborated in international
unfulfilled objectives of the Programme of Action, treaties, regional human rights instruments and
the elaboration and fulfilment of rights are a critical national constitutions and laws. As those rights are
metric for determin-ing whether, for whom, and to guaranteed without distinction of any kind, a
what extent these aspirations have been achieved. commitment to non-discrimination and equality in
dignity lies at the core of all human rights treaties.
0 Furthermore, the framework acknowledges This principle was reinforced in the outcomes
that Governments are accountable, as duty of regional reviews as well as at global thematic
bearers and vital actors, for the realization of all meetings on the Programme of Action beyond
development goals and the fulfilment of the 2014. The operational review also afforded an
aspirations of the Programme of Action. opportunity to focus on the recurrent question of
whether achievements since 1994 have expanded
1 Finally, consistent with objectives stated in the opportunities and rights across all segments of
Programme of Action, as well as the call of the society and across diverse locations. Recognizing
General Assembly in resolution 65/234 to respond that poverty is both the cause and the result of
to new challenges relevant to population and social exclusion and that quality education is a
development, the framework highlights the special path to individual agency, both income inequality
concerns raised by the environmental crises of and education gains since the International Con-
today and the threat that current patterns of ference are addressed in the section on dignity and
production, consumption and emissions pose for human rights.
equitable development and sustainability. Figure 1
illustrates and reaffirms the core message of the 0 Health. The right to the highest attainable standard
Programme of Action: that the path to sustainable of health, the significance of good health to the
development is through the equitable achievement enjoyment of dignity and human rights and the
of dignity and human rights, good health, security importance of healthy populations to sustainable
of place and mobility, and achievements secured development are undeniable. The International
through good governance and accountability, and Conference recognized the centrality of sexual and
that the responsibilities of governance extend to reproductive health and rights to health and
the national and global promotion of integrated development. Sexual and reproductive health and
social, economic and environmental sustainabil-ity rights spans the lives of both women and men,
in order to extend opportunity and well-being to offering individuals and couples the right to have
future generations. control over and decide freely and responsibly on
matters related to their sexual and reproductive
health, and to do so free from violence and coercion.
2 Dignity and human rights. The primary Sexual and reproductive health and rights are
attention to dignity and human rights is motivated essential for all people, particularly women and girls,
by the assertion that completing the unfinished to achieve dignity and to contribute to the enrichment
agenda of the International Conference will and growth of society, to innovation and to
require a focused and shared commitment to sustainable development. Between 1990 and 2010,
human rights, non-discrimination and expanding the global health burden shifted towards non-
opportunities for all. Any development agenda that communicable diseases and injuries, including those
aims at individual and collective well-being and due to ageing. At the same time, communicable,
sustainability has to guarantee dignity and maternal,


nutritional and neonatal disorders, many of which the planning and evaluation of population- and
are preventable, have persisted in developing development-related investments and in the
countries, especially in sub-Saharan Africa and elaboration of common indicators to measure
Southern Asia. Despite aggregate gains in sexual development. As the world reappraises goals for
and reproductive health indicators, marked the future, progress in participation is at the core,
disparities persist across and within countries, along with the generation and use of knowledge,
further highlighting the persistent inequalities adequate resources and cooperation, and the
inherent in a development model that continues to critical and continuing need for global leadership to
leave many behind. The achievement of uni- implement population and development beyond
versal access to sexual and reproductive health 2014. International human rights protec-tion
and rights will depend on strengthening health systems have gained in authority, jurisdiction and
systems by expanding their reach and compre- monitoring power, and the formal participa-tion of
hensiveness in a holistic manner. civil society as a political force has grown
measurably since 1994, yielding important shifts in
0 Place and mobility. Place and mobility encom- rights-based investments. Yet the political power of
passes the social and spatial environments that we private wealth has never been more promising, nor
live in and move between. The importance of place more threatening, to global development,
and mobility as a thematic pillar resides in linking demanding more representative, public-sector,
the large-scale trends and dynamics of population accountable global leadership.
— household formation and compo-sition, internal
mobility and urbanization, interna-tional migration 23 Sustainability. Finally, sustainability reaffirms
and land and displacement — to the achievement the intrinsic linkages between the goals elabo-
of both individual dignity and well-being and rated in the preceding paragraphs on dignity and
sustainable development. Section IV of the present human rights, health, place and mobility, and gov-
report reviews the changing social and spatial ernance, and underscores that discrimination and
distributions of the human popu-lation since 1994 inequality must be prioritized in both the beyond
and puts forward approaches to integrating these 2014 and post-2015 agendas for the well-being of
changes into public policies so they can support the human population and our common home, the
the human needs for a safe and secure place to planet. The current development model has
live and for mobility. It also highlights the need to improved living standards and expanded oppor-
ensure dignity and human rights for those whose tunity for many, yet the economic and social gains
security of tenure and freedom of movement are have been distributed unequally and have come at
threatened. great cost to the environment. Environmental
impacts, including climate change, affect the lives
1 Governance and accountability. Gover- of all people, but particularly the poor and margin-
nance and accountability is the primary means alized who have limited resources to adapt while
of achieving these goals. The world has seen having contributed the least to human-driven en-
important shifts in the diffusion of authority and vironmental change. This section addresses the
leadership since 1994, with a growing linkages between increasingly diverse population
multiplicity of national, municipal, civil society, dynamics, the environment and inequality, and
private sector and other non-State actors. The builds on the four thematic pillars to put forward a
International Conference generated momentum set of paths to sustainability that can help to deliver
at the national level for the creation and renewal dignity and human rights for all beyond 2014. The
of institutions to address population dynamics, integrated and comprehensive ap-proach to
sustainable development, sexual and repro- population and development set forth in the
ductive health, the needs of adolescents and present report is essential for achieving
youth, and gender equality. The past 20 years sustainable development, as set out by Member
have also seen a measureable increase in the States and the Secretary-General in their vision for
formal participation of intended beneficiaries in the post-2015 development agenda.


Programme of Action beyond 2014: building almost 15 years. As the United Nations

global sustainability on a foundation of considers the post-2015 development agenda,
individual dignity and human rights the goals and principles of the Programme of
23 As the debates and policies on population before Action and the findings of the operational review
the International Conference demonstrated, large- contribute important elements to fulfil human
scale global fears have too often been prioritized over rights, equality and sustainable development.
the human rights and freedoms of individuals and
communities, and at worst have been used to justify A. The realization of human rights
constraints on human rights. Debates on
environmental sustainability, and on stimulating 23 In analysing the situation regarding individual well-
economic growth following the crisis of 2008, risk the being as envisaged in the Programme of Action,
same consequences. The imperative of the post- underlying questions have been the extent to which
2015 development agenda is to bring social, progress has been equitable across diverse segments
economic and environmental sustainability together of society and the extent to which human rights
within one set of global aspirations; the findings and affirmed in the Programme of Action have been
conclusions of the operational review argue for realized. Consistent with the fundamental
integrating these often disparate aims. commitment of the Programme of Action to create a
more equitable world, one in which security, educa-
24 The vital importance of the paradigm shift of tion, wealth and well-being would be shared by all
the International Conference — subsequently persons, the operational review explicitly examined
affirmed by progress in the two decades since — social and spatial inequalities wherever possible.
was precisely in demonstrating that individual and
collective development aspirations benefit from a 24 The shared vision of development, human
central focus on individual dignity and human rights and a world order based on peace and
rights. By updating such principles and advancing security has been at the foundation of the United
their implementation, Governments can achieve Nations since its conception. Article 1, paragraph
the goals set forth in 1994 while accelerating 3, of the Charter of the United Nations (1945)
progress towards a resilient society and a sustain- states that a main purpose of the Organization is to
able future for all. Central to this exercise are laws “achieve international cooperation in … promoting
and policies that will ensure respect and protec- and encouraging respect for human rights and for
tion of the sexual and reproductive health and fundamental freedoms for all without distinction as
rights of all individuals, a condition for individual to race, sex, language, or religion”. The Universal
well-being and for sustainability. Declaration of Human Rights (1948) and the two
binding International Covenants on Human Rights
25 As elaborated in the findings of the operational (1966) set out an expansive list of civil and
review described below, the ideals of equitably political, as well as economic, social and cultural
expanding human rights and capabilities, especially rights that Member States are obliged to respect,
for young people, are shared by most Member protect and fulfil. The human rights protection
States, and most Governments report having system has evolved substantially since 1948,
addressed efforts at reducing poverty, raising the incorporating numerous international conventions
status of women, expanding education, eradicating as well as resolutions, declarations, decisions and
discrimination, improving sexual and reproductive principles. A growing regional human rights
health and well-being, and embracing sustainability. protection system has emerged to complement
Progress is nonetheless uneven, and the persis- international efforts, providing rights protections
tence of inequalities is evident throughout. Much that are responsive to the context of each region.
work will be needed in the decades ahead.
25 While all human rights are indivisible and
26 The Millennium Development Goals have been interconnected, a variety of treaties and policy
guidance elaborate specific areas of rights. The
the unifying global framework for development for


Convention on the Elimination of All Forms of 5888 In affirming the centrality of human rights
Discrimination against Women (1979) and the with regard to population, the Programme of Action
Convention on the Rights of the Child (1989) acknowledged “that reproductive rights embrace
clarify specific rights and obligations, articulate certain human rights that are already recognized”,
the rights of women and children more and that these rights rest on the recognition of “the
completely, and provide guidance on how these basic right of all couples and individuals to decide
rights are to be respected, protected and fulfilled. freely and responsibly the number, timing and
spacing of their children and to have the informa-
23 Following as it did the World Conference on tion and means to do so, and the right to attain the
Human Rights (1993), which affirmed that all highest standard of sexual and reproductive
human rights are universal, indivisible and health”, as well as the “right to make decisions
interdependent and interrelated, and devoted a concerning reproduction free of discrimination,
special section of the Vienna Declaration and coercion and violence, as expressed in human
Programme of Action to the equal status of women, rights documents” (para. 7.3).
the International Conference on Population and
Development brought together development and 5889 The Programme of Action also reaffirmed
human rights in a compelling and operational civil rights of direct relevance to migration, mobility
manner. The Beijing Declaration put it simply: and human security. It called on all countries to
“Women’s rights are human rights” (para. 14). “guarantee to all migrants all basic human rights
as included in the Universal Declaration of Human
24 The International Conference on Population Rights” (principle 12), and “the right to seek and
and Development affirmed that the widely ac- enjoy in other countries asylum from persecution”
knowledged international commitments to human (principle 13). It also provided protections for
rights should be applied to all aspects of popula- mobil-ity, elaborating that “population distribution
tion and development policies and programmes. policies should ensure that the objectives and
Building on the World Conference on Human goals of those policies are consistent with ... basic
Rights, a major achievement of the International human rights” (para. 9.3). Regarding human
Conference was the explicit recognition of the security, the Programme of Action reaffirmed for all
connection between human rights, population and persons “the right to an adequate standard of
development. The Programme of Action affirmed living for themselves and their families, including
that “the right to development is a universal and in- adequate food, clothing, housing, water and
alienable right, and an integral part of fundamental sanitation” (principle 2).
human rights, and the human person is the central
subject of development”. Looking forward to the 5890 The 19 years following the International
challenges and obligations of sustainability, the Confer-ence on Population and Development
Programme of Action acknowledged that “the right witnessed the expansion of both international and
to development must be fulfilled so as to equitably regional systems for the protection of human rights,
meet the population, development and environ- with specific advances related to many of the popu-
mental needs of present and future generations” lation and development objectives proposed in the
(principle 3). Programme of Action. In particular, the Fourth World
Conference on Women, held in Beijing in 1994,
25 The Programme of Action also affirmed that marked an important milestone for women’s
all human beings are born free and equal in empowerment, gender equality and human rights
dignity and rights and entitled to all the rights and globally. The Platform for Action adopted by the
freedoms set forth in the Universal Declaration of Beijing Conference outlined objectives and key
Human Rights, without distinction of any kind, actions regarding gender equality, including in the
such as race, sex, language, religion, political or fields of poverty eradication, education and training,
other opinion, national or social origin, property, health, violence against women, women’s economic
birth or other status (principle 1). participation and women’s human rights.


0 The elimination of violence against women has on Human and Peoples’ Rights on the Rights of

also received substantial attention in regional Women in Africa (2003) and the African Youth Charter
commitments since 1994, with the African, inter- (2006). The Protocol to the African Charter on Human
American, and European human rights systems all and Peoples’ Rights on the Rights of Women in Africa
developing instruments that address violence made important advances in protecting and
against women. promoting women’s rights and gender equality,
elaborating international com-mitments within the
1 Human rights laws related to mobility, in specific cultural and political contexts of the region. In
particular the rights of migrant populations, have addition to affirming the rights to development,
also gained attention since the International education, employment and socioeconomic welfare,
Conference. The Programme of Action invited the Protocol highlights the specific impact of many
States to ratify the International Convention on the issues for women in Africa, including land rights and
Protection of the Rights of All Migrant Workers inheritance, harmful prac-tices, HIV/AIDS and
and Members of Their Families of 1990 (para. reproductive health, as well as marriage, divorce and
10.6); the Convention entered into force in 2003, widowhood. Globally, the African Youth Charter and
less than a decade later. the Ibero-American Con-vention on the Rights of
Youth (2005) represent the only youth-centred,
2 Particular advances were also noted in extend- binding regional instru-ments to date that explicitly
ing the human right to dignity and non-discrimina- aim to respect and fulfil the rights of youth. These
tion to all persons and affording rights protections expansive documents promote youth empowerment,
to population groups that endure persistent stigma, development and participation, and protect and
discrimination and/or marginalization. For example, promote youth rights to non-discrimination, freedom
the Programme of Action affirmed the rights of of expression, health, work and professional training.
persons with disabilities, and in 2006 the Conven-
tion on the Rights of Persons with Disabilities was 23 Despite the numerous advances in human
adopted, formally acknowledging those rights. rights in the past two decades, as described
In 2007 the United Nations Declaration on the throughout the present report, significant gaps
Rights of Indigenous Peoples was adopted by the remain in the equitable application of these
General Assembly, recognizing the right to self- rights to all persons, as well as in the
determination of indigenous peoples as well as the development of systems of accountability. 36 The
principle of free, prior and informed consent on all prospects and need for accountability systems
matters affecting their rights. In 1997, the Interna- are foreshadowed throughout the report and
tional Guidelines on HIV/AIDS and Human Rights reviewed in greater depth under the heading
presented a framework for promoting the rights of “Governance”, with specific recommendations.
persons living with HIV and AIDS.
B. Methodology, data sources
3 Despite such developments, the human rights
principles related to equality and non-discrimi- and structure of the report
nation have unfortunately remained unrealized for 5888 The methodology and activities of the op-
many groups, principal among them girls and erational review were developed jointly, on the
women, and persons of diverse sexual orientation basis of consultation and agreement with Member
or gender identity. In some countries, laws banning States, the United Nations system and other
certain consensual adult sexual behaviour and re- relevant partners identified in General Assembly
lationships, including relations outside of marriage, resolution 65/234, including civil society and other
remain in force. institutions. The operational review was based on
the highest-quality data generated by Member
4 The African regional human rights system has States, including the global survey of the
developed markedly since 1994, notably through Programme of Action beyond 2014 (2012)
the adoption of the Protocol to the African Charter


and country implementation profiles designed in 5888 Data and analysis from peer-reviewed
consultation with all partners, principally sources and related inter-agency processes
Govern-ments. In addition, global thematic such as special ad hoc consultations organized
conferences or meetings were held on a number by the thematic groups and the secretariat of
of issues where more in-depth examination and the International Conference on Population and
multi-stakeholder discussion was required, Development beyond 2014 on the implementa-
beyond the global survey, on youth, women’s tion of the Programme of Action
health, human rights and monitoring framework
for the Programme of Action beyond 2014. 5889 Data, analyses and reports on financial
resource flows relating to the implementation of
0 The results of these activities, regional reviews the Programme of Action, including available
by the regional commissions and ministe-rial cost estimates for implementation up to 2015
regional reviews of the Programme of Action 5890 Documentation issued in connection
beyond 2014 and the source material listed below with the tenth and the fifteenth
provided the basis for the analyses and recom- anniversaries of the International
mendations contained in the present report: Conference on Population and
0 Country implementation profiles
5891 Documents concerning the post-2015 de-
1 Global survey on the implementation of the velopment agenda that are relevant to the
Programme of Action of the International operational review, in particular the outcome of
Conference on Population and Development the Global Consultation on Population Dynam-
ics in the Post-2015 Development Agenda and
2 Outcome document of the Global Youth the declaration adopted at the Global
Forum and technical papers prepared in the Leadership Meeting on Population Dynamics
context of the meeting and the Post-2015 Development Agenda, held
in Dhaka in March 2013; the United Nations
3 Report of the International Conference on Task Team paper on population dynamics; as
Population and Development beyond 2014 well as papers and outcome documents from
International Conference on Human Rights the global thematic consultations on health,
and technical papers prepared in the context education, inequalities and governance.
of the meeting
23 The global survey was completed by 176
4 Recommendations of the expert consultation Member States and 7 territories and areas,
on women’s health: rights, empowerment and representing all regions; it provides new data on
social determinants and technical papers the establishment of government institutions to
prepared in the context of the meeting address key concerns related to the Programme of
Action, on the extent to which Governments have
5 Recommendations of the international addressed selected issues in the preceding five
meeting on monitoring and implementation of years, and on government priorities in related
the Programme of Action of the International domains for the coming 5-10 years.
Conference on Population and Development
beyond 2014 24 Data on health outcomes, population change,
gender values, socioeconomic status and educa-tion
6 Reports prepared by the regional are based on evidence reported by countries and
commissions based on the regional analyses obtained through censuses; household surveys
of the global survey data and the outcomes (such as demographic and health surveys and
of the regional conferences multiple indicator cluster surveys); trends and
projections generated by the United Nations
Population Division; monitoring systems of United

5888 ICPD BEYOND 2014

Nations entities such as the World Health Organi- Assembly resolutions; and outcome documents

zation (WHO), the Joint United Nations Programme of intergovernmental processes that reaffirm
on HIV/AIDS (UNAIDS) and the United Nations Chil- human rights commitments.
dren’s Fund (UNICEF); and other surveys, including
the World Values Survey, that were the results 23 Elaborations on international and regional
of academic collaboration requiring approval by human rights instruments that have been adopted
Member States; the data were enriched by anal- since 1994 and that are relevant to key topics are
yses drawn from technical reports commissioned shown in boxes throughout the report. These
as part of the operational review. Details on the correspond to three levels of obligation: 39
methods of analysis are provided in the annex.
23 For analytical purposes, data presented in the 23 Treaties, covenants and conventions that
present report have been aggregated, or grouped, are legally binding for States that have
into geographic regions and subregions, income ratified them and that have entered into
groups, and more developed and less developed force once they have received a sufficient
regions. The geographical regions or subregions number of ratifications;
used are based on the standard country or area
codes and geographical regions for statistical use 24 Negotiated outcomes and consensus
(M49)37 classification of the United Nations but they statements of intergovernmental bodies on
may vary slightly within the report, depending on human rights, such as resolutions and
the distinct groupings used by the international or- declarations that elaborate human rights
ganizations from which data have been drawn and/ commitments related to specific topics. Several
or the statistical clustering of countries according to other intergovernmental negotiated outcomes
selected characteristics. Classification of countries were selected in view of their importance to
by income group is as provided by the World Bank,
based on gross national income (GNI) per capita. 38
The “more developed countries” include all
European countries, Australia, Canada, Japan,
New Zealand and the United States of America.
How to read the human rights
Countries or areas in Africa, Latin America and the boxes
Caribbean, Asia (excluding Japan) and Oceania
(excluding Australia and New Zealand) are 5888 Binding Instruments
grouped under “less developed regions”. Conventions, Covenants, Treaties

24 Key principles, objectives and actions 5889 Intergovernmental

contained in the Programme of Action that are Human Rights Outcomes
representative of the relevant thematic pillar Declarations, Resolutions
are listed at the beginning of each section.
2a. Other Intergovernmental
25 The human rights mapping contained in the
present report was conducted by means of a
Conference Outcome and
review of the Universal Declaration of Human
Consensus Documents
Rights; the International Covenant on Civil and
Political Rights; the International Covenant on
Economic, Social and Cultural Rights and the
23 Other Soft Law Documents
Guiding Principles, General
seven additional core international human rights
treaties; key international and regional human Comments, Recommendations,
rights instruments; general comments and rec- Concluding Observations of the
ommendations of the human rights treaty bodies; Treaty Monitoring Bodies
reports of special rapporteurs; selected General


the operational review including conference contained in the Programme of Action are
outcomes and consensus documents which, based and the mechanisms through which
although not human rights instruments, they have evolved over the past 20 years.
contain human rights standards;
23 The text in bold type in the report indicates
23 Other soft law instruments, such as general recommendations for addressing specific issues
comments and recommendations of the raised within each thematic pillar. At the end of
human rights treaty monitoring bodies that each section, key areas for future action
offer interpretations on the content of human synthesize the main findings and recommendations
rights provisions included in the core of the thematic pillar. The final section concludes
international treaties. with seven “paths to sustainability” that define the
contributions of the new framework for the
23 The principal human rights instruments men- Programme of Action beyond 2014 to the
tioned in the boxes define the foundational rights achievement of sustainable development.
upon which the principles, objectives and actions

23 A. Sen, Development as Freedom (New 5888 United Nations Millennium Project, Task 0 Joint United Nations Programme on HIV/AIDS
York, Knopf, 1999). Force on Education and Gender Equality, Taking (UNAIDS), Global Report: UNAIDS Report on the
24 Report of the International Conference on Popu- action: Achieving Gender Equality and Empow- Global AIDS Epidemic 2013 (Geneva, 2013).
lation and Development, Cairo, 5-13 September ering Women (London, Earthscan, 2005). 1 WHO, Everybody’s Business: Strengthening Health
1994 (United Nations publication, Sales No. 5889 United States of America. Office of the Systems to Improve Health Outcomes — WHO’s
E.95.XIII.18), chap. I, resolution 1, annex. Director of National Intelligence, Global Trends Framework for Action (Geneva, 2007).
25 Paragraph 7.2 of the Programme of Action defines 2025: A Transformed World (Washington, D.C., 2 P. Collier, The Bottom Billion: Why the
reproductive health as “a state of com-plete physical, Govern-ment Printing Office, 2008). Poorest Countries Are Failing and What
mental and social well-being and not merely the 0 Ibid. Can Be Done About It (New York, Oxford
absence of disease or infirmity, in all matters relating 1 The World’s Women 2010: Trends and University Press, 2007).
to the reproductive system and to its functions and Statistics (United Nations publication, Sales 3 Paul Collier, op. cit.; State of World Population
processes. Reproduc-tive health therefore implies No. E.10.XVII.11). Data analysed from the World 2002: People, Poverty and Possibilities (United
that people are able to have a satisfying and safe Values Survey ( Nations publication, Sales No. E.02.III.H.1).
sex life ...” Paragraph 7.4 states that “The 2 C. Garcia-Moreno and others, WHO Multi-Country 4 UNFPA, Marrying too Young: End Child
implementation of the Programme of Action is to be Study on Women’s Health and Domes-tic Violence Mar-riage (see footnote 5 above); WHO
guided by the comprehensive definition of against Women: Initial Results on Prevalence, and others, Trends in Maternal Mortality
reproductive health, which includes sexual health”. Health Outcomes and Women’s Responses (see footnote 6 above).
Based on this and paragraph 7.3 which states that (Geneva, World Health Organization, 2005); C. 5 World Population Prospects: The 2012
“… re-productive rights embrace certain human Garcia-Moreno and others, Global and Regional Revision (see footnote 7 above).
rights that are already recognized in national laws, Estimates of Violence against Women: Prevalence 6 Ibid.
international human rights documents and other and Health Effects of Intimate Part-ner Violence and 7 World Population Prospects: The 2012 Revision —
consensus documents”, sexual and reproduc-tive Non-partner Sexual Violence (Geneva, World Health Highlights and Advance Tables (ESA/P/WP.228).
health and rights derive from rights under the Organization, 2013). 8 World Population Prospects: The 2012
definition of reproductive health. Revision (see footnote 7 above).
3 H. Kharas, “The emerging middle class in 9 N. Halewood and C. Kenny, “Young people
26 The Millennium Development Goals developing countries”, OECD Development and ICTs in developing countries”
Report 2013 (United Nations publication, Centre Working Paper No. 285 (Paris, OECD (Washington, D.C., World Bank, 2008). Available
Sales No. E.13.I.9. Publishing, 2010); F. H. G. Ferreira and from
27 United Nations Educational, Scientific and Cultural others, Economic Mobility and the Rise of solid/_layout/dc/k-r/youngsub.pdf.
Organization (UNESCO), World Atlas of Gender the Latin American Middle Class 10 L. Themnér and P. Wallensteen, “Armed con-
Equality in Education (Paris, 2012); United Nations (Washington, D.C., World Bank, 2013). flicts, 1946-2012”, Journal of Peace Research,
Population Fund (UNFPA), Mar-rying too Young: 4 WHO and others, Trends in Maternal Mortality (see vol. 50, No. 4 (2013), pp. 509-521.
End Child Marriage (New York, 2012); United footnote 6 above); United Nations Popula-tion Fund, 11 “Religion, politics and gender equality”, UNRISD
Nations, Department of Economic and Social “Giving birth should not be a matter of life and Research and Policy Brief No. 11 (Geneva, United
Affairs, Population Division (2011), World Fertility death”, UNFPA Factsheet (December 2012), Nations Research Institute for Social Develop-ment,
Policies 2011. available from 2011). Available from
28 World Health Organization (WHO) and others, site/global/shared/factsheets/srh/EN-SRH%20 fact 12 The World’s Women 2010: Trends and
Trends in Maternal Mortality: 1990-2010 —WHO, %20sheet-LifeandDeath.pdf. Statistics (see footnote 11 above).
UNICEF, UNFPA and The World Bank Estimates 5 I. H. Shah and E. Ahman, “Unsafe abortion 13 Human Rights Watch, World Report 2013: Events of
(World Health Organization, Geneva, 2012). differ-entials in 2008 by age and developing 2012 (New York, Seven Stories Press, 2013).
29 The decrease in the total fertility rate is calcu-lated country region: high burden among young 14 World Urbanization Prospects: The 2011
using the point estimates for the years 1990 and
women”, Reproductive Health Matters, vol. Revi-sion (ST/ESA/SER.A/322).
2010 from World Population Pros-pects: The 2012
20, No. 39 (2012), pp. 169-172.
Revision (ST/ESA/SER.A/336).


0 Estimated average weekly growth of the 0 Potsdam Institute for Climate Impact Research and
total urban population between 2005 and Climate Analytics for the World Bank, Turn Down

2010, derived from World Urbanization the Heat: Why a 4o C Warmer World Must Be
Prospects: The 2011 Revision. Avoided (Washington, D.C., World Bank, November
1 M. Bell and S. Muhidin, Cross-National Compar-ison 2012).
of Internal Migration, Human Development Reports, 1 International Conference on Population and
Research Paper 2009/30 (United Nations Development Beyond 2014 International
Development Programme, July 2009). Conference on Human Rights, Netherlands, 7-
2 M. Temin and others, Girls on the Move: Ado- 10 July 2012, Chair’s closing statement.
lescent Girls and Migration in the Developing 2 For the composition of macrogeographical
World — A Girls Count Report on Adolescent (continental) regions and geographical subre-
Girls (New York, Population Council, 2013); gions, see
A. M. Gaetano and T. Jacka, eds., On the m49/m49regin.htm.
Move: Women and Rural-to-Urban 3 As at 1 July 2012. For further details see
Migration in Con-temporary China (New
York, Columbia Univer-sity Press, 2004). classifications.
3 United States, Department of Commerce, 4 The list of human rights documents reviewed in this
National Oceanic and Atmospheric Administra- report is not exhaustive. The report focuses on
tion, Earth System Research Laboratory, Global international human rights instruments rele-vant to
Monitoring Division, Up-to-date weekly average the operational review, and does include
CO2 at Mauna Loa. Retrieved from www.esrl. International Labour Organization Conventions or on instruments of international humanitarian law. The
8 December 2013. list of “Other intergovernmental outcomes” is
selective and abbreviated, representing only several
documents that were critical to this review.


2 Dignity and
Human Rights

Programme of Action, principle 1

All human beings are born free and equal in dignity and rights. Everyone is entitled to all the rights
and freedoms set forth in the Universal Declaration of Human Rights, without distinction of any kind,
such as race, colour, sex, language, religion, political or other opinion, national or social origin,
property, birth or other status. Everyone has the right to life, liberty and security of person.”

Programme of Action, principle 4

“Advancing gender equality and equity and the empowerment of women, and the elimination of
all kinds of violence against women, and ensuring women’s ability to control their own fertility,
are cornerstones of population and development-related programmes. The human rights of
women and the girl child are an inalienable, integral and indivisible part of universal human
rights. The full and equal participation of women in civil, cultural, economic, political and social
life, at the national, regional and international levels, and the eradication of all forms of
discrimination on grounds of sex, are priority objectives of the international community.”
people. The principles of the Programme of Action
establish the link between dignity and human rights and
0 Principle 1 of the Programme of Action of individual well-being.
the International Conference on Population and
Development affirms that “all human beings are
born free and equal in dignity and rights” and
are entitled to all the rights and freedoms as set
forth in the Universal Declaration of Human
Rights, without distinction of any kind. These
principles underscore the urgent need to
eradicate all forms of discrimination and affirm
that the principal aim of population-related goals
and policies is to improve the quality of life of all
economic and political life; to freedom of informa-
tion; to be free from discrimination and violence; to
0 Dignity is intrinsically interlinked with security of residence as well as freedom of human
human rights and fundamental freedoms. mobility; it requires that individuals be provided
As reflected in the Programme of Action, access to opportunities to build and renew their
dignity includes far more than the meeting capabilities across the life course. Dignity includes
of basic needs; it includes the right to the foundational human right to sexual and repro-
education; to full participation in social, ductive health and the freedoms to choose whom to
love, whether and when to have children, and


the guarantee that sex and reproduction are a people, or more than 30 per cent of the world’s
source of human happiness and can be engaged population, live in poverty. In fact, the number of
in without fear of illness or a risk to health. These people living in multidimensional poverty
entitlements and freedoms are a precondition for a surpasses that of those living in income poverty
thriving, inclusive society, composed of resilient in many fast-growing countries of the South.43
individuals who can innovate and adapt, and
ensure a shared and vibrant future for all persons. 0 Poverty occurs in all countries, and women
bear a disproportionate burden of its conse-
ᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ匀ĀĀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ quences, as do the children they care for. Be-
舀0This section of the report examines progress cause poverty has historically been measured at
since 1994 in the achievement of equality and non- the level of the household, without measures of
discrimination, especially among population groups intra-household inequality, the differential
at high risk of discrimination. It identifies gaps and poverty of women and men has been obscured.
challenges in implementing the Pro-gramme of But when comparing households occupied by a
Action as it relates to dignity and human rights, single adult (with or without children), the greater
provides concrete recommendations and highlights poverty among women compared to men is
key areas for future action. irrefutable.44 For similar reasons, poverty among
specific population groups, e.g. persons with
A. The many dimensions disabilities and older persons is equally difficult
to measure. The eradication of extreme poverty
of poverty is universally achievable, and is at the centre of
0 Poverty is the deprivation of one’s ability to live realizing dignity and human rights for all.
as a free and dignified human being with the full
potential to achieve one’s desired goals in life. 40 1 Central to the other thematic pillars, health is
Poverty has many manifestations. It is the lack of vital to all conceptions of poverty. Health is nec-
income and productive resources suffi-cient to essary for the achievement of well-being and for
ensure sustainable livelihoods, but also includes longevity. Poverty undermines health by exposing
many other deprivations, such as food insecurity; people to poor living conditions, where sanitation,
lack of health care, education and other basic shelter and clean water are lacking, and by cre-
services; inadequate or no housing; lack of safety ating barriers to access to health, social and legal
or means of redress; and lack of voice or access to services in societies where access to services is
information or political participation.41 The limited to those who have sufficient resources.45
experience of poverty is dynamic, with some
trapped in it while others move in and out, and 2 Each of these factors is in turn shaped by
many are living at the threshold. place and mobility. Insecurity of place, whether in
the form of homelessness, limited rights to land
1 Between 1990 and 2010, the number of people ownership or tenure, substandard housing or
globally living in extreme poverty fell by half as heightened exposure to natural or manmade
a share of the total population in developing disasters, war or conflict, threatens the livelihoods
countries (from 47 per cent to 22 per cent), a of the poor and drives many in poverty, or traps
reduction of 700,000,000 people.42 However, them there. Such insecurity, combined with a lack
despite this significant reduction in the number of of freedom and resources to move, is itself a
people living in poverty, an estimated 1.2 billion critical contributor to extreme vulnerability.
poor people have been left behind in extreme
poverty. Using a multidimensional definition of 3 Lack of participation in governance and
poverty that includes, for example, a measure of accountability is a vital component of multidimen-
human deprivation in terms of health, education sional poverty. The benefits of society go to those
and standard of living, the United Nations who are able to participate in its creation. Poverty
Development Programme (UNDP) estimates that, undermines participation and dims the voices of
in 104 countries studied, some 1,570,000,000


the poor, especially where there is a high degree of the waste and by-products of environmentally so
inequality. Poverty is both a cause and a conse- unfriendly industry and development heavily ci
quence of multiple human rights deprivations for impact the poor and compound poverty. al
which, often, no one is held accountable. Partici-
pation means ensuring that duty bearers are held 0 In responding to the global survey of the
responsible and that laws are enforced. Programme of Action beyond 2014, not only did an
overwhelming majority of Governments (93 per bi
0 Finally, poverty is fundamentally related to cent) indicate that they are addressing46 “the lit
sustainability. Economic growth is a necessary eradication of poverty, with special attention to y,
engine of poverty reduction. However, the global income generation and employment strategies”, a
rise in income and wealth inequality, together with but “social inclusiveness, and protection of the n
the environmental impacts of economic growth, poor” were prioritized across numerous segments d
underscore that economic growth alone is of the survey. For example, when asked to identify
insufficient for inclusive development. Economic public policy priorities for sustaining family welfare
growth and finite environmental resources are over the next 5-10 years, Governments were most
being directed disproportionately to the wealthy, likely to include “social protection of the family” (77 h
undermining poverty reduction. At the same time, per cent), which captured all priorities per-taining to c
the provision of social services and/or investments o
for the fulfilment of basic needs. n
Human rights elaborations di
1 States should develop, strengthen and
since the International implement effective, integrated, coordinated
Conference on Population o
and coherent national strategies to eradicate
and Development poverty and break the cycles of exclusion and


inequality as a condition for achieving
BOX 1: Poverty
development, also targeting persons belonging
to marginalized or disadvantaged groups, in
Intergovernmental human rights
both urban and rural areas, guaranteeing for all
outcomes. The General Assembly has
people the chance to live a life free from poverty
adopted a series of resolutions on the
and to enjoy protection and exercise of their
relationship between human rights and
human rights.
extreme poverty, including resolution
65/214 on human rights and extreme
poverty (2012), in which the Assembly The economic and social cost of
reaffirmed “that extreme poverty and ex- income and wealth inequality
clusion from society constitute a violation 0 Achieving equal opportunity and equitable
of human dignity and that urgent national outcomes is the basis for sustained economic and
and international action is therefore re- social well-being. Expanding the capabilities of
quired to eliminate them”. diverse people, through better health, education
and opportunity, expands the collective pool
Other soft law: The Guiding Principles of creative energy, ideas and contributions in a given
on Human Rights and Extreme Poverty society. Technical, economic and social innovations
(2012) are international global policy thrive under conditions in which many people have
guidelines that address the human rights the opportunity to fully participate and succeed in
of people living in poverty in accordance society. The reverse is also true: severe inequalities
with international human rights norms
in access to health, security and high-quality
and standards.
education can prevent large sec-tors of the
population from rising out of poverty and achieving


increasingly narrow the selection of persons while almost 70 per cent of adults possessed
and ideas that contribute to society. only 3 per cent of the wealth.

23 The current distribution of wealth (see figure 2) 0Owing to the convergence of mean incomes of
presents a serious threat to further economic developing and developed economies, global income
growth, inclusiveness, and both social and envi- inequality has been falling in recent years, albeit only
ronmental sustainability. According to the Credit slightly, and from a very high level. The more recent
Suisse Global Wealth Report, global wealth was stabilization and slight narrowing of global income
estimated at US$ 223 trillion in mid-2012. This inequality largely reflect economic growth in China
works out to an estimated US$ 48,500 for each of since the 1990s, growth in India, and growth in other
the world’s 4.6 billion adults. However, this figure emerging and developing economies since 2000.47
hides enormous inequalities. Approximate-ly 69 per Nevertheless, income inequality within and among
cent of all adults were found in many countries has been rising.48
the lowest wealth category, accounting for only
23 per cent of global wealth. The next
category (US$ 10,000 to US$ 100,000) contained 1Figure 3 depicts the unequal distribution of
1,066 million adults who owned 13.7 per cent of gains in global income from 1988 to 2008.
global wealth. The category from US$ 100,000 to More than half of the gains went to the richest
US$ 1 million included 361 million adults, or 7.7 5 per cent, while 5 per cent or less of global
per cent of the total adult population, who income went to each ventile in the bottom 90
commanded per cent of the population.
5888 3 per cent of global wealth. Finally, the
cate-gory of those with wealth of more than US$ 1 2Increasing economic inequality is disruptive and
mil-lion included 32 million adults, representing highly detrimental to sustainable development.
only 0.7 per cent of the global adult population, From a social perspective, inequality impedes trust
who commanded 41 per cent of the world’s wealth. and social cohesion, threatens public health, and
In short, 8.4 per cent of the adult population in the marginalizes the poor and the middle class from
world commanded 83.3 per cent of global wealth,

The global wealth pyramid 32 million

>USD 1 million USD 98.7 trillion (41%)
USD 100,00 million USD 101.8 trillion (42.3%)
to 1 million (7.7%)
USD 10,000 to 1,066 million USD 33.0 trillion (13.7%)

100,000 (22.9%)

Source: James Davies, Rodrigo < USD 3,207 million USD 7.3 trillion (3%)
Lluberas and Anthony Shorrocks, 10,000 (68.7%)
Credit Suisse Global Wealth
Total wealth
Databook 2013, in Credit Suisse
Global Wealth Report 2013, p. 22,
available from https://publications.
Wealth (percent of world)
file/?fileID=BCDB1364-A105-0560-1 Number of adults
332EC9100FF5C83. (percent of world population)


political influence. Social sustainability, which can 0 Finally, the social and health consequences of


be understood as the capacity of a given society to inequality and exclusion not only hinder the human
promote innovation and adaptability under chang- rights-based development championed at the
ing economic, social and environmental conditions International Conference on Population and
in a manner respectful of human rights, is directly Development, but they also have the potential to
threatened by having a large — and potentially destabilize societies. In today’s globalized world,
growing — sector of the population caught in where information spreads throughout countries
“development traps”, living day-to-day without real and the world in an instant, the increasing concen-
prospects for a better future. tration of wealth and its links with unemployment,
social injustice and powerlessness of millions have
0 Growing inequality also reduces prospects for become a touchstone for political protests, conflict
grappling with emerging environmental crises and and instability.
rebalancing our economic growth with responsibili-
ty for the planet. It has been estimated that 11 1 States should accord the highest priority
per cent of the world’s population accounts for half to poverty eradication by ensuring that all
of all emissions, yet it is the poorest segments of persons have equal opportunities to share in the
the population who are disproportionately affected fruits of economic and social development, to
by natural disasters due to climate change. 49 find productive employment, and to live in peace
and dignity, free from discrimination, injustice,
1 Given the enormous environmental costs of fear, want or disease.
economic growth under the current development
paradigm, the world simply cannot afford the 0 As noted at the outset of this section, eco-
current trajectories of wealth concentration while nomic inequalities are both the cause and the
at the same time sustaining efforts to reduce consequence of other social inequalities, includ-
poverty. Reductions in environmental impact ing those experienced because of gender, race,
necessary to achieve environmental sustainability disability, age or other dimensions of identity and
only heighten this contradiction. circumstance. Given the principal message of

Distribution of global absolute gains in income by population ventile, 1988-2008
(Calculated in 2005 purchasing power parity (PPP) international dollars)
gains in income




0 0 1 1 1 1 1 1

10 10

2 2 2 3 3 4 5 4 3 5
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
Population ventiles, poorest to richest

Source: Branko Milanovic, “Global income inequality by the numbers: in history and now: an overview”, World Bank Policy Research Working
Paper No. 6259, November 2012, pp. 12-16, as cited in World Economic and Social Survey 2013: Sustainable Development
Challenges (United Nations publication, Sales No. E.13.II.C.1).


the International Conference, namely, that invest- 0 As reported by Governments in the global
ments in individual capability, dignity and freedom survey, over 97 per cent of countries worldwide
are the foundation of shared human well-being had programmes, policies and/or strategies to ad-
and sustainable development, the ensuing parts of dress “gender equality, equity and empowerment
this section are devoted to a closer look at the of women”. At least 9 out of every 10 countries,
extent to which dignity, human rights and well- across all regions, had such frameworks in place:
being have, or have not, been advanced for 5888 per cent of countries in Africa; 100 per
women and girls, and for numerous population cent in Asia; 94 per cent in Europe; 94 per cent in
groups identified in the Programme of Action as the Americas; and 93 per cent in Oceania.
experiencing long-standing vulnerability to stigma
and discrimination. 0 However, only three quarters of responding
countries committed themselves to “improving
the situation and addressing the needs of rural
B. Women’s empowerment
women” (76 per cent) and to “improving the
and gender equality welfare of the girl child, especially with regard to
0 Discrimination against certain populations is health, nutrition and education” (80 per cent).
common in many countries, but discrimination
against women is universal. Many young women 0 Changing patterns in productive
are not empowered in the course of childhood.
and reproductive roles
Instead, they are socialized to embrace sub-
ordination to men and to adopt gender values that (a) Changing patterns of employment
hold ideal femininity to be incompatible with 0 The gender gap in labour force participation
independence, power or leadership. In certain has narrowed slightly since 1990, but women
regions, women’s agency may be further com- continue to be paid less than men, to be em-ployed
promised by early or forced marriage, unin-tended more often in the informal sector and in temporary
pregnancy and early childbearing (partic-ularly and insecure jobs, and to command less authority.
without adequate support from the health system), The overall rate of women’s participation in the
lack of education, lower wages than men and labour force remained generally steady at the
gender-based violence. The hallmark commitment global level; however, in the last few years the rate
at the International Conference to women’s of participation of both women and men showed a
empowerment was therefore not only the slight decline. At the regional level, women’s labour
expression of the aspiration for dignity, but pivotal force participa-tion has been variable. It increased
to creating the conditions that will enable half the the most in Latin America and the Caribbean, and
world’s population to have the possibility to define decreased slightly in Eastern Europe and much of
the direction of their lives, expand their capabilities Asia other than South Asia, where it increased
and elaborate their chosen contribu-tions to slightly.50 The labour force participation of women
society. aged
25-5451 has increased in all regions since 1990
1 The Programme of Action was historic in except for Eastern Europe; this is due to
drawing attention, long overdue, to the intimate declin-ing fertility and a lessening impact of
relationship between women’s relative freedom fertility on labour force participation.52
with regard to marriage, sexuality and reproduc-
tion, their gendered position in society, and their 1 Women’s share in wage employment in
lifetime health and well-being. In the years since the non-agricultural sector and in traditionally
1994, the world has seen an impressive prolifer- male-dominated occupations has increased,
ation of national institutions to address women’s although it remained low in jobs associated with
empowerment and gender equality. These status, power and authority. In all regions,
institutions span countries at all income levels women remain significantly underrepresented
and in all regions (see sect. VI.A below). among business leaders and managers.53


0 The gender pay gap is closing slowly, and Asia; it decreased in Asia and increased in


only in some countries,50 and women continue sub-Saharan Africa.
to be paid less than men for equal work. They
also tend to hold jobs that are less secure and ᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀꔀĀȀ⸀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ0 Since
have fewer benefits than those accorded to 1995, the participation of women in paid employment
men, and to be engaged in vulnerable employ- has increased substantially, raising the question how
ment (see figure 4), which comprises contrib- paid employment has affected wom-en’s overall work
uting family workers and own-account workers burden. Studies undertaken in Africa reveal that time
as opposed to wage and salaried workers.54 poverty and income poverty may be interrelated and
Although the overall proportion of total employ- that women in particular suffer from both. In one
ment that is vulnerable employment declined country, while the average man worked 38.8 hours
over the past 20 years, it remains high in many per week, women on average worked 49.3 hours and
regions outside the developed countries, at least a quarter of women reported working 70
particularly in sub-Saharan Africa, Oceania, hours per week, a clear sign that time poverty is a
Southern Asia and South-East Asia (see figure problem;55 similar patterns have been found in Latin
4). Women continue to be more concentrated in America.56
vulnerable jobs than men in all but the wealthi-
est countries. The gender gap is widest in North ᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀꔀĀȀ⸀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ1 The
and sub-Saharan Africa and Western Programme of Action called on Gov-ernments
to take steps to eliminate inequalities
between men and women by:

Human rights elaborations since the International Conference

on Population and Development
BOX 2: Women’s empowerment and gender equality

Binding instruments. In 1999, the General Assembly adopted the Optional Protocol to the
Convention on the Elimination of All Forms of Discrimination against Women, which enables
the Committee on the Elimination of Discrimination against Women to consider
communications by individuals and groups alleging that their rights under the Convention
have been violated, and created an inquiry procedure that allows the Committee to
investigate violations of women’s rights in a State party to the Convention. At the regional
level, the Protocol to the African Char-ter on Human and Peoples’ Rights on the Rights of
Women in Africa recognizes the importance of women’s political, economic and social
participation and calls for the elimination of all forms of discrimination against women.

Intergovernmental human rights outcomes. In its resolution 15/23 on the elimination of

discrimination against women (2010), the Human Rights Council expressed “concern at the fact that,
despite the pledge made at the Fourth World Conference on Women and the review conducted by the
General Assembly at its twenty-third special session to modify or abolish remaining laws that dis-
criminate against women and girls, many of those laws are still in force and continue to be applied,
thereby preventing women and girls from enjoying the full realization of their human rights”.

Other intergovernmental agreements. The Beijing Declaration (1995) reaffirmed the com-
mitment to “[e]nsure the full implementation of the human rights of women and of the girl child as
an inalienable, integral and indivisible part of all human rights and fundamental freedoms”.


0 Adopting appropriate measures to improve the same access as men to formal and secure
women’s ability to earn income beyond tradi- employment, with equal pay for equal work.
tional occupations, achieve economic self- Guaranteeing equal employment opportunities for
reliance, and ensure women’s equal access to women and men advances equality and is also
the labour market and social security systems beneficial for economic growth. Gender equality in
education, skill development, and equal access to
1 Eliminating discriminatory practices all sectors of employment can result in broad pro-
by employers against women ductivity gains and increased profitability; improved
well-being of women and their families; and more
0 The Member States participating in the regional inclusive institutions and policy choices.57
operational review conferences ac-knowledged
that increasing women’s access to paid 5888 Companies that invest in women’s
employment has many advantages, both for employ-ment often find that it benefits their bottom
women themselves and for economic develop- line by improving staff retention, innovation, and
ment more generally. By pulling women into paid access to talent and new markets.58 A recent report
employment, not only does national income rise, by the International Monetary Fund (IMF)
but societies can draw more extensively on the estimates that closing the gender gap in the labour
many talents and skills women have to offer. market would raise GDP in the United States of
Additionally, women’s increased engagement with America by 5 per cent, in the United Arab Emirates
the monetary economy creates a positive feed- by 12 per cent and in Egypt by 34 per cent, 59 and
back loop in terms of job creation. that economic benefits of women’s empowerment
and gender equality are particularly high in rapidly
1 States should enact or review, strengthen ageing societies, where women’s labour force
and enforce laws against workplace discrim- participation can help to offset the impact of an
ination against women, guaranteeing women otherwise shrinking workforce.

FIGURE 4 Developed regions Latin America and the Caribbean

100 100
Proportion of own-account 90
and contributing family 80
workers in total employment 70
Per cent

Per cent

by region, 1991-2012 50
40 40
30 30
20 20
Women 10
Men 0 0
1991 2000 2010 2012 1991 2000 2010 2012

Western Asia Caucasus and Central Asia

100 100
90 90
80 80

70 70
Per cent

60 60

50 50
40 40
30 30
Source: United Nations, Millennium
20 20
Develop-ment Goals Report 2013, annex:
Millennium Development Goals, targets and 10 10
indicators, 2013: statistical tables. 0 0
1991 2000 2010 2012 1991 2000 2010 2012


0 On the issue of enhancing women’s income- maternity leave (of any length); however, only 54
generation ability, 85 per cent of all countries per cent have such an instrument in place for
reported having budgetary policies and pro- paid paternity leave, constituting a major barrier
grammes to address “increasing women’s par- to men’s participation in parenting. Europe is the
ticipation in the formal and informal economy”; the region with the highest proportion of countries
proportion does not vary with the wealth of with a law guaranteeing paternity-related benefit
countries. Eighty-five per cent of countries also (81 per cent), followed by the Americas (53 per
reported that they had a law in place (with an cent), Africa (52 per cent), Asia (43 per cent) and
enforcement provision) prohibiting gender dis- Oceania (29 per cent).
crimination at work in hiring, wages and benefits.
5888 Fewer than half of responding countries
(b) Support for working parents reported having enforced laws guaranteeing
23 The Programme of Action encouraged day-care centres and facilities for breastfeeding
countries to create policies and programmes to mothers in the public (41 per cent) or private
support work-life balance and enable parents to sectors (39 per cent). These limitations can
participate in the workforce without compromising make it impossible for women to rejoin the
the well-being of children and households by labour market after childbirth, or to breastfeed
making it possible, through laws, regulations and after doing so, with negative implications for
other appropriate measures, for women to com- both women’s productivity and child health. In
bine the roles of childbearing, breastfeeding and fact, only one in four African countries — the
child-rearing with participation in the workforce. region where most of the population growth will
occur in the next decades — have laws in place
24 Ninety per cent of countries reporting in to ensure compatibility between maternal and
the global survey stated that they have a law in work responsibilities (25 per cent for both public
place, with an enforcement provision, for paid and private sectors).

Northern Africa Sub-Saharan Africa Oceania

100 100 100
90 90 90
80 80 80



70 70 70
40 40 40

60 60 60
50 50 50
30 30 30

20 20 20
10 10 10
0 0 0
1991 2000 2010 2012 1991 2000 2010 2012 1991 2000 2010 2012
Eastern Asia South-Eastern Asia Southern Asia

100 100 100

90 90 90
80 80 80
Per cent


70 70 70
Per cent

60 60 60

50 50 50
40 40 40
30 30 30
20 20 20
10 10 10
0 0 0
1991 2000 2010 2012 1991 2000 2010 2012 1991 2000 2010 2012


0 If a composite indicator is created for the sibility and are unlikely to realize their full and fair
five family-work balance issues described above participation in both productive and reproductive
(promulgated and enforced laws against work- life and to enjoy equal status in society.
place discrimination against women; facilitating
compatibility between labour force participation 0 While many countries have made substantial
and parental responsibilities; promulgated and advances in enhancing women’s participation in the
enforced laws that enable maternity leave; pro- labour force since 1994, gender inequalities in the
mulgated and enforced laws that enable paternity balance of work and family life have not garnered the
leave; promulgated and enforced laws that same level of support. For example, fewer than two
facilitate breastfeeding in the workplace), of 113 thirds of countries (64 per cent) reporting to the
countries with complete information, only 26, or global survey have addressed the issue of “facilitat-
0 per cent, have addressed all five dimensions. ing compatibility between labour force participation
and parental responsibilities”, making it easier for
0 States should ensure universal access women to combine child-rearing with participation in
to paid parental leave for both mothers and the workforce. This issue has been prioritized by a
fathers, including adoptive parents, and to high- smaller proportion of countries in the Americas (53
quality infant and childcare for working parents, per cent) and in Africa (55 per cent) compared with
including extended after-school care; and Asia (74 per cent) or Europe (92 per cent). In fact, a
establish and enforce laws that require that higher proportion of richer countries and countries
public and private workplaces accommodate the with slow population growth have ad-dressed these
needs of breastfeeding mothers. issues compared with poorer coun-tries and
countries with rapid population growth.
(c) Co-responsibility
ᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀĀȀ⸀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ0 Women 1 Two thirds of countries reporting to the
continue to bear most of the respons-ibilities at global survey have “engaged men and boys to
home, caring for children and other dependent promote male participation [and] equal sharing of
household members, preparing meals, cleaning or responsibilities such as care work” during the past
doing other housework. It is estimated that, in all five years (63 per cent). Although no major
regions, women spend at least twice as much time regional variations are observed, grouping coun-
as men on unpaid domestic work; and when paid tries by income shows that this is a greater con-
and unpaid work are combined together, women’s cern for high-income countries that are members
total work hours are longer than men’s. Balancing of the Organization for Economic Cooperation and
work and family is par-ticularly challenging for Development (OECD) (81 per cent), while the
employed parents with young children, and often proportion of countries addressing this issue in the
women are the ones to discontinue their four other income groups is just above or below
employment or take on part-time jobs while their the world average (low-income countries:
partners keep a full-time job.60 0 per cent; lower-middle-income countries:
5888 per cent; higher-middle-income countries:
ᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀĀȀ⸀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ1 The 0 per cent; high-income non-OECD countries:
Programme of Action recognized that the full 0 per cent).
participation of and partnership between both
women and men is required in productive and 0 Uneven progress in attitudes
re-productive life, including co-responsibility for
towards gender equality
the care and nurturing of children and
maintenance of the household. 0 The majority of the public supports women’s
empowerment and gender equality in most of the
ᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀĀȀ⸀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ2 Gend countries for which there are data, but the extent of
er equality in the home and the work-place support depends on the specific gender value
demands changes in the involvement of men under consideration. The most recent round
and boys in reproductive roles and house-hold
chores; without such task shifting, women take
on an inordinate double burden of respon-
of the World Values Survey, undertaken in 47 there is a large consensus with regard to the
countries, provides evidence that public values are importance of tertiary education for both girls and
most gender equitable with respect to access to boys; in most countries, the majority of people no
higher education, highly variable with regard to longer believe that a university education makes a
men’s and women’s equal access to jobs, and difference only for boys. However, with regard to
consistently more modest with regard to wom-en’s other public spheres, distinct gender roles that
effectiveness (relative to men’s) as leaders in give advantage to men are still valued in countries
business or politics (see figure 5). Currently, in Africa and Asia and in some of the

FIGURE 5 Africa Egypt

Support for gender Mali

equality in university Burkina Faso
education, business Morocco
executives, political South Africa

leaders, and Asia Jordan

women’s equal right Iran
to employment by Malaysia
region, 2004-2009 Georgia
University education Indonesia
South Korea
Business executives
Viet Nam
Political leaders China
Right to a job

Eastern Russian Federation

Europe Romania


Latin Argentina
America Brazil
and the Mexico
Caribbean Trinidad and Tobago

Western Japan
Europe United States
and other Australia
Source: World Values Surveys 2004- developed France
2009 data (downloaded and countries Spain
analysed on 20 August 2013). Great Britain
Note: Support for gender equality is
measured as the proportion of Finland
respondents who disagree with the Germany
following statements: (a) “a university Canada
education is more important for a boy Netherlands
than for a girl”; (b) “on the whole, men Switzerland
make better business executives than Norway
women do”; (c) “on the whole, men Andorra
make better political leaders than Sweden
women do”; and (d) “when jobs are
0 10 20 30 40 50 60 70 80 90 100
scarce, men should have more right to
Per cent
a job than women”.


Support for women as political leaders by region, 2004-2009
Latin America Western Europe and other
Asia Eastern Europe and the Caribbean developed countries
Per cent

1994–98 1999–04 2005–09 1994–98 1999–04 2005–09 1994–98 1999–04 2005–09 1994–98 1999–04 2005–09

Source: World Values Surveys 2004-2009 data.

Note: Measured as the proportion of respondents who disagree with the following statement: “on the whole, men make better political leaders than women do”.

Support for gender equality in access to employment by region, 2004-2009
Latin America Western Europe and other
Asia Eastern Europe and the Caribbean developed countries
Per cent

1994–98 1999–04 2005–09 1994–98 1999–04 2005–09 1994–98 1999–04 2005–09 1994–98 1999–04 2005–09

Source: World Values Surveys 2004-2009 data.

Note: Measured as the proportion of respondents who disagree with the following statement: “when jobs are scarce, men should have more right
to a job than women”.

Support for gender equality in access to university education by region, 2004-2009

Latin America Western Europe and other

Asia Eastern Europe and the Caribbean developed countries
Per cent

1994–98 1999–04 2005–09 1994–98 1999–04 2005–09 1994–98 1999–04 2005–09 1994–98 1999–04 2005–09

Source: World Values Surveys 2004-2009 data. (downloaded and analysed 20 August 2013).
Note: Measured as the proportion of respondents who disagree with the following statement: “a university education is more important for a boy than for a girl”.


countries of Eastern Europe. For example, men 5888 Although women are stronger supporters of
are considered better business and political gender equality than men, there have been positive
lead-ers by 50 per cent or more of people in changes in gender attitudes and values for both women
almost half of the surveyed countries, with and men. The overall differences in gender values and
perceptions of male superiority in political attitudes between women and men have increased in
leadership more pronounced than in business. some countries, for example, concerning values related
to women as political leaders in Ukraine, the Republic of
23 The data suggest that values of gender Moldova and Argentina, and values related to education
equality have been trending upwards in most in the Russian Federation. In those cases, the
countries since the mid-1990s (see figure 5), proportion of women who support gender equality has
with the exception of the value “when jobs are increased significantly, while the proportion of men
scarce, men should have more right to a job remained at the same lower levels as in the previous
than women”, which is highly variable between surveys. Conversely,
countries and over time.
in other countries, men progressed more than
24 The regional and development gaps in women, for example, regarding values related to
gender values have been getting smaller, as tertiary education in Turkey and Brazil. While
countries in Western Europe and wealthy non- women remain stronger in their support for gender
OECD countries have already reached a high equality, in some cases men are getting closer to
degree of social consensus while countries in the higher level of support shared by women.
Latin America and the Caribbean, as well as
countries in Eastern Europe, are catching up. 5889 Younger generations also tend to be more
positive towards gender equality than older
25 Some countries showed no significant cohorts, although the intergenerational gap is sig-
change in support for gender equality values. nificant only in a few countries. In about half of the
These countries are in all regions, and they countries surveyed in 2005, younger generations
vary depending on the issue in question. No showed significantly stronger support for gender
progress was observed for one eighth of equality in political and managerial leadership and
countries (3 out of 25 with available data) with higher education. With regard to the right to a job,
regard to tertiary education; a quarter of young people strongly supported gender equality
countries (6 out of 25) with regard to political in about three quarters of countries.
leadership; and a third of countries (8 out of 25)
with regard to access to the job market. 5890 Countries in Western Europe have the
highest intergenerational consensus with regard
26 There is greater support for gender to politics, while countries in Eastern Europe and
equality among women than men. This is the Africa have the highest intergenerational consen-
case for all four issues explored, and in the sus with regard to the right to a job.
majority of countries. The gender gap is not
marginal, and becomes larger in countries with 5891 The results suggest that changes in attitudes
less overall support for gender equality. and values regarding gender are taking place across
Overall, the gender gap is smaller on the issue whole societies over time, rather than only among
of access to tertiary/university education, and younger generations. For some countries with available
larger on men’s favoured access to jobs and data on trends, the cross-sectional differences over 10
women’s leadership in politics and business. years were larger than differ-ences between older
For all four issues, the gap is lowest in Western cohorts of over 50 years of age and younger cohorts of
European countries and other developed 15-29 years. This is the case of some Eastern and
countries, where men are as likely, or only Western Euro-pean countries. For example, regarding
slightly less likely, as women to acknowledge attitudes towards women and men as political leaders
gender equality.


in 2005, there were no significant differences a general lack of data on that form of violence.
between older and younger cohorts in Bulgaria, Current global estimates are that 7 per cent of
Romania, Ukraine, Finland or Sweden, while all of women have experienced sexual violence by
those countries had shown increased support for someone other than an intimate partner. Com-
gender equality between 1995 and 2005. bined estimates show that 36 per cent of women
globally have experienced either intimate partner
57600⸀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀȀ⸀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ violence, non-intimate partner violence, or both
forms of gender-based violence.65

States should ensure equal opportunities for women to contribute to A recent (2013) United Nations multi-country study on

society as leaders, managers and decision makers, granting them

men and violence in Asia and the Pacific found that
nearly half of the 10,000 men inter-viewed reported
access to positions of power equal to that of men in all sectors of
using physical and/or sexual vi-olence against a female
public life. As part of these efforts, it is important to address public
partner; across the sites, the proportion of men using
views and values regarding sexism or other forms of discrimination, violence ranged from
including through creative communication and education campaigns, per cent to 80 per cent.66 Nearly a quarter of the
and monitor these on a regular basis as indicators of social men interviewed reported committing rape against
a woman or girl, 10-62 per cent across the sites.
Men begin perpetrating violence at young ages,
3. Gender-based violence with half of those who admitted to rape reporting a
0 An estimated one in three women worldwide report first incident when they were teenagers, and some
that they have experienced physical and/or sexual even younger than 14. Of those men who admitted
abuse, mostly at the hands of an intimate partner, to rape, the vast majority (72-97 per cent in most
making this form of violence against women and girls sites) had experienced no legal consequences,
one of the most prevalent forms of human rights confirming that impunity remains a serious issue in
violations worldwide.61 the region. Across
all sites, the most common motivation that men
1 The first multi-country study (2005) estimating the cited for rape related to sexual entitlement, that is
extent of domestic violence against women, found that the the belief that men have a right to have sex with
proportion of adult women who had ever suffered physical women regardless of whether they consent; over
violence by a male partner ranged widely across the 10 per cent of men who admitted to rape in sites in
countries studied, from 13 per cent to 61 per cent.62 The rural parts of two countries gave this response.
proportion of women who had experienced severe physical Overall, 4 per cent of all respondents said that
vio-lence by a male partner, defined as “being hit with a fist, they had participated in gang rape of a woman or
kicked, dragged, threatened with a weapon or having a girl, 1-14 per cent across the sites. These are the
weapon used against her”, ranged from first data from such a large sample of men on the
perpetration of gang rape.67
per cent to 49 per cent, with most countries fall-ing
between 13 per cent and 26 per cent.63 The first The health effects of intimate partner vio-lence are
global and regional prevalence estimates (2013) of substantial and contribute, directly and indirectly, to
sexual and physical intimate partner violence and numerous negative health outcomes among women and
non-partner sexual violence showed that 30 per their children. Thirty-eight per cent of all murders of
cent of women worldwide aged 15 and older who women globally are committed by intimate partners.
had ever had a partner had experienced some Beyond non-fatal and fatal injuries, experiences of
form of intimate partner violence, with as many intimate partner violence among women are associated
as 38 per cent of women in some regions with an increased risk of HIV and other sexually transmit-
having experienced such violence.64 ted infections. Further, women who have experi-enced
sexual or physical intimate partner violence
Metrics to measure non-partner sexual violence are
less clearly defined, highlighting


show higher rates of induced abortion and poor these trends suggest positive change in


birth outcomes, including low birth weight and men’s respect for women’s dignity, it must
preterm births. Gender-based violence also has be noted that in five countries, more than 40
serious short- and long-term social and economic per cent of respondents still endorsed
costs for societies, including direct costs through justifications for domestic violence.69
health expenditures; indirect economic costs on
workforce participation, missed days of work and Similar trends are noted in women’s atti-tudes, with an
lifetime earnings; as well as indirect costs to the overall decline between survey time points. Despite
long-term health and well-being of children and positive trends, however, as many as 70 per cent of
other people living in a violent household.68 women surveyed in some countries continue to agree
that wife-beating is justified under certain
The Demographic and Health Surveys pro-gramme collected data in circumstances.70
12 countries on attitudes towards “wife-beating” at a minimum of two

points in time, to determine the percentage of men and women aged

Government accountability and community-supported
policies to promote women’s empowerment and
15-49 who agreed that a husband/ partner is justified in hitting or
gender equality are key to preventing and responding
beating his wife/part-ner for at least one of the following reasons: if
to gender-based violence, alongside social and
she burns the food, argues with him, goes out without telling him, economic interventions that challenge social norms
neglects the children or refuses sexual relations. As displayed in and promote women’s economic rights and gender
figure 6, there has been a measurable decline in the proportion of empowerment.71 The Commission on the Status of
Women at its fifty-seventh session adopted agreed
males who endorse any of these justifications for this particular form
conclusions on the elimination and pre-vention of all
of physical intimate partner violence. While
forms of violence against women

Trends in men’s attitudes towards “wife beating”


70 Zambia

Kenya Uganda

50 Lesotho

Burkina Faso Ethiopia

United Republic
30 Ghana Zimbabwe of Tanzania

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Source: Demographic and Health Surveys, all countries with available data for at least two time points, available from (accessed on 15 November 2013).


(E/2013/27, chap. I, sect. A) in which the if they lack gender-equitable attitudes,
Commis-sion urged Governments to witnessed or experienced household violence
strengthening legal and policy frameworks and during childhood, are under acute economic
monitoring and to ensure accountability, while stress, or are experiencing the disruptions of
addressing structural causes of violence and displacement or conflict.76
promoting multisectoral responses.
Psychologists suggest that acute fear, prevalent
WHO guidelines urge a strengthened during war or conflict, may be tempo-rarily
multipronged health system response to intimate dissipated for some people by perpetrating
partner and sexual violence, improving access to aggression against others. Such a response can
critical treatment services such as emergency also lead to heightened non-combatant violence.
contraception, abortion in cases of pregnancy Rape and other forms of sexual violence are
resulting from rape, prophylaxis for HIV and other used as tactics of war, but their incidence also
sexually transmitted infections, and mental health increases within the non-combatant population
support.72 during war-related instability and conflict.77

In a number of resolutions the Security Council has Recent data from eastern Democratic Republic of
recognized and responded to the extent the Congo, which has experienced sustained
of violence against women and girls, including internecine violence for over a decade,
resolution 2122 (2013), in which the Council demonstrate that almost half (48 per cent) of male
recognized the importance of humanitarian aid non-combatants reported using physical violence
including a full range of health services for women against women; 12 per cent acknowledged having
affected by conflict, including those who become carried out partner rape; and 34 per cent reported
pregnant as a result of rape; resolution 1325 (2000) perpetrating some kind of sexual violence. In
on the impact of conflict on women and their role in addition, of all men and women surveyed, 9 per
conflict resolution and peacebuilding; resolution 1820 cent of adult men had been victims of sexual
(2008) in which the Council noted that sexual violence, and 16 per cent of men and 26 per cent
violence against women in conflict could constitute a of women had been forced to watch sexual vio-
war crime; and resolution 1888 (2009) in which the lence.78 All available evidence suggests that the
Council explicitly charged peacekeeping missions consequences of such violence can be serious and
with the job of protecting women and children from long term,79 and several small-scale efforts are
sexual violence in conflict. under way in the eastern Democratic Republic of
the Congo to try and address the emotional trauma
Violence against children takes many forms, is of victims and their families, as well as physical
perpetrated by both adults and peers, and can scarring.80
lead to greater risk of suicide, depression and
other mental illness, substance abuse, a reduced Of all the issues related to the Programme of
ability to avoid other violent relationships and, for Action listed in the global survey, “ending
some, a heightened risk of perpetrating violence gender-based violence” was one of those
themselves.73 While girls are especially vulnerable addressed by the highest proportion of Govern-
to sexual violence and abuse, new multi-country ments (88 per cent). Regionally, this issue was
data74 draw attention to the violent experiences of addressed by 94 per cent of Governments in
boys during childhood, which are too often treated Africa, 87 per cent in the Americas, 90 per cent
as normal for boys but which can have long-term in Asia, 82 per cent in Europe and 77 per cent
effects no less traumatic than for girls. in Oceania.

Recent data from six countries75 affirm the With regard to legal frameworks aimed at
longstanding observations that men are more preventing and addressing abuse, neglect and
likely to use violence against women and children violence, only 87 per cent of countries reported


in the global survey that they had promulgated consequences of violence and enable the full
and enforced laws criminalizing rape and other rehabilitation of those who experience it. In
forms of sexual exploitation, and only 53 per cent addition, States should strengthen routine
of countries had promulgated and enforced laws monitoring and extend research into impor-tant
criminalizing marital rape (Africa: 39 per cent; unaddressed issues such as the number of
Americas: 57 per cent; Asia: 48 per cent; Europe: people living in conditions of sustained fear;
75 per cent; Oceania: 62 per cent). violence within schools, prisons and the
military; the causes and consequences of vio-
Seventy-three per cent of countries had lence; and the effectiveness of interventions
promulgated and enforced laws criminalizing and of laws and systems for the protection and
intimate partner violence, an issue that has recovery of victims and/or survivors.
been prioritized in the Americas (88 per cent)
and Europe (84 per cent) in contrast to Asia (61 States should further ensure that all
per cent), Africa (68 per cent) and victims/survivors of gender-based violence
Oceania (71 per cent). have immediate access to critical services,
including 24-hour hotlines; psychosocial and
In relation to the criminalization of sexual mental health support; treatment of injuries;
exploitation of young people, particularly girls, post-rape care, including emergency
per cent of countries reported that they had contraception, post-exposure prophylaxis for
promulgated and enforced laws, and 77 per HIV prevention and access to safe abortion
cent had promulgated and enforced laws services in all cases of violence, rape and
preventing the use of children in pornography. incest; police protection, safe housing and
shelter; documentation of cases, forensic
If a composite indicator is calculated for the six services and legal aid; and referrals and
legal dimensions cited above, results show that longer-term support.
only 28 per cent of countries have promul-gated
and enforced laws in all cases. Almost half of Priorities of civil society organizations
the countries in Europe (48 per cent) and regarding gender-based violence
Oceania (46 per cent) have done so, but a
smaller share of countries in Africa (26 per A recent survey (2013) among 208 civil society
cent), Asia (15 per cent) and the Americas (14 organizations81 in three regions (the Americas,
per cent) have done so. States should adopt Africa and Europe) that work in the area of gender-
and imple-ment legislation, policies and based violence found that in Africa,
measures that prevent, punish and eradicate per cent of civil society organizations cited
gender-based violence within and outside the “gender norms and male engagement” as the
family, as well as in conflict and post-conflict number one top priority issue for public policy for
situations. Laws that exonerate perpetrators of the next 5-10 years. In the Americas and Europe,
violence against women and girls, including per cent and 21 per cent of civil society organi-
provi-sions that allow them to evade punishment zations respectively identified the “development of
if they marry the victim, or are the partners or programmes, policies, strategies, laws and the
husbands of the victim, should be revised. creation of institutions to eradicate gender-based
Sexual violence should also be eliminated from violence” as a priority. Finally, the “elimination of all
post-conflict amnesty provisions within the forms of violence”, including sexual violence, rape,
framework of strengthened legislation and domestic violence and femicide, among others, is
enforcement to end impunity. also consistently mentioned by civil soci-ety
organizations across all regions as the number one
States should enhance their capacity to recognize top priority issue for public policy for the next
and prevent violence, ensure the provision of 5-10 years (Africa: 20 per cent; the Americas:
services that can mitigate the per cent; Europe: 26 per cent).


Human rights elaborations since the International Conference
on Population and Development
BOX 3: Gender-based violence

Binding instruments. In the years following the International Conference on Population and
Development, gender-based violence emerged as a prominent human rights issue, particularly in
regional binding instruments, including: The Inter-American Convention on the Prevention,
Punishment and Eradication of Violence against Women (1994), which has been ratified by most
States members of the Organization of American States (OAS); the Protocol to the African
Charter on Human and Peoples’ Rights on the Rights of Women in Africa (1995); and the Council
of Europe Convention on Preventing and Combating Violence against Women and Domestic
Violence (2011), which will enter into force once it has been ratified by 10 States.

Intergovernmental human rights outcomes. The Human Rights Council has adopted a
series of resolutions on intensifying efforts to eliminate all forms of violence against women,
including resolution 14/12 on accelerating efforts to eliminate all forms of violence against
women: ensuring due diligence in prevention (2010).

Other soft law. Concluding observations of various treaty monitoring bodies require States
to take measures to prevent sexual violence, provide rehabilitation and redress to victims of
sexual violence, and prosecute offenders.82

4. Female genital mutilation/cutting

prevalence of and attitudes towards female
Female genital mutilation/cutting refers to all practices geni-tal mutilation/cutting within countries, while,
that include the “partial or total removal of the external owing to increased migration, the prevalence of
female genitalia or other injury to the female genital the practice among women and girls living
organs for non-medical reasons”.83 The practice can outside their countries is also on the rise.86
have both short- and long-term health consequences
and risks, which increase Since the joint statement issued by UNICEF, the
in accordance with the severity of the procedure. United Nations Population Fund (UNFPA) and WHO
Female genital mutilation/cutting offers no known in 1997,87 great efforts have been made to eliminate
health benefits to women and girls.84 female genital mutilation/ cutting, and indeed the past
decades have seen increased international attention
An estimated 125 million women and girls and resources devoted to ending the practice.
worldwide live with the consequences of female Numerous international and regional human rights
genital mutilation/cutting, with approximately 3 instruments protect the rights of women and girls and
million girls, the majority under age 15, at risk of call for the eradication of female genital
undergoing the procedure each year. It is practiced mutilation/cutting. It is a violation of the rights of the
widely in more than 29 countries, predominately in child, the right of all persons to the highest attainable
the western, eastern and north-eastern regions of standard of health, the right to be free from torture
Africa and in some Arab States (see figure 7).85 and cruel, inhuman or degrading treatment, and is a
form of gender inequality and discrimination against
Socioeconomic factors such as educational women.88
attainment and household income influence the


Percentage of girls and women aged 15-49 who have undergone female
genital mutilation/cutting by country


Chad Sudan Yemen

Mauritania Mali
Senegal 69% Niger
26% 2%
44% 88% 23% Eritrea
Gambia Guinea- Burkina Faso
76% 89%
Bissau Djibouti
27% Ethiopia 93%
Guinea Central 74%
African Republic
96% Togo Cameroon 24%
1% Uganda Kenya Somalia
Sierra Liberia Côte 4%
Leone 66% d’lvoire Benin 1% 98%
88% 38% 13% 27%

4% United
Above 80% of Tanzania


Less than 10%

Female Genital Mutilation/Cutting is

not concentrated in these countries

Source: UNICEF, Female Genital Mutilation/

Cutting: A Statistical Overview and Exploration
of the Dynamics of Change (New York, 2013).

However, its persistence and scale, coupled The global survey revealed that 46 per cent of
with statistical projections that by 2030, 20.7 countries have promulgated and enforced laws
million girls born between 2010 and 2015 will protecting the girl child against harmful practices,
likely experience some form of female genital including female genital mutilation/cutting, with 66
mutilation/cutting,89 further highlight the urgent per cent of countries in Africa and just 26 per cent
need to intensify, expand and improve efforts to of countries in Asia having done so.
accelerate the current annual rate of reduction
and eliminate the practice in less than a gener- Punitive laws that criminalize female genital
ation. The new inter-agency statement issued by mutilation/cutting are unlikely to succeed on their
a wider group of United Nations agencies in own, and must be accompanied by culturally sen-
2008 calls for increased support, advocacy and sitive public awareness and advocacy campaigns
resources for the elimination of female genital that create sustained change in cultural and
mutilation/cutting at the community, national and community attitudes. Community-led approaches
international levels.88 endorsed by national and local leaders will be


Human rights elaborations since the International Conference on
Population and Development
BOX 4: Female genital mutilation/cutting

Binding instruments: The Protocol to the African Charter on Human and Peoples’ Rights on the
Rights of Women in Africa (1995; entry into force 2005) states, “States Parties shall prohibit and
condemn all forms of harmful practices which negatively affect the human rights of women.
... States Parties shall take all necessary legislative and other measures to eliminate such
prac-tises, including: … prohibition through legislative measures backed by sanctions, of all
forms of female genital mutilation.” Article 38 of the Council of Europe Convention on
Preventing and Combating Violence against Women and Domestic Violence (2011; not in
force) states that “Par-ties shall take the necessary legislative or other measure to ensure
that the following intentional conducts are criminalized: (a) excising, infibulating or
performing any other mutilation to the whole or any part of a woman’s labia majora, labia
minora or clitoris; (b) coercing or procuring a woman to undergo any of the acts listed in point
(a); (c) inciting, coercing or procuring a girl to undergo any of the acts listed in point (a).”

Intergovernmental human rights outcomes: The General Assembly has adopted sev-
eral resolutions on eliminating harmful practices, including female genital mutilation/cutting,
including milestone resolution 67/146 on intensifying global efforts for the elimination of
female genital mutilation (2012).

critical to creating the sustained behavioural Government priorities: gender equality

change necessary to protect the rights of and women’s empowerment
women and girls by ending the practice.88 by per cent
Indeed, those communities that have employed Priority of governments
a process of collective and participatory
Economic empowerment 71%
decision-making have been able to abandon it.90 and employment

States should develop, support and imple-ment Political empowerment and 59%
comprehensive and integrated strategies for the participation
eradication of female genital mutilation/ cutting,
Elimination of all forms of 56%
including the training of social workers, medical violence
personnel, community and religious leaders and
relevant professionals, and ensure that they provide Gender norms and male 22%
competent, supportive services and care to women
and girls who are at risk of, or who have undergone, Work-life balance 7%
female genital mutila-tion/cutting, and establish formal
mechanisms for reporting to the appropriate
authorities cases in which they believe women or girls Promoting and enabling the “economic empowerment” of
are at risk, and ensure that health professionals are women was the priority most frequently mentioned by at
able to recognize and address health complications least two thirds of countries, in four of the five regions:
arising from the practise. Africa (67


per cent), Asia (78 per cent), Europe (79 per cent) to WHO, while the lifetime incidence of partner and
and Oceania (71 per cent). In the Americas, it was non-partner physical and sexual violence is highest
the second most frequently mentioned priority (59 in Africa, a smaller proportion of countries in the
per cent of Governments), following “elimination of region prioritized this issue (49 per cent) compared
all forms of violence”. These numbers are in with the Americas (69 per cent), Europe (69 per
keeping with the widespread recognition that cent) and Oceania (57 per cent).
women’s participation in the workplace drives
economic growth and development, a phenome- “Gender norms and male engagement” was a priority
non that has contributed to the recent economic for only 22 per cent of Governments glob-ally, and
growth in many Asian countries. was most frequently included by Govern-ments in
Europe (34 per cent). This issue was not prioritized by
“Political empowerment and participation” Governments of most low-income and lower middle-
was a priority for two thirds of Governments across income countries, only 15 per cent and 14 per cent of
Africa (63 per cent), Asia (66 per cent) and Oceania which, respectively, included it. “Addressing son
(64 per cent); in Europe and the Americas the issue preference” was prioritized by only three countries
was a priority for 48 per cent and 53 per cent of (Armenia, China, India), countries where the sex ratio
Governments, respectively. It was notable that “po- is significantly skewed.
litical empowerment and participation of women” was
prioritized by only 45 per cent of Governments of In contrast to the shared global priority of
high-income non-OECD countries and 41 per cent of promoting the economic participation of women,
high-income OECD countries. It was a higher priority “work life balance”92 was mentioned as a priority by
within other income groups; among low-, lower-middle only 7 per cent of countries worldwide, most of
and upper-middle income countries it was prioritized them in Europe. Globally, it appears that the inclu-
by 62 per cent, 67 per cent and 62 per cent of sion of women in the workplace is recognized as
Governments, respectively. an obvious step forward; however, holistic policies
that include parental (maternity and paternity)
The low level of support for the political leave and quality childcare will be necessary to
empowerment of women among wealthy non- ensure the well-being of children and families, and
OECD and wealthy OECD countries may reflect to avoid the overburdening of women.
different underlying values. The highest propor-
tion of parliamentary seats held by women is in States should initiate national campaigns, including
high-income OECD countries, suggesting that the through information and education curricula, and
political participation of women is well advanced
enhance the ability of the education system, both formal
and may not be seen as demanding government
and informal, and community groups to eliminate sexism,
intervention. In contrast, the lowest proportion of
seats are in high-income non-OECD countries, including violence against women and girls, and promote
suggesting relatively lower support for women’s the participation of men and boys and equal sharing of
political leadership, which may reflect the fact that responsibility, including through the establishment of
these countries have experienced very rapid
special schools for men and boys and other community-
economic development that has outpaced social
and political change. based institutions, to enable awareness, exposure and
behaviour change.
Globally, the third most frequently cited priority for
gender equality and women’s empowerment, C. Adolescents and youth
mentioned by 56 per cent of countries, was the
The demographic importance
“elimination of all forms of violence”.91 Among coun-
tries in the Americas, this was the priority that was
of young people
mentioned most often, by 69 per cent of Govern- Demographic changes in the past decades have
ments, well above the global average. According led to the largest generation of young


people (aged 10-24 years) in the world today, absolute terms,94 but rather because of four
comprising adolescents (aged 10-19 years) and crucial conditions:
youth (aged 15-24 years). In 2010, 28 per cent The decline in fertility that followed their births
of the global population was between 10 and 24, means that they must become self-supporting
slightly higher than the proportion in Asia, and and thrive, for there will be no larger, younger
more than 31 per cent of the population of Africa cohort to support them as they themselves age,
(see figure 8). While this proportion will decline and they can be expected to live to an
in most regions in the coming 25 years, it will advanced age, given increasing life expectancy;
remain above 20 per cent in all regions except
Europe until 2035, and above 30 per cent in They will also need to support the existing and
Africa until 2035.93 growing population of elderly persons;

The centrality of adolescents and youth to the The majority of this cohort is growing up in poor
development agenda in the coming two decades is countries, where education and health systems
not however because of their numbers in are of poor quality, reproductive choice and

Trends and projections in the proportion of young people (10-24
years), worldwide and by region, 1950-2050
(medium fertility variant)

Worldwide 35


Per cent

Americas 15

Asia 10
Europe 5
Oceania 0
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Africa by 35

sub-region 30

Per cent


Eastern Africa 15
Middle Africa 10
Northern Africa 5
Southern Africa
Western Africa 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Americas by
Per cent

Caribbean 15

Central America 10
Northern America 5
South America 0
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Source: World Population Prospects: The 2012 Revision, November 2013 (ST/ESA/SER.A/336).


health are not guaranteed, good jobs are not economic growth and development. Therefore, as
abundant and migration is constrained; acknowledged in Commission on Population and
Development resolution 2012/1 on adolescents and
They have expectations — higher than the
youth, the well-being and the positive social
generations before them — for self-direction,
participation of this cohort of adolescents and youth
freedom and opportunity. The information age has
hinges on the commitments of Govern-ments to
taught them their human rights and given them a
broader vision of what their lives could be. protect their human rights, develop their
capabilities, secure their sexual and reproductive
The declining fertility rates are also providing low- health and rights, prepare them for productive and
and middle-income countries with a window of creative activities and reward them for their labours.
opportunity because the proportion of the Investments in human development targeting
population that is of young working age is his- adolescents and youth are most critical to ensure
torically high, and these cohorts can, if provided
that they have the capabilities and opportunities to
with learning and work opportunities, jump-start
define their futures, and to spur the innovations
needed for a sustainable future.

Asia by 35

subregion 30

Per cent

Central Asia
Eastern Asia
South-Eastern Asia 10

Southern Asia 5
Western Asia 0
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Europe by 35

sub-region 30

Per cent

Eastern Europe 15

Northern Europe 10
Southern Europe 5
Western Europe 0
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Oceania by 30
sub-region 25

Per cent

Australia/ 15
New Zealand 10
0 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050


Subregional trends highlight the high propor-tion of young as affirmed in Commission on Population and
people across the subregions of Africa, with declining Development resolution 2012/1. In addition, a
proportions in only Northern and Southern Africa. In Asia,
number of intergovernmental outcomes, including
the World Programme of Action for Youth to the
the decline in the proportion of young people began earlier
Year 2000 and Beyond, resolution 2012/1 and the
and proceeded faster in Eastern Asia than elsewhere in the regional review outcomes, as well as the multi-
region. Similarly, the proportion of young people declined stakeholder declaration adopted at the Global
rapidly in the 1980s in North America, and other subregions Youth Forum held in Bali, Indonesia, highlight the
of the Americas are now converging with the North. The
importance of the full and effective participation of
young people, as well as the importance
subregions of Europe all have low proportions of young
of investing in young people as key agents
people and Oceania displays wide variations between
of development and social change.
subregions, with the highest proportions in Melanesia.
Countries that will host a large youth cohort over
the next two decades have in the past five years
For youth overall, Governments responding to the addressed the needs of their adolescent and
global survey prioritize economic empow-erment youth populations, in particular with regard to job
and employment (70 per cent), and social creation and access to sexual and repro-ductive
inclusion and education (both 56 per cent). These health services (“creating employment
priorities underscore the intersections between the opportunities for youth”, 94 per cent; “ensuring the
right to productive employment and decent work same rights and access to sexual and
and education, training, social integration and reproductive health services, including HIV
mobility, taking into account gender equality, prevention”, 94 per cent (see sect. III.D of the

Human rights elaborations since the International Conference

on Population and Development
BOX 5: Adolescents and youth

Binding instruments: Since the International Conference on Population and Development,

regional youth charters, including the Ibero-American Convention on the Rights of Youth (2005;
entry into force 2008) and the African Youth Charter (2006; entry into force 2009) promote a
broad range of rights for young people. The African Youth Charter provides a framework for
youth empowerment, strengthening youth’s participation and partnership in development.
Specific articles in the Charter affirm rights related to, inter alia, non-discrimination; freedom of
movement, expression, thought and association; development and participation; education and
skill development; employment; health; and peace and security. The Ibero-American Convention
recognizes the right of all youth aged 15-24 to the full realization of civil, political, economic,
social and cultural rights and recognizes youth as key actors in development. The Convention
recognizes youth rights related to, inter alia, peace, non-discrimination, gender equality, family,
life, personal integrity, participation, education, sexual education, health, work and working
conditions, housing and a healthy environment. Internationally, through the Optional Protocol to
the Convention on the Rights of the Child on the sale of children, child prostitution and child
pornography (2000; entry into force 2002) States parties commit, at a minimum, to ensure that
such acts “are fully covered under its criminal or penal law, whether such offences are committed
domestically or transnationally or on an individual or organized basis”.


present report on sexual and reproductive health Girls living in rural areas of the developing world


and rights and lifelong health for young people). tend to marry or enter into union at twice the rate of
A high percentage also have “addressed the their urban counterparts (44 per cent and 22 per
violence, exploitation and abuse” (81 per cent), cent, respectively). Girls with a primary educa-tion
and “instituted concrete procedures and mecha- are twice as likely to marry or enter into union as
nisms for participation” (81 per cent). those with a secondary or higher education.
“Addressing the adverse effects of poverty on However, those with no education are three times
adolescents and youth” is the issue addressed more likely to marry or enter into union before age
by the small-est proportion of countries (75 per as those with a secondary or higher education.
cent), but this proportion is still higher than that Furthermore, more than half (54 per cent) of girls in
observed for any ageing-related issue. the poorest quintile are child brides, compared with
only 16 per cent of girls in the richest quintile.95
2. Child, early and forced marriage
Denial of the human rights of a child by the As of 2010, 158 countries have a legal age of
practice of child, early and forced marriage is a marriage of 18 years. Nevertheless, for the
violation that remains commonplace in many period 2000-2011, an estimated 34 per cent of
countries and most regions worldwide, even where women aged 20 to 24 in developing regions had
laws forbid it. Vulnerability to child, early and forced been married or in union before age 18; further,
marriage is related to extreme poverty, the low an estimated 12 per cent had been married or in
status of women and community vulnerability, as union before age 15.95
much as to cultural norms. If current trends con-
tinue, by 2020, an additional 142 million girls will be The global survey shows that only 51 per cent of
married before their eighteenth birthday.95 countries have “addressed child marriage/forced

Human rights elaborations since the International Conference on

Population and Development
BOX 6: Child, early and forced marriage

Binding instruments: Reinforcing pre-1994 obligations enshrined in international human

rights law, regional instruments include the Protocol to the African Charter on Human and
Peoples’ Rights on the Rights of Women in Africa (1995; entry into force 2005), which
requires signatory States to ensure that the “minimum age for marriageable women shall be
18 years”. The Council of Europe Convention on Preventing and Combating Violence
against Women and Domestic Violence (2011; not in force) requires States to “take the
necessary legislative or other measures to ensure that the intentional conduct of forcing an
adult or child to enter into a marriage is criminalized”.

Intergovernmental human rights outcomes: The Human Rights Council adopted its
land-mark resolution 24/23 on strengthening efforts to prevent and eliminate child, early and
forced marriage: challenges, achievements, best practices and implementation gaps (2013).

Other soft law: Through general comments and recommendations, treaty monitoring bodies
have agreed that 18 is the appropriate minimum age for marriage and that States should enact
legislation to increase the minimum age for marriage to 18, with or without parental consent. 96


marriage” during the past five years, reflecting with lower adolescent birth rates (see figure 9). While
probably that this practice is not a problem greater literacy among young women is associated
worldwide. When analysis was confined to the with lower birth rates in all regions, this pattern is less
41 ”priority countries” in which marriage before age evident in countries in the Americas, which are
18 affects more than 30 per cent of girls, 90 per cent characterized by high adolescent fertility rates
of reporting countries had addressed this issue. despite high rates of enrolment in education. Indeed,
Yet three of the poorest countries with high rates of Latin America has the second highest adolescent
child marriage (affecting 39-75 per cent of girls) had fertility rate in the world, after sub-Saharan Africa,
not addressed it, and 11 of the 41 priority countries and secondary school enrolment does not have the
did not provide a response to this question. same impact on youth fertility in Latin America as it
does in other regions.
States should preserve the dignity and rights of
women and girls by eradicating all harmful Education of all children increases their capacity to
practices, including child, early and forced participate socially, economically and politically, but the
marriage, through integrated multisec-toral education of girls leads to special benefits for girls
strategies, including the universal adoption and themselves, their families and communities. When girls
enforcement of laws that criminalize mar-riage are educated it reduces the likelihood of child marriage
before the age of 18, and through wide-spread and delays childbearing, leading to healthier birth
campaigns to create awareness around the outcomes. Female education is consistently asso-ciated
harmful health and life consequences of early
with greater use of family planning, more couple
marriage, supporting national targets and
communication about family planning and lower overall
incentives to eliminate this practice within a
fertility.102 A recent analysis in East Africa found that
temporal fertility trends across demographic and health
survey waves were associated with changes in female
Adolescent births, and the mediating educational attainment, and there was an association
role of female education
between the proportion of females having no education
Worldwide, more than 15 million girls aged 15 to 19 and stalled fertility declines in Kenya, the United Republic
years give birth every year,97 with about 19 per cent of of Tanzania, Uganda and Zimbabwe.103
young women in developing countries be-coming
pregnant before they turn 18.98 A significant proportion
of adolescent pregnancies result from non- Researchers have presented theories and evidence
consensual sex, and most take place in the context of to explain why greater female education leads to
early marriage.99 Pregnancies occurring at young lower fertility, showing that education affects girls in
ages have greater health risks for mother and child, numerous critical domains that each affect fertility:104
and many girls who become pregnant drop out of education expands opportunities and aspirations for
school or are dismissed from school, drastically work outside the home, it enhances girls’ social status
limiting their future opportunities, their future and alters the types of men they marry,105 it increases
earnings, and both their own health and the health of their bargaining power within marriage,106 increases
their children.100 Globally, adolescent birth rates are their use of health services, and enhances the health
highest in poor countries, and in all countries they are and survival of their chil-dren.107 Greater educational
clustered among the poorest sectors of society, attainment also shapes attitudes of both girls and
compounding the risk of poor maternal outcomes for boys to gender equality, i.e., their gender values, with
both mother and child.101 greater education leading to more positive attitudes
towards gender equality among both males and
Adolescent birth rates have been declining from females.108
1990 to 2010 across countries in all income groups
and regions. Higher secondary school enrolment Comprehensive sexuality education, as part of in-
among those aged 15-19 is associated and out-of-school education, is recognized as


Adolescent fertility rate and net secondary education female enrolment
rate by region, 2005-2010
200 Africa

180 Europe
per1,000 womenaged

160 Oceania



Source: United Nations, Department of Economic and Social Affairs, Population Division, 2013. World Population Prospects: The 2012 Revision, DVD Edition, retrieved

from, November 2013 and UNESCO, Institute for Statistics, Data Centre, Custom Table retrieved from
reflect the latest available point estimate for the
Note: Adolescent fertility rates are period estimates for 2005-2010. Net secondary education female enrolment rates
period 2005-2010.



0 10 20 30 40 50 60 70 80 90 100
Net enrollment rate, secondary education, all programmes, female (%)

Source: World Population Prospects: The 2012 Revision, November 2013 (ST/ESA/SER.A/336); and United Nations Educational, Scientific and
Cultural Organization (UNESCO), Institute for Statistics, Data Centre, Custom Table, available from aspx?ReportId=136&IF_Language=eng&BR_Topic=0.
Note: Adolescent fertility rates are period estimates for the period 2005-2010. Net secondary education female enrolment rates reflect the
latest available point estimate for the period 2005-2010.

an important strategy that empowers young people per cent) reported policies, budgets and imple-
to make responsible and autonomous decisions mentation measures; in Europe and Asia only 29
about their sexuality and sexual and reproductive per cent and 21 per cent of countries, respec-
health. Evidence also suggests that rights-based tively, reported addressing it. Proportions remain
and gender-sensitive comprehensive sexuality very similar if countries are grouped by income
education programmes can lead to greater gender level. Support for this issue in Latin America and
equality. The Commission on Population and De- the Caribbean underscores the relatively high
velopment, in its resolutions 2009/1 and 2012/1, for adolescent fertility rate in the region.
example, called on Governments to provide young
people with comprehensive education on human States should implement their commitments to
sexuality, sexual and reproductive health, and promote and protect the rights of girls by enacting
gender equality to enable them to deal positively and implementing targeted and coordi-nated
and responsibly with their sexuality. policies and programmes that concretely address:
(a) ensuring gender parity in access to school; (b)
Only 40 per cent of all countries have providing comprehensive sexuality education; (c)
addressed “facilitating school completion for reducing adolescent pregnancy;
pregnant girls”. The Americas is the only region (d) enabling the reintegration of pregnant girls
where a higher proportion of Governments (67 and young mothers into education at all levels,


with a view to empowering the girl child and Numerous inequalities nevertheless persist with
young women to achieve their fullest potential; respect to gender, residence (urban versus rural)
and (e) eliminating of harmful traditional prac- and household wealth. Girls have been the main
tices such as child, early and forced marriage beneficiaries of the trend towards higher gross
and female genital mutilation/cutting. enrolment ratios,110 with girls’ enrolment increasing
at a faster rate than that of boys, and nearly two
4. Uneven progress in education thirds of countries (128 out of 193) reported in
Over the past 15 years the number of children who 2012 that they had achieved gender parity in
are attending primary school worldwide has primary schools. However, boys continue to
increased to an extraordinary degree, with global benefit from greater access, as reported by 57 of
enrolment now reaching 90 per cent. However, the 65 countries that have not achieved gender
attaining universal primary education by 2015 is far parity in primary education.111
from certain, and large geographic disparities persist.
Primary school enrolments have increased most The global survey found that during the past five
dramatically in West and South Asia, the Arab States years, 82 per cent of countries had addressed
and in sub-Saharan Africa, but because of low the issue of “ensuring equal access of girls to
starting levels (approximately 60 per cent) in Africa at education at all levels”, and 81 per cent had
the turn of the millennium, nearly one in four primary addressed “keeping more girls and ado-lescents
school-aged children in sub-Saharan Africa is still out in secondary school”. When countries are
of school (see figure 10). grouped according to income, there are no major
differences in the proportion of countries that
Primary completion rates have risen along with addressed ensuring equal access; however,
overall enrolments, globally as high as 88 per cent in keeping girls in secondary school is a policy that
2009 and ranging from 67 per cent in sub-Saharan is budgeted for and implemented by a higher
Africa to 100 per cent in Latin Amer-ica and the proportion of poor countries than rich countries.
Caribbean. The largest gains over the last decade
have been in sub-Saharan Africa, South and West Rural versus urban inequalities persist in
Asia and the Arab States.109 school attendance. Lower overall attendance

Adjusted net enrolment rate for primary education by region, 1999-2009
100 North America and Western Europe
Central and Eastern Europe
Adjusted NER for primary education (%)

90 East Asia and the Pacific

World Latin America and the Caribbean
Central Asia
South and West Asia
Arab States
70 Sub-Saharan Africa


1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: UNESCO Institute for Statistics, Global Education Digest 2011: Comparing Education Statistics Across the World, figure 1, citing
UNESCO Institute for Statistics database and statistical table 3. Available from en.pdf.
Note: East Asia and the Pacific and South and West Asia are UNESCO Institute for Statistics estimates based on data with limited coverage
for the reference year, produced for specific analytical purposes.


is clearly driven by lower attendance in rural pletion rates are still generally lower for girls.


areas, with the largest shortfalls in Africa and Primary school completion rates increased to
Asia. The majority of countries have urban- 87 per cent for girls overall in the same
rural differentials that are close to parity, or period, close to the 90 per cent rate for boys.
between parity and 1.5, but a small group of Region-ally, South and West Asia saw the
countries have more severe urban-rural greatest relative gains for girls. 111
differentials coinciding with net attendance
rates of 60 per cent or less. Regarding school-life expectancy,112 the average
number of years of instruction that a child entering
Among the 81 countries with available data, primary school the education system can expect to receive also
attendance is higher in rural areas than in urban areas in only increased between 1990 and 2009, from 8.3 to 11
years for females and from 9.6 to
12 countries in the Americas, Asia and Europe. However, the
11.4 years for males. Consistent with progress in
urban-rural differential is small in all those cases (less than 5
primary school completion, the greatest progress in
per cent), and most countries already present primary school reducing the gender gap in school-life expectancy
net attendance rates higher than 90 per cent, with the exception has been made in South and West Asia, where
of Ukraine (73 per cent) and Bangladesh (86 per cent). a girl who started school in 2009 can expect to
receive 9.5 years of education, up from 6 years in
1990. Nevertheless, boys continue to have the
In nearly half of 162 countries with compa-rable advantage, with an average school-life expectancy
data, boys and girls do not have an equal of 10.5 years. Likewise, in sub-Saharan Africa and
chance of completing primary education. Girls the Arab States, girls who started school in 2009
generally lag behind boys, though not in all can expect to receive 8 and 10 years of education
countries. As with enrolment, the largest gains in respectively, whereas boys in these regions still
completion between 1999 and 2009 were have the advantage of at least one extra year of
observed among girls (see figure 11), yet com- instruction. In East Asia and the Pacific, not only

Primary completion rates by region and by gender, 1999-2009
1999 2009 Male Female


Primary completion rate





Sub-Saharan South and Arab Latin America Central and East Asia Central North America World
Africa West Asia States and the Eastern and the Asia and Western
Caribbean Europe Pacific* Europe

Source: World Atlas of Gender Equality in Education (Paris, 2012), figure 3.6.1, citing UNESCO Institute for Statistics. Available from http://unesdoc.
* 2009 data for East Asia and the Pacific refer to 2007.


did school-life expectancy for girls rise by 38 per and a lack of adequate learning materials,
cent between 1990 and 2009, but girls enrolled therefore producing poorer outcomes, even in
in primary education can expect to spend about wealthy countries.114 A recent comparison of the
12 years in school, slightly surpassing the pupil-teacher ratios at primary level in Asian
average for males. Similarly, in Latin America countries, for example, highlights the wide
and the Caribbean, a girl starting primary school range between countries, from 16 pupils per
can expect to receive almost 14 years of teacher in Indonesia and Thailand to 17 in
instruction, compared to 13.3 years for boys.113 China, and up to 40, 41, and 43 pupils per
teacher in India, Pakistan and Bangladesh.115
Although gains in secondary education have not
been as rapid as those at the primary level, Quality education includes access to knowledge
countries around the world are making progress about human biology and comprehensive
towards increased access to secondary education. sexuality education, which remain
Of 187 countries with data, a quarter (27 per cent) underresourced and incomplete in many schools
have gross enrolment ratios of throughout the world, in both poor and wealthy
per cent or more, approaching universal countries.
secondary enrolment; however, in 43 per cent of
countries, enrolment is less than 80 per cent. 113 Finally, although access to higher education
remains limited in many countries, the last
Access to secondary education remains a decades have seen a major expansion of higher
challenge for girls in many regions, especially in education in every region of the world, and women
sub-Saharan Africa and South and West Asia. have been the prime beneficiaries. Globally, the
While the disproportionate exclusion of girls from gross enrolment ratio in tertiary education was 28
access to education is not only greater at the per cent for females in 2009, compared with 26 per
secondary than at the primary level, it increases cent for males. Regionally, more women than men
from lower to upper secondary levels. Numerous were enrolled in institutions of tertiary education in
factors may be the cause, pointing to gender North America and Western Europe, Central and
discrimination both inside and outside school, Eastern Europe, Latin America and the Caribbean,
including family and social pressures for girls to and East Asia and the Pacific, while in sub-
devote more time to household work, early Saharan Africa and South and West Asia, the
marriage, potential increases in emotional and gross enrolment ratios favoured men.116
physical dangers as girls age and face risks of
sexual harassment and assault, lack of
bathrooms, families’ unwillingness to pay school Governments’ priorities in education for
fees for girls, and the potentially unsafe daily the next 5-10 years highlight their concern for
journey to school for girls and young women. 113 equality in access, the quality of education, and
the importance of linking education to decent
Globally, young males are more likely than work opportunities. In addressing these priorities
young females to enrol in vocational education it will be important that teacher shortages be
programmes, though there are notable addressed. According to new global projections
exceptions such as Burkina Faso and Ethiopia, from the UNESCO Institute for Statistics, the
where females outnumber males.113 world will need an extra 3.3 million primary
teachers and 5.1 million lower secondary
Gains in school enrolment mask other important
teachers in classrooms by 2030 to provide
inequalities, particularly in the quality of education.
all children with basic education.117
Access to good quality education is especially limited
for those living in poverty. Schools serving poor States should commit to and support early and
children characteristically have teachers who are lifelong learning, including pre-primary education,
overburdened, unsu-pervised and underpaid, crowded to ensure that every child, regardless of
classrooms circumstance, completes primary


education and is able to read, write and count, by per cent of ex
to undertake creative problem-solving and to Priority governments


responsibly exercise his or her freedoms. Improve quality standards 61%
States should also ensure access to in education, including the
secondary education for all and expand post- curriculum
secondary opportunities; enable the
Maximize social inclusion, 54%
acquisition of new skills and knowledge at all
equal access and rights to
ages; and enhance vocational education and education
training, and work-directed learning linked to
the new and emerging economies. Capacity strengthening 43%
(human resources in
5. Government priorities: Education
When asked to identify public policy priorities for Development of education 43%
education over the next 5-10 years, over half of programmes, policies,
strategies, laws/creation of
Governments highlighted the importance of
“improving quality standards in education, includ-
ing the curriculum” (61 per cent) and “maximizing Capacity strengthening (build, 36%
social inclusion, equal access and rights” (54

Human rights elaborations since the International Conference

on Population and Development
BOX 7: Education

Binding instruments: The regional human rights systems contain specific protections of
the rights of young people to education. The Council of Europe European Revised Social
Charter (1996; entry into force 1999) reaffirms the right of young persons to “a free primary
and sec-ondary education as well as to encourage regular attendance at schools”. The
Ibero-American Convention on the Rights of Youth (2005; entry into force 2008) recognizes
that “youth have a right to education” and stipulates that “States Parties recognize their
obligation to guarantee a comprehensive, continuous, appropriate education of high
quality”. The African Youth Charter (2006, entry into force 2009), states that “[e]very young
person shall have the right to educa-tion of good quality” and embraces “the value of
multiple forms of education, including formal, non-formal, informal, distance learning, and
lifelong learning, to meet the diverse needs of young people”.

Other soft law: General comment No. 13 on the right to education, adopted by the Committee on
Economic, Social and Cultural Rights (1999), recognizes that “[e]ducation is both a human right in itself
and an indispensable means of realizing other human rights. As an empowerment right, education is
the primary vehicle by which economically and socially marginalized adults and chil-dren can lift
themselves out of poverty and obtain the means to participate fully in their communi-ties. Education
has a vital role in empowering women, safeguarding children from exploitative and hazardous labour
and sexual exploitation, promoting human rights and democracy, protecting the environment, and
controlling population growth … [A] well-educated, enlightened and active mind, able to wander freely
and widely, is one of the joys and rewards of human existence”.


per cent). The need to improve the quality and 6. Youth employment
coverage of education were in fact the top two Achieving decent work for young people is crucial for
priorities identified by Governments in all the progression towards wealthier economies, fairer
regions, although Africa was the only region societies and stronger democ-racies. Decent work
where a higher proportion of Governments involves opportunities for work that are productive and
mentioned coverage (61 per cent) than quality deliver a fair income; provides security in the
(55 per cent), pointing to the unfinished agenda workplace and social protection for workers and their
of universal enrolment. families; offers better prospects for personal
development; and empowers people by giving them
Two other priorities linked to labour and the freedom to express their concerns, to organize
infrastructure investments in the educational system and to participate in decisions that affect their lives.118
garnered the next tier of support and were
mentioned by over a third of Governments:
“capacity strengthening (human resources in edu- The challenge of providing decent work to young
cation)” (43 per cent) and “capacity strengthening people is a concern for both industrialized and
(build, expand and equip schools)” (35 per cent). A developing countries. Of the estimated 197 million
regional breakdown shows that the proportion of unemployed people in 2012, nearly 40 per cent
countries in Africa that identify both priorities is were between 15 and 24 years of age. 119 The
higher than the world average (human resources: economy will need to create 600 million produc-
per cent; infrastructure: 45 per cent), while in tive jobs over the next decade in order to absorb
Europe it is lower (human resources: 31 per the current unemployment levels and to provide
cent; infrastructure: 23 per cent). employment opportunities to the 40 million labour
market entrants each year over the next decade.120
While one third of countries globally cite “training to
work/education-employment linkages” (33 per cent) Figure 12 illustrates the overall decline in
as their priority, this issue is of special relevance for youth employment-to-population ratios, high-
a higher proportion of countries in Europe (58 per lighting that job opportunities have not kept
cent) and Oceania (46 per cent), illustrating the need pace with the growing youth population, nor
for transforming education to better suit the job has increased school enrolments. Youth (age
market. 15-24 years) employment-to-population ratios
have declined for both males and females in all
Facilitating access to and improving the qual-ity of regions of the world since 2000. Male youth
“pre-school education” is a priority for one in every employment remains higher (49 per cent) than
four countries in the Americas (25 per cent), females’ (35 per cent), reflecting the movement
demonstrating that early childhood development is of many young women into early marriage and
key to foster the capabilities of children in their first childbearing by this age, and thereby into
years of life. In all other regions, no more than 15 unpaid work within the household.
per cent of Governments identified it
as a priority. Although all regions face a youth em-ployment
crisis, large differences exist across countries and
Finally, “gender parity”, which captures all regions. For example, youth unemployment rates
priorities pertaining to ensuring equality in school in 2012 were highest in the Middle East and North
enrolment and completion rates between males Africa, at 28 per cent and 24 per cent, respectively,
and females, was identified as a priority by about and lowest in East Asia (10 per cent) and South
one fifth of Governments in Asia (20 per cent) and Asia (9 per cent). The youth unemployment rate for
Africa (18 per cent), while this issue was of lesser the developed economies and the European Union
concern for Governments in the Americas (9 per in 2012 was estimated at 18 per cent, the highest
cent), Oceania (8 per cent) and Europe level for this group of countries in the past two
(4 per cent). decades.119


FIGURE 12 Developed Economies
and European Union
Youth Employment-to-Population Ratio by region, 1991-2011
Central and South-Eastern
75 Europe (non-European
Union) and Commonwealth

of Independent States
65 East Asia

South-East Asia and

the Pacific

50 South Asia
Latin America and

the Caribbean
Youth employment

45 Middle East

40 North Africa

Sub-Saharan Africa


1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010p 2011p

Source: International Labour Organization (ILO), Global Employment Trends for Youth (Geneva, 2010), figure 4.

Gender differentials in youth unemployment rates are cent of the total working poor, compared with 19
small at the global level and in most regions. Regional per cent of non-poor workers in the 52 countries
youth unemployment rates are lower for young women in where data are available.118 Many of the young
the advanced econo-mies and East Asia. However, large working poor are in countries and regions where
gaps between female and male rates are evident in unemployment rates are relatively low, such as
some regions, such as North Africa and the Middle East,
South Asia, East Asia and sub-Saharan Africa.119
Furthermore, where age-disaggregated data on
and, to a lesser extent, Latin America and the Caribbean,
informality are available, they confirm that young
with young women at a disadvantage. Household wealth,
workers are more likely to work in the informal
investment in education and urban origin offer critical
sector than their adult counterparts.119
advantages to youth undertaking the transition from
education to the labour market, and in countries where A review of the policy frameworks of several
such data are available, young males are more likely countries shows that since the mid-2000s, there
than young females to complete the transition to stable has been an increasing commitment by countries
and/or satisfactory employment.119 to prioritize youth employment in national policy
frameworks, as reflected in the poverty reduction
strategies of low-income countries.121 Compared to
In many countries, the unemployment sce-nario is the first generation of poverty reduction strategies,
further aggravated by the large numbers of young from which youth employment was absent, nearly
people in poor quality and low paid employment half of the second-generation strategies prioritize
with intermittent and insecure work arrangements, youth employment. Similar results are found in
including in the informal economy. As many as 60 national development strategies of countries that
per cent of young persons in developing regions do not have pov-erty reduction strategies.
are either without work, not studying, or engaged in Increased attention
irregular employment and thus not achieving their to youth employment is necessary to ensure
full economic poten-tial.119 According to ILO, youth young people’s effective transition from school
account for 24 per to decent jobs; however, the challenge of job


creation is particularly daunting for countries preparing them for full participation in the labour
that have large cohorts of youth entering their market, and the importance of their social protec-
productive years. The 49 poorest countries face tion and rights. “Economic empowerment and em-
a stark demographic challenge, as their ployment” was especially noted by Governments of
collective population, about 60 per cent of which poorer countries: 69 of 85 Governments in the
is under the age of 25, is projected to double to bottom two World Bank income categories, versus
1.7 billion by 2050. In the coming decade these 16 of 33 Governments in the top two income cate-
countries will have to create about 95 million gories. Youth cohorts are larger in countries lower
jobs in order to absorb new entrants to the on the income ladder owing to higher fertility in
labour market, and another 160 million jobs in recent years, and providing employment, particu-
the 2020s.122 larly employment that leads out of poverty, is very
challenging. Youth unemployment has become an
States should invest in building young people’s enormous issue in wealthier countries also,
capabilities and equip them with the skills to particularly since the 2008 global economic crisis,
meet the labour demands of the current and underscoring the priority Governments assign to
emerging economies, and develop labour this issue.
protection policies and programmes that
ensure employment that is safe, secure and That “maximizing social inclusion, equal access
non-discriminatory and that provides a decent and rights” is a global priority was re-flected in
wage and opportunities for career the fact that it was mentioned by a majority of
development. Efforts must also include a focus countries in Europe (63 per cent of
on produc-tive investment in technologies, Governments) and the Americas (56 per cent);
machineries, infrastructure, and the in Africa and Asia, approximately 40 per cent of
sustainable use of natural resources to create Governments highlighted it. The Programme of
employment opportunities for young people. Action recognized the critical role of youth and
the need to integrate them into society. Priority
areas under “social inclusion, equal access and
Government priorities:
rights” included addressing neglect, discrimina-
adolescents and youth
tion and ensuring human rights protections,
by per cent
areas of significant focus in the declaration
Priority of governments adopted at the Global Youth Forum in Bali.
Economic empowerment 70%
and employment Three additional priorities were very common among
Governments. The first, “sexual and reproductive
Maximize social inclusion, 46% health information and services for youth, including
equal access and rights HIV”, was listed as a priority by
per cent of Governments globally but was a high
Education 46%
priority for half of all countries in Africa and Asia,
half of low-income and lower-middle-income
SRH information and 38%
services for youth, Governments and 40 per cent of all upper-middle-
including HIV income Governments. However, only 1 of the 33
wealthiest countries included sexual and
Training to Work 36% reproductive health among their top five priorities
for youth, which may reflect the better access to
health existing in most of the wealthiest countries.
Governments that responded to the global survey
regarding their priorities for adolescents and “Political empowerment and participation” was
youth in the coming 5-10 years expressed strong highlighted by 38 per cent of Governments,
support for their economic empowerment, evenly distributed regionally and by income. This


provides a strong complement to, and a mecha- than 20 per cent of the global population will be de
nism for achieving, both social inclusion and rights aged 60 and above by 2050 (see figure 13). ve
and economic empowerment, and highlights Persons aged 60 and above already make up lo
the rising strength of youth in influencing more than 20 per cent of the population in Europe
social, economic and political systems. Finally, and 15 per cent of the population in Oceania, and
“training to work” was listed by 36 per cent of are anticipated to make up 15 per cent of the
Govern-ments globally, including 52 per cent population in the Americas by 2015. If projections co
of African Governments and 56 per cent of of rapid growth in the population of older persons un
low-income Governments. in the coming decades are correct, the number of tri
older persons will surpass the number of children es
Taken together, this collection of priorities — by 2047. Many developed countries are already an
economic empowerment; education, both general- facing extremely low old-age support ratios. 123 d
ly and targeted for work; sexual and reproductive
health; and political empowerment — reinforce Subregional trends highlight the low pro-portion
Governments’ emphasis on strengthening the of persons aged over 60 years in Africa, but
capabilities of their young people. greater proportions in Southern and Northern y
Africa relative to other subregions. All subregions o
D. Older persons of the Americas are ageing rapidly, with North ne


America furthest ahead. Within Europe, in 2010
The demographic importance only Eastern Europe had a population of persons
of population ageing aged over 60 years of less than 20 per cent, but
An inevitable consequence of demographic it will pass that mark soon. In Asia, only Eastern
changes resulting from fertility decline and in- Asia had an over-60 population of more than 10
creased longevity is population ageing. One of hu- per cent, but all subregions are ageing quickly.
manity’s greatest achievements is that people are Oceania remains diverse, with Australia and New
living longer and healthier lives, with the number Zealand closer to European proportions.
and proportion of older persons aged 60 years or
over rising in all countries. Population ageing Owing to longer life expectancy among women
presents social, economic and cultural challenges than among men at older ages, elderly women
to individuals, families and societies, but also outnumber elderly men in most societies. In
opportunities to enrich entire households and the 2012, globally there were 84 men per 100
larger society. From 1990 to 2010, the population women in the age group 60 years or over and
aged 60 years or over increased in all regions, with 61 men per 100 women in the age group 80
Asia adding the greatest number of older persons, years or over.123 Integrating gender into policies
million, to its population. From 2005 to 2010, the annual and support for older persons is therefore
growth rate of the population aged 60 years or over was 3 critical, including in health, other types of care,
per cent, while that of the total population was 1 per cent. In family supports and employment.
the coming decades, this gap is expected to widen.123
Older individuals are much more likely to
live independently in developed countries than in
Globally, in the past 20 years, the population of older developing countries. Globally, 40 per cent of older
persons aged 60 years or over has increased by 56 persons aged 60 years or over live alone or only with
per cent, from 490 million in 1990 to 765 million in
their spouse, and older persons living alone are more
2010. During this period, the increase
likely to be women given their longer life expectancy.
in the population of older persons in developing
countries (72 per cent) was more than twice that of
But the living arrangements of older people vary
developed countries (33 per cent). The number greatly by level of development. About three
and proportion of older persons are rising in almost quarters of older persons in developed countries live
all countries, with projections estimating that more independently, compared with only one quarter in


eighth in the least developed countries.124 Popu- remains largely taboo in many cultures. Yet in a
lation ageing demands attention to the physical recent large study of older adults in the United
infrastructure to ensure safe housing, mobility States of America, in which a broad definition of
and the means of meaningful participation of sexual functioning was used, women between
older persons. States should modify legislation, 57 and 74 years showed no decline in sexual
design and planning guidelines, and activity.125 Sexual functioning was found to be
infrastructure to ensure that the increasing more associated with self-rated physical health
number of older, single persons have access to than age. States should adapt policies and
needed and appropriate housing, transport, programmes on sexual health to better meet the
recreation and the amenities of communal life. changing sexual needs of older persons.

The sexual health of older persons is often As people live longer, there are growing con-cerns
overlooked both in academic discourse and policy about the sustainability of benefits such as
responses to rapid population ageing, perhaps pensions, health care and old-age support, which
because the subject of sexuality in older people will need to be paid over longer periods. There

Trends and projections in the proportion of older persons (over 60 years),
worldwide and by region, 1950-2050
(medium fertility variant)

Worldwide 40

Per cent

Africa 20
Asia 10
Oceania 0
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Africa by sub-region 40

Per cent

Eastern Africa 20
Middle Africa
Northern Africa
Southern Africa
Western Africa
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Americas by
sub-region 30
Per cent

Central America 10
Northern America
South America 0
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Source: World Population Prospects: The 2012 Revision, November 2013 (ST/ESA/SER.A/336).


are also concerns about the long-term viability of particular consideration for older women, those


intergenerational social support systems, which living in isolation and those providing unpaid
are crucial for the well-being of both the older care, by extending pension systems and non-
and younger generations. Such concerns are contributory allowances and by strengthening
especially acute in societies where provision of intergenerational solidarity, and by ensuring the
care within the family becomes increasingly inclusion and equitable participation of older
difficult as family size decreases and as women, persons in the design and implementation of
typically the main caregivers, work outside the policies, programmes and plans that affect their
home. Increasing longevity may also result in lives.
rising medical costs and increasing demands for
health services, since older people are typically At the same time, many persons continue to
more vulnerable to chronic diseases.126 contribute to their families, communities and
societies well into old age. Not all older persons
States should ensure the social protection and require support, nor do all persons of working age
income security of older persons, with provide direct or indirect support to older persons.

Asia by 40

Per cent

Central Asia 20
Eastern Asia
South-Eastern Asia 10
Southern Asia
Western Asia 0
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Europe by 40

Per cent

Eastern Europe
Northern Europe 10
Southern Europe
Western Europe 0
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Oceania by
sub-region 30
Per cent

New Zealand 10
Micronesia 0
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050


In fact, older persons in many societies are often labour market, for their own benefit, for that of
providers of support to their adult children and their families, and as an essential resource for
grandchildren.127 Further, while expenditures in successful economies that cannot afford to
health care and other sectors that cater to older lose their experience and expertise.
populations may be a challenge, they are also an
investment. The expansion of these sectors gen- In the years following the International Confer-ence on
erates important employment opportunities in both Population and Development, the Ham-burg Declaration on
the public and private health-care sectors.128 Adult Learning, adopted at the Fifth International Conference
States should strengthen health and care systems on Adult Education (1997), and the Madrid International Plan
by promoting universal access to an integrated, of Action on Ageing, 2002 affirmed the importance of edu-
balanced continuum of care through old age,
cation for older persons.129 The provision of lifelong
including chronic disease management, end-of-life
education enables persons of all ages to strength-en and
and palliative care.
augment their literacy and related skills, to adapt to
changing employment opportunities and to participate fully in
In 2002, the international community gath-ered
in Madrid for the Second World Assembly on changing personal and economic conditions, to the benefit

Ageing to discuss the growing challenges of of themselves, their families, their communities and the
population ageing. By then, it was clear that society at large. Lifelong learning is not only for older
ageing was no longer a concern of developed persons; it is also for young or middle-age workers
countries alone; it was affecting, or beginning to experiencing loss or change of employment, or who may
affect, an increasing number of countries, both have missed earlier opportunities to get an education
developed and developing, and its social,
because of poverty, early entry into employment, early
economic and political consequences could no
childbearing, or voluntary or forced mobility. In addition, a
longer be ignored. The phenomenon of pop-
global network of universities of the third age focus on
ulation ageing could no longer be considered a
education to enhance quality of life for retired persons. Their
stand-alone issue or an afterthought. The
Second World Assembly and its outcome doc- membership has expanded further in response to the

ument, the Madrid International Plan of Action growing demands of non-retired persons for non-formal
on Ageing, 2002 (see A/CONF.197/9, chap. I) education.130
marked the first time that Governments agreed
to link questions of ageing to other frameworks
for social and economic development and to Ninety-two per cent of Governments appear to
human rights agreed at previous United have some policy on adult education, which
Nations conferences and summits. overwhelmingly targets skills development and
training for the labour market, an oft-cited priority
Lifelong education, economic and of ministers of education in both developing and
social participation developed countries.131 Since 2000, numerous
The Programme of Action recommended that countries or territories, including Belize, Canada,
Governments enhance and promote older persons’ China, Denmark, El Salvador, Hungary, Japan,
self-reliance, quality of life and ability to work as Mexico, Puerto Rico the Russian Federation,
long as possible and desired, and enable their Serbia and Sweden, have adopted policies and
continued participation using their skills and initiatives focusing on retraining older persons.132
abilities fully for the benefit of society. Many older
persons continue to work and often their earn-ings Despite national policies on lifelong educa-tion and
support the entire household. Older persons may retraining, adult illiteracy remains high, and 651
also wish to lead satisfying professional lives. million adults aged 25 and over are func-tionally
Flexible employment, lifelong learning and illiterate (2011 data), the majority (64 per cent) of
retraining opportunities are critical to enable and them women.133 Among persons aged 65 or older,
encourage older persons to remain in the the total global illiteracy rate is 26 per


cent, ranging from 25 per cent in Latin America enabling them to set up small stores and business-
to 68 per cent in Africa, with rates among es.138 States should strengthen lifelong learning
women consistently above those of men. Adult and adult literacy opportunities that enable all
illiteracy rates are higher in rural areas and in persons, regardless of age, to gain new skills for a
zones of conflict, and among persons with changing economy, pursue better employment and
disabilities and ethnic minority populations.134 income, or simply explore the development of
personal talents and ambitions.
Illiteracy traps many in a cycle of poverty, with
limited opportunities for employment or income Globally, the highest proportion of older per-sons
generation, and a greater likelihood of poor participating in the labour force is in Africa, where
health.135 The effects of illiteracy, incomplete and/ more than 40 per cent of those over 65 years of
or poor quality education (see sect. II.C.4 above on age are economically active, followed by Asia,
uneven progress in education) linger through-out Latin America and the Caribbean, with nearly 25
the life course, with adverse consequences in per cent (see figure 14).
particular for adults and older persons in countries
without social security systems, who may be com- Given their longer life expectancy, women make up an
pelled to work at older ages in informal, physically increasing proportion of the older workforce, and the
demanding and poorly paid work.136 likelihood of their participating in the labour force after
age 65 has been rising for several decades (see figure
In 2002, 88 per cent of Governments reported 15) even as the likelihood of men’s working after age 65
having a law or policy on adult literacy. 137 In Cam- has declined. Women’s increased participation in the
bodia, where 70 per cent of women over 65 years older workforce and greater rates of illiteracy contribute
old cannot read or write, adult literacy classes to the persistent inequalities faced by working women
organized with volunteer teachers (retired school- and the greater likelihood of their participating in
teachers and monks) markedly improved older informal, insecure and lower-paid
women’s ability to read and perform calculations,

Labour force participation of older persons as a proportion of total
population aged 65 and over by region, 1980-2009

Latin America and
the Caribbean 25
Northern America 12 2009



0 10 20 30 40 50
Per cent
Source: United Nations, World Population Ageing 2009 (ESA/P/WP/212), figure 38.


FIGURE 15 work (see sect. II.B.1 above on changing patterns
Global labour force participation in productive and reproductive roles. States should
age 65 and over by sex, 1980-2020 monitor and eradicate all forms of discrimination in
employment against older persons; and devel-op
35 labour protection policies and programmes that
ensure employment that is safe, secure, and that
25 provides a decent wage.

The results of the global survey show that a higher
15 percentage of countries with old-age struc-tures
address the issues related to the needs of older

2009 persons. These are countries with current old-age
5 dependency ratios higher than 12 persons aged
0 or over per 100 persons of working age (15-64).

1980 1990 2000 2010 2020

Total Male Female
Globally, 40 countries whose populations will be
ageing rapidly over the next two decades —
including Brazil, China, India, Indonesia, the Islamic
Source: United Nations, World Population Ageing 2009 Republic of Iran, Mexico and Viet Nam — have an
(ESA/P/ WP/212), figure 36.
old-age dependency ratio between 6 and 12 in

Human rights elaborations since the International Conference

on Population and Development
BOX 8: Older persons

Intergovernmental human rights outcomes: In resolution 65/182 on follow-up to the Second

World Assembly on Ageing (2011), the General Assembly decided to establish an open-ended
working group on ageing in order to strengthen recognition of the human rights of older persons,
assess gaps, and consider, as appropriate, the feasibility of implementing further instruments and
measures. In resolution 67/139, entitled “Towards a comprehensive and integral international
legal instrument to promote and protect the rights and dignity of older persons” (2013), the
Assembly decided that the Open-ended Working Group on Ageing would “consider proposals for
an interna-tional legal instrument to promote and protect the rights and dignity of older persons”.

Other intergovernmental outcomes: The Madrid Political Declaration and International Plan of
Action on Ageing, 2002, adopted at the Second World Assembly on Ageing, offered a new
agenda on ageing in the twenty-first century focusing on: older persons and development; health
and well-being into old age; and ensuring enabling and supportive environments.

Other soft law: Regional systems have also shown increased momentum towards
developing mechanisms to promote, protect and fulfil the human rights of older persons. The
African Com-mission on Human and Peoples’ Rights, the Inter-American system and the
Steering Committee for Human Rights of the Council of Europe have all established working
groups with the aim of drafting an instrument to promote the human rights of older persons.


2010; it is estimated that the ratio will increase to When countries were asked to identify the most g
more than 12 in 2030 (medium projection). A high relevant issues anticipated to receive priority in public o
proportion of these countries addressed the issues policy related to older persons, “preventative and v
of “providing social services including long-term curative health care” was a particular focus of er
care” (94 per cent), “providing affordable, appro- countries in Africa, where 68 per cent listed it among n
priate and accessible health care” (91 per cent), their top five priorities; in Europe, Asia and the m
“extending or improving old age allowances” (88 Americas, about half of countries included it, as did e
per cent), “enabling older persons to live inde- of 10 countries in Oceania. European and Asian nt
pendently as long as possible” (89 per cent) and countries listed “economic empowerment, employ- a
“collecting disaggregated data” (88 per cent). ment and pensions” most often (62 per cent and 59 ct
per cent respectively). In these two regions, as well io
Such progress in the areas of social protection, health as in the Americas, the identification of economic n
care and data collection have not been matched by contributions and sustainable support systems for s.
advances in employment, non-discrimination or


older persons aligns with the significant progression
participation in society: a smaller share of countries of ageing and the need to maintain both economic
mentioned “addressing neglect, abuse and violence growth and social welfare given the relative decline in
against older persons” (74 per cent), “enabling older traditional working age populations.
persons to make full use of their skills and abilities”
(69 per cent), “providing sup-port to families caring for Despite high poverty rates among older persons
older persons” (67 per cent), “instituting concrete around the world and across country income group-
procedures and mechanisms for participation” (63 per ings, “addressing poverty” among older persons
cent), “preventing discrimination against older emerged as a priority only among African countries, of
persons, especially widows” (58 per cent) and which nine listed it. Only three countries in the other
“promoting employment opportunities for older regions combined reported it to be a priority.
workers” (39 per cent). States should monitor and
eradicate all forms of direct and indirect abuse, In line with the significant shift reflected
including all forms of violence, overmedica-tion, in the Madrid International Plan of Action on
substandard care and social isolation. Ageing, “social inclusion and rights” of older
persons was a consistent priority of about 40
3. Government priorities: older persons per cent of countries in Africa, the Americas and
Europe. Only 9 of 41 Asian countries listed it,
by per cent of
however, and only 1 country in Oceania.
Priority governments Prioritization of “social inclusion and rights” was
Preventive and curative 54% also more frequently found on the higher end of
health care the income spectrum: over 40 per cent of upper-
middle, high non OECD and OECD countries
Economic empowerment, 54% and 30 per cent of low- and lower-middle-
employment and pensions/ income countries listed it as a priority.
support schemes

Development of 39% “Capacity strengthening” on ageing, partic-ularly in

programmes, policies and the areas of data and research, emerged more
strategies and the creation of frequently as a priority among low-income
laws and institutions related
to older persons
countries, 10 of 32 of which included it among their
top five priorities. Low-income countries are in the
Social inclusion and rights of 37% early stages of a transition to an ageing population,
older persons but they share other countries’ awareness of the
need for support for older persons and some are
Elder care 36%
clearly looking to expand the evidentiary basis for


E. Persons with disabilities Persons experiencing a disability are more likely to
experience “violations of dignity”,142 including social
Disability is experienced by the majority of people exclusion, violence and prejudice, than persons
in the world at some point in their lives, some without a disability. And the impli-cations of
throughout their lives, some moving in and out of disability, including the need for social support,
disability. It is variously estimated that 15 to 20 extend beyond the individual to house-holds and
per cent139 of persons 15 years and older around families impacted by disability, given the added
the world currently live with a disability, cost of resources spent on health care, loss of
2-4 per cent of whom have a significant or severe income, stigma, and the need for support systems
disability. According to the WHO World Report on for caregivers. States should monitor and eradicate
Disability, approximately 93 million, or 5 per cent, all forms of direct and indirect discrimination
of children aged 0-14 are disabled.140 against persons with disabilities, including all forms
of interpersonal violence, overmedication and
Disability is experienced unevenly across substandard care, and the social isolation of such
countries: those with per capita GDP below US$ persons, through na-tional programmes,
3,255 have a total disability prevalence of 18 per particularly in the areas of education, employment,
cent, compared with just 12 per cent for those rehabilitation, housing, transportation, recreation
above this figure. Women are also significantly and communal life, as well as support for family
more prone to disability than men; 22 per cent of caregivers.
women in lower-income countries and 14 per cent
in higher-income countries have a disability. 140 The World Programme of Action concerning
Disabled Persons (1982), the Programme of Action
The likelihood of having a disability rises of the International Conference on Popu-lation and
dramatically with age, with over 46 per cent of Development (1994), the Convention on the Rights
all people over 60 years of age having a of Persons with Disabilities (2006) and the
moderate or severe disability compared with outcome document of the high-level meeting of the
just 15 per cent of people aged 15-49 years. General Assembly on the realiza-tion of the
Millennium Development Goals and other
The number of persons with disabilities is
internationally agreed development goals for
growing, as a result of both general population
persons with disabilities: the way forward, a
ageing and the spread of non-communicable
disability-inclusive development agenda towards
diseases associated with disability, such as
2015 and beyond (General Assembly resolution
diabetes, heart disease and mental illness.140
68/3 of 23 September 2013) all recognized that
There is a suggestive, though understudied, link persons with disabilities constitute a significant
between poverty and disability, both as a driver portion of global and national populations. These
and as a consequence of disability.141 Cau-sality documents set as objectives the realization of
human rights, participation, equal opportunities,
between disability and poverty is not well
valuing of capabilities in social and economic
established owing to limited availability of longi-
development, and dignity and self-reliance for
tudinal data and the fact that poverty is frequently
persons with disabilities. States should take
measured at the household level. Studies in both
concrete measures to realize their commit-ments to
developed and developing countries have shown
enhancing accessibility and inclusive development
that disability hampers educational attainment and
and to enabling full participation in social,
interferes with labour market participation.142
economic and political life for all, including persons
States should monitor and eradicate all forms of
with disabilities.
discrimination in employment against persons with
disabilities and develop enabling policies and
National and global data on disability also suffer
programmes that ensure employ-ment that is safe
from significant validity and comparability problems,
and secure, and provides a decent wage.
leading to highly variable estimates, as


well as frequent undercounting, owing in part to average in Oceanic and African countries. States
stigma associated with the term. The Washington should guarantee persons with disabilities, in par-
Group on Disability Statistics, which promotes inter- ticular young people, the right to health, including
national cooperation in health statistics by focusing sexual and reproductive health and rights, as well
on disability measures suitable for censuses and as the right to the highest standard of care,
national surveys, is making continuous progress in ensuring that people with disabilities are partners
the measurement of disability. Strengthening in programming and implementation, and policy
definitions and data systems for monitoring and development, monitoring and evaluation, taking
addressing disability is critical for defining and into account the structural factors that hinder the
monitoring progress towards well-being and exercise of these rights.
participation. Enhanced international cooperation to
this end is more vital than ever before. “Providing support to families caring for persons with
disabilities” is addressed by 61 per cent of countries,
According to the responses to the global survey, the and again the level of concern is proportional to the
primary issue of concern relevant to persons with countries’ income level and inversely proportional to
disabilities that is being addressed by countries is the countries’ population growth. Although 59
“ensuring a general education system where children countries did not address this issue during the past
are not excluded on the basis of disability”. It is worth five years, considerable differ-ences are observed
noting that 82 per cent of countries, that is, all except regionally. While 88 per cent of European countries
28 (13 in Africa, 6 in Asia, reported addressing the issue, only 39 per cent of the
in the Americas, 2 in Europe and 1 in Oceania) were countries in Oceania and 39 per cent of those in
committed to implementing this commitment. The Africa (the majority) did so.
level of concern around this issue was inversely
proportional to the countries’ population growth and Finally, the issue which elicited the least
directly proportional to the countries’ income level. commitment from countries was “promoting
equality by taking all appropriate steps to ensure
Secondly, 78 per cent of countries expressed the that reasonable accommodation is provided in all
need to “strengthen comprehensive habilitation aspects of economic, social, political and cultural
and rehabilitation services and programmes”, with life”, which was not a priority issue for 47.9 per
no major regional differences observed, and 77 per cent of countries, most of them in Africa (23), Asia
cent of countries reported “creating employment (23) and Oceania (10), and most of them poorer
opportunities for persons with disabilities”. The and fast-growing.
number and percentage of countries that do not
address the issue is small in Europe (8 per cent), Increasing “accessibility and mobility” for
Asia (10 per cent) and the Americas (19 per cent) persons with disabilities is among the top five
and larger in Oceania (54 per cent) and Africa priorities for half or more of countries at the
(38 per cent). This may suggest that a higher lower end and middle of the income spectrum
percentage of wealthier countries have (low-income: 50 per cent; lower-middle-income:
committed themselves to addressing this issue per cent; upper-middle-income: 66 per cent).
during the past five years than poorer ones. Given the central importance of accessibility in
building inclusive societies and sustainable and
The issues of “developing infrastructure to ensure equitable development for all, this is an area that
access on an equal basis with others” (68 per cent), should receive greater attention and prioritization
“ensuring the same rights and access to sexual and beyond 2014 and post-2015. Success in this area
reproductive health services, including HIV would significantly contribute to the full economic
prevention” (65 per cent) and “guaranteeing equal and social participation of persons with disabili-
and effective legal protection against discrimi-nation” ties, many of whom live in developing countries
(60 per cent) are addressed by about 6 in 10 and face accessibility and mobility challenges in
countries globally; the proportion is below the world their everyday life.


Human rights elaborations since the International Conference
on Population and Development
BOX 9: Persons with disabilities

Binding Instruments: Recognized among the core international human rights instruments, the
Convention on the Rights of Persons with Disabilities (2006; entry into force 2008) constitutes a
tremendous advance in promoting the rights of persons with disabilities. The Convention recog-
nizes persons with disabilities to include individuals with “long-term physical, mental, intellectual
or sensory impairments”, where such disabilities interact with additional barriers to prevent ef-
fective and equal participation in society. The Convention aims to “promote, protect and ensure
the full and equal enjoyment of all human rights and fundamental freedoms by all persons with
disabilities, and to promote respect for their inherent dignity”. The Optional Protocol to the
Convention on the Rights of Persons with Disabilities provides individuals with a communications
mechanism to address instances where human rights have not been respected. Regionally, the
Inter-American Convention on the Elimination of All Forms of Discrimination against Persons with
Disabilities (1999; entry into force 2001) affirms that persons with disabilities are entitled to the
full enjoyment of human rights and fundamental freedoms protected through international law.

Intergovernmental human rights outcomes: The Human Rights Council has adopted a
series of resolutions on persons with disabilities, most recently resolution 22/3 on the work
and employment of persons with disabilities (2013). Regional systems have elaborated rights
of persons with disabilities in regional human rights instruments and documents. 143

Government priorities: ment, access and mobility, and education. Ten of

persons with disabilities 48 African countries, or 21 per cent, also listed
When Governments were asked to identify the most “training for employment”144 as a top five priority in
relevant issues anticipated to receive priority in public a region above and beyond the distinct support for
policy relating to persons with disabilities, the top “econom-ic empowerment and employment”,144
three priorities across 4 of 5 regions, and by a affirming the importance of bringing disabled
substantial margin, focused on economic empower- populations into the labour force in the region.

by per cent of Equal access to “education” for disabled

Priority governments persons was a consistent priority for Govern-
Economic empowerment 65% ments around the world, but particularly for low-
and employment income countries (63 per cent). Discrimina-tion
faced by persons with disabilities in access-ing
Accessibility and mobility 57%
the general education system, as well as the
Education 55% lack of an education system tailored to their
needs, poses serious barriers to their self-
Social inclusion and rights 37% reliance and access to equal opportunity.

Development of programmes, 28% Finally, a number of other priorities were

policies, strategies, laws and the
frequently listed. For instance, more than half of
creation of institutions pertaining
to persons with disabilities low-income (53 per cent) and high-income OECD
(52 per cent) Governments listed “social inclusion


and rights”145 as a key priority. “Rehabilitation and Expert Mechanism on the Rights of e
habilitation”146 was one of the top five priorities for Indigenous Peoples was established by the n
more than a third of Asian Governments (35 per Human Rights Council (resolution 6/36). s
cent), while “autonomy”147 was prioritized by 21 per ur
cent of European Governments. Despite the expansion of these concerted efforts to in
address the needs of indigenous peoples, significant g
F. Indigenous peoples disparities persist, with indigenous peoples th
experiencing significantly higher preva-lence of ei
There are an estimated 370 million indigenous tuberculosis, non-communicable diseases, poor r
persons worldwide. Indigenous people have histor- mental health, and a shorter life expectancy a
ically been, and continue to be, subject to social compared to non-indigenous nationals of the same c
and political marginalization that has undercut their country. For example, more than 50 per cent of c
access to development. They have often been indigenous adults over age 30 worldwide suffer from e
denied both the opportunity to sustain their own type 2 diabetes. In the United States of Amer-ica the s
cultural heritage and the opportunities commensu- risk of contracting tuberculosis is 600 times higher s
rate with full social, political and economic integra- among Native Americans than in the general to
tion into the prevailing political system.148 population. In Ecuador, the risk of contracting throat s
cancer is 30 times greater among indigenous per- er
For many, structural discrimination included the sons than other nationals. The life expectancy gap vi
violence of forced displacements, loss of homeland between an indigenous child and a non-indigenous c
and property, separation of families, enforced loss child in Nepal or Australia is 20 years, 13 years in e
of language and culture, the com-modification of Guatemala and 11 years in New Zealand.148 s
their cultures, and a disproportion-ate burden of


the consequences of climate change and A study undertaken by the World Bank in 2005 on
environmental degradation. Conditions of poverty indigenous peoples in Latin America, some 28 million
are, for some groups, exacerbated by geographic persons, found that “despite signifi-cant changes in
distance and the remoteness of indig-enous poverty overall, the proportion of indigenous peoples
territories, itself a consequence of historic forced in the region living in poverty
displacements.148 — at almost 80 per cent — did not change much
from the early 1990s to the early 2000s”,149 with
The Programme of Action of the International poverty rates 7.9, 5.9 and 3.3 times higher among
Conference on Population and Development indigenous relative to non-indigenous peoples, in
affirmed the human rights of indigenous peoples in Paraguay, Panama and Mexico, respectively.150
1994. Later that year, the first International Decade
of Indigenous Peoples was launched, followed by States should guarantee indigenous peoples’
the Second International Decade right to health, including their sexual and
of the World’s Indigenous People in 2005. The reproductive health and rights, as well as their
past two decades have seen a notable growth in rights to both the highest standard of care and
international actions aimed at protecting, promot- the respectful accommodation of their own
ing and fulfilling the rights of indigenous peoples. traditional medicines and health practices,
The United Nations Permanent Forum on Indige- especially as regards reducing maternal and
nous Issues was established in 2000. In 2001 the child mortality, considering their socio-territorial
Commission on Human Rights decided to appoint and cultural specificities as well as the structural
a special rapporteur on the rights of indigenous factors that hinder the exercise of these rights.
peoples, whose mandate was renewed by the
Human Rights Council, most recently in 2007. The In its actions and objectives, the Programme of
same year, the United Nations Declaration on the Action called on Governments to address the
Rights of Indigenous Peoples was adopted by the specific needs of indigenous peoples, including
General Assembly (resolution 61/295), and the


and full participation, and protecting, promoting of providing culturally appropriate “sexual and
and fulfilling their right to development, including reproductive health care, including HIV preven-
their integration into national censuses. tion services” for indigenous peoples.

Among respondents to the global survey, only a Regarding issues of governance, 58 per cent of
small proportion of countries reported having countries reported having policies, budgets and
addressed the concerns of indigenous peoples implementation measures for “instituting concrete
during the past five years; this was consistent procedures and mechanisms for indige-nous
across all regions. No more than two thirds of peoples to participate”, 52 per cent reported that
reporting countries affirmed having government they had addressed the issue of “protecting and
policies, budgets and implementa-tion restoring the natural ecosystems on which in-
measures to meet the needs of indigenous digenous communities depend”, and half (50 per
peoples, and responses on this question were cent) had policies, budgets and implementation
often provided by fewer than half of all countries measures that addressed “enabling indigenous
in each region. This low response rate most peoples to have tenure and manage their lands”.
likely reflects the fact that many countries do The issue addressed by the smallest proportion of
not recognize “indigenous peoples” living within countries (31 per cent) was “seeking free, prior and
their national boundaries. informed consent of indigenous peoples in trade
agreements [and] foreign direct investment
The most positive response was with regard to agreements” affecting indigenous peoples.
education. Sixty-seven per cent of Governments
stated that they had policies, budgets and States should respect and guarantee
implementation measures to ensure indigenous the territorial rights of indigenous peoples,
people access to “all levels and forms of public including those of peoples living in voluntary
education without discrim-ination”, but only 59 isolation and those in the initial phase of
per cent had policies for creating access to contact, with special attention to the chal-
education in a person’s “own language and lenges presented by extractive industries and
respecting their culture”. Just under half of other global investments, mobility and forced
Governments (49 per cent) reported addressing displacements, and design policies that re-
the issue of “creating different work spect the principle of free, prior and informed
opportunities for indigenous peoples without consent on matters that affect these peoples,
discrimination” during the past five years. Just pursuant to the provisions of the United
over half of the reporting countries (56 per cent) Nations Declaration on the Rights of
had addressed the issue Indigenous Peoples.

Human rights elaborations since the International Conference

on Population and Development
BOX 10: Indigenous peoples

Intergovernmental human rights outcomes: Following the International Conference on

Population and Development, a number of international human rights instruments have
addressed the rights of indigenous peoples. The landmark United Nations Declaration on
the Rights of Indigenous Peoples (2007) states that “indigenous peoples have the right to
the full enjoyment, as a collective or as individuals, of all human rights and fundamental
freedoms as recognized in the Charter of the United Nations, the Universal Declaration on
Human Rights and international human rights law”.


Government priorities: indigenous peoples health)” all garnered the same level of
support (5 Governments).
by per cent of

Priority governments In Africa, contrary to global and regional trends,

Education 55% “economic empowerment and employ-ment”
was the most frequently mentioned priority (8 of
Economic empowerment and 36% the 15 responding Governments) and the only
priority mentioned by more than half of
Political empowerment and 33%
Governments. “Education” (7 Governments)
participation and “language, culture and territory” (6
Governments) were the second and third most
Language, culture and identity 32% important priori-ties in the region.

Land and territory 30% States should adopt, in conjunction with

indigenous peoples, the measures needed to
Social Protection 30% ensure that all indigenous persons enjoy
protection from, and full guarantees against, all
Globally, 69 of the 176 Governments forms of violence and discrimination, and take
responding to the global survey answered the measures to ensure that their human rights are
question on priorities for indigenous peoples: respected, protected and fulfilled.
in the Americas, 18 in Asia, 15 in Africa, 7 in
Europe and 6 in Oceania. States should respect and implement the
provisions of the United Nations Declaration on the
In the Americas, after “education”, which was Rights of Indigenous Peoples as well as the
indicated to be a priority by 14 of the 23 re- Indigenous and Tribal Peoples Convention, 1989
sponding Governments, the next most frequently (No. 169) of the International Labour Organiza-
mentioned priorities were “political empowerment tion, and call on those countries that have not
and participation” (12 Governments) and “land and already done so to sign and ratify the Conven-tion;
territory” (10 Governments). These were followed adapting legal frameworks and formulating the
by “social protection” (9 Governments), “health policies necessary for their implementation, with
care (other than sexual and reproductive health)” 151 the full participation of indigenous peoples,
(9 Governments) and “development of policies, including those who live in cities.
programmes, strategies, laws/creation of
institutions”152 (8 Governments). Hence, the key G. Non-discrimination
focuses for the region are capabilities and security, applies to all persons
including education, health care, land and ways to
secure them, particularly through political The Programme of Action affirmed human rights
participation. principles related to equality and non-dis-
crimination established in the Universal Decla-
In Asia, “education” for indigenous persons was ration of Human Rights (1948), the International
also the top priority listed (11 of the 18 re-sponding Covenant on Civil and Political Rights (1966) and
Governments) followed by “economic the International Covenant on Economic, Social
empowerment of employment” (9 Governments), and Cultural Rights (1966), and elaborated in other
suggesting the importance of accessing in-come- international human rights instruments such as the
generating activities by indigenous per-sons. International Convention on the Elimination of All
Prioritized by a smaller number of Govern-ments, Forms of Racial Discrimination (1965) and in the
the issues “political empowerment and Declaration on the Rights of Persons Belonging to
participation”, “language, culture and identity” and National or Ethnic, Religious and Linguistic
“health care (other than sexual and reproductive Minorities (1992). Yet many people throughout


the world continue to suffer from Many individuals and groups continue to be
discrimination, a fact affirmed at the regional frequently exposed to discriminatory behaviour,
meetings on the International Conference on including stigma, unfair treatment or social exclu-
Population and Development beyond 2014. sion, owing to dimensions of their identity or cir-
cumstances. Discrimination may be compounded
The operational review showed that persons with by laws criminalizing their behaviour; or laws that
diverse sexual orientations and gender iden-tities remain silent regarding their need for social
in parts of the world suffer from the risk of protection. The persistence of discriminatory laws,
harassment and physical violence. The outcomes or the unfair and discriminatory application of law,
of the regional reviews reinforced the importance may reflect underlying stigma inflicted by powerful
of the principles of freedom and equality in dignity sectors of society, generalized public indifference
and rights as well as non-discrimination. Structural and/or weak political leverage of those suffering
violence in the form of homonegativity marginal- discrimination.156
izes and dehumanizes persons of diverse sexual
orientation and gender identity, hindering their The global survey and the regional reviews and
capacity to fully contribute to society, and denying outcomes highlight the continuing gaps in fulfilling
them the civil rights that are typically afforded to the human rights principle of non-discrim-ination
other persons.153 The commitment to individual affirmed at the International Conference on
well-being cannot coexist with tolerance of hate Population and Development in all cases where
crimes or any other form of discrimination against individuals or groups remain vulnerable, with
any person. direct effects on their health, including their risk of
HIV/AIDS, and their exposure to violence,
In her report to the Human Rights Council on the including sexual violence. The regional review
subject (A/HRC/19/41), the High Commis-sioner outcomes contain various commitments to
for Human Rights noted that the Inter-American address these gaps, requiring States to protect the
and African human rights systems have both human rights of all individuals, including the right
reported upsurges in violence against sexual to gainful employment, residence, access to
minorities, and the Council of Europe found that services and equality before the law.
hate-motivated violence against lesbian, gay,
bisexual, and transgender persons occurs in all its States should guarantee equality before the law and
member States. The report noted that “young non-discrimination by adopting laws and policies to
[lesbian, gay, bisexual and transgender] people protect all individuals, without distinction of any
and those of all ages who are seen to be kind, in the exercise of their social, cultural,
transgressing social norms are at risk of family economic, civil and political rights. States should
and community violence”. Discrimination is also promulgate, where absent, and enforce laws to
compounded by the fact that prevent and punish any kind of violence or hate
countries worldwide continue to criminalize crime, and take active steps to protect all persons,
consensual, same-sex behaviour,154 and new without distinction of any kind, from discrimination,
research underscores a relationship between stigma and violence.
laws restricting the civil rights of persons of
diverse sexual orientations and gender identi- International human rights law reflects global
ties, and their mental health and well-being.155 commitments to ending discrimination against
States and the international community should racial and ethnic minorities (see box 11 on non-
express grave concern at acts of violence, discrimination). However, racial and ethnic minor-
discrimination and hate crimes committed ities worldwide continue to face discrimination and
against individuals on the grounds of their marginalization that negatively impacts their health
sexual orientation and gender identity. Na- and freedoms and their access to educa-tion,
tional leaders should advocate for the rights of employment, land, and natural resources.157
all persons, without distinction of any kind. Mapping global racial and ethnic diversity


requires tackling the complex challenge of defining of a diverse civic life, such that men and women
and classifying what constitutes a distinct “ethnic from different backgrounds may find with one
or racial” group, categories that do not always another the fulfilment of their humanity.
accommodate consistent definitions. Ethnicity and
race may be defined by self-identity or State- Migratory flows are more visible and more diverse
defined census categories, or they may reflect than ever before, with profound socioeco-nomic
cultural, political, linguistic, phenotypical or impacts at both destination and origin. Yet
religious affiliations, many of which have marginal migrants are frequently stigmatized and their risk
or no correspondence to genetic distinctions, of social discrimination remains high. Ratification
existing largely as social categories. of conventions on migrants’ rights has been
limited and uneven. International protocols on the
Estimates of global ethnic diversity, for exam-ple, trafficking and smuggling of people, focused
have documented 822 ethnic groups in 160 mainly on criminalizing trafficking, suppressing
countries. Sub-Saharan Africa, which comprises organized crime and facilitating orderly migration,
approximately a quarter of the world’s countries, have garnered broad support. By comparison, the
has 351 ethnic groups, a striking 43 per cent of the ILO conventions seeking to promote minimum
world’s culturally defined ethnic groups. 158 standards for migrant workers have received less
widespread endorsement. The International
The Minorities at Risk project has identified Convention on the Protection of the Rights of All
minority groups experiencing political discrim- Migrant Workers and Members of Their Families
ination, of which 45 are most at risk because of (1990; entry into force 2003) has been ratified
repressive policies that exclude group members by only 47 countries to date, and the number of
from political participation.159 signatories is particularly low among countries with
higher levels of migration or emigration.162 States
Historic and sustained, discrimination can often should ensure that migrants are able to realize
lead to intergenerational cycles of poverty and the fundamental human rights of liberty, security
disadvantage. For example, Afro-descendent of person, freedom of belief and protection
populations in the Caribbean and Latin American against forced labour and trafficking, and full
face persistent conditions of poverty and social rights in the workplace, including equal pay for
exclusion, as well as ongoing exploitation, through equal work and decent working conditions, as
large-scale development projects that compro-mise well as equal access to basic services, particu-
their access to land and natural resources. In a larly equal access to education, health, including
wide range of countries, public health data sexual and reproductive health services, and
illustrate persistent disparities in morbidity and support for integration for migrant children.
mortality among minority racial and ethnic groups,
reflecting the collective impact of numerous While the negative effects of migration are
overlapping forms of discrimination in arenas such generally assessed to be small, negative public
as access to health care, education, paid employ- attitudes towards migrants may nevertheless
ment, nutrition and housing; socioeconomic and reflect fear of job displacement or reduction in
wealth disparities; and limited opportunities for wages, increase in the risk of crime, and added
advancement over the life course.160 burden on the local public services.163 As ob-
served in the analysis of the World Values Survey,
States should guarantee the full and equal attitudes towards immigrants and foreign workers
participation of racial and ethnic minorities in vary greatly between and within regions (figure
social, economic and political life; guarantee free 16), pointing to a variety of important contextual
and safe integration in housing; lead an open factors that include not only migration flows, but
dialogue on agreed public reconciliation and/or also political debates, media discourse, and the
redress for past wrongs; and actively promote
overall economic and cultural environment. In
ties of mutual regard which are the backbone
Latin America and the Caribbean the proportion


of the population that shares intolerant attitudes Changes in attitudes towards immigrants and foreign
towards immigrants and foreign workers is less workers over the past 5-10 years have been mixed in
than 10 per cent, the lowest of any region. Low all regions. Of 24 countries with available trend data,
proportions are also observed in most Western more tolerant attitudes over time were observed in
European countries; however, the range is wide, eight countries and less tolerant attitudes in nine
from 2 per cent in Sweden to 37 per cent in countries, with the remaining seven countries showing
France. In Eastern Europe the proportion of the no statistically significant changes within the past
population sharing intolerant attitudes varies decade.164 More active efforts, including by
from 14 per cent in Poland to 32 per cent in the training relevant law enforcement officials, are
Russian Federation, while in Asia it varies from needed to combat dis-crimination, reduce
20 per cent in China to 66 per cent in Jordan.164 misinterpretation of migration

Human rights elaborations since the International Conference

on Population and Development
BOX 11: Non-discrimination

Binding Instruments: The Optional Protocol to the International Covenant on Economic, Social
and Cultural Rights (2008; entry into force 2013) was adopted by States “[n]oting that the
Universal Declaration of Human Rights proclaims that all human beings are born free and equal
in dignity and rights and that everyone is entitled to all the rights and freedoms set forth therein,
without distinction of any kind, such as race, colour, sex, language, religion, political or other
opinion, national or social origin, property, birth or other status”. The Optional Protocol estab-
lished a complaint and inquiry mechanism for persons who believe their economic, social
and cultural rights have been violated, advancing human rights principles relating to non-
discrimination and providing individuals with a mechanism to register rights violations.

Intergovernmental human rights outcomes: Non-discrimination is a special focus of the

Office of the United Nations High Commissioner for Human Rights. Rights related to non-
discrimination are elaborated in numerous instruments and are monitored by the Human Rights
Council through special rapporteurs, independent experts and working groups, committees and
forums that strive to combat discrimination and ensure the application of human rights to
particular cases and/or issues.161 Relevant resolutions include Council resolution 17/19 on human
rights, sexual orientation and gender identity (2011), the first United Nations resolution on sexual
orientation, in which the Council expressed grave concern at violence and discrimination based
on sexual orientation and gender identity. In 2005 the Commission on Human Rights adopted
resolution 2005/85 on the protection of human rights in the context of HIV/AIDS.

Other intergovernmental outcomes: The Durban Declaration and Programme of Action (2001) of
the World Conference against Racism, Racial Discrimination, Xenophobia and Related Intoler-ance
recognized and affirmed that “a global fight against racism, racial discrimination, xenophobia and
related intolerance and all their abhorrent and evolving forms and manifestations is a matter of priority
for the international community” and “that everyone is entitled to a social and international order in
which all human rights can be fully realized for all, without any discrimination”.


in public and political discourse, address social duced participation in economic and social life; and poor
tensions and prevent violence against migrants. physical and mental health outcomes.167 Perse-cution of
HIV-related stigma acts as a barrier to preven-tion, persons living with HIV, including through laws that
testing, disclosure, treatment and care.165 The People criminalize HIV non-disclosure, exposure, and/or
living with HIV Stigma Index has shown that in a transmission,168 creates a climate of fear that undermines
number of countries people living with HIV re-ported human rights, and efforts to encourage people to seek
being denied access to health services and HIV prevention, testing, treatment and social support. 169
employment because of their HIV status.166 Stigma is States should respect, protect and promote the
manifested in many forms, including physical, social human rights of all people living with HIV and enact
and institutional stigma, contributing to isolation from protective laws facilitating access to health and
family and community; experiences of violence; re- social services to ensure that

FIGURE 16 Asia Jordan

Public tolerance towards South Korea

selected population groups by Georgia
region, 2004-2009 China
People who have AIDS
Viet Nam
Immigrants/foreign workers India
People of a di erent race
Africa Ghana
Burkina Faso
South Africa

Eastern Moldova
Russian Federation

Latin Colombia
America Guatemala
and the
Trinidad and Tobago
Puerto Rico

Western Italy
Source: World Values Surveys (data downloaded and Europe France
analysed on 20 August 2013). and other
New Zealand
Key: 0, absolute public tolerance; 100, absolute absence Finland
of public tolerance. Australia
Note: Intolerance is measured in the World Values Surveys as the Germany
proportion of respondents who mentioned certain popula-tion Spain
groups when asked the question: “On this list are various groups of United States
people. Could you please mention any that you would not like to Great Britain
have as neighbours?”. The list included the following: people with a Canada
criminal record; people of a different race; heavy drinkers; Netherlands
emotionally unstable people; immigrant/foreign work-ers; people Switzerland
who have AIDS; drug addicts; and homosexuals. The same list was Andorra
used for most countries covered by the World Val-ues Surveys, but Norway
selected countries added to the list population groups specific to Sweden
their country contexts. 10 20 30 40 50 60 70 80 90 100 Per cent


all persons living with, and at risk of, HIV can do so; and include sex workers in the design and
live free from stigma and discrimination. implementation of policies and programmes for
According to the latest available data from the World which they are the intended beneficiaries.
Values Surveys covering 48 countries, the proportion
of the population that expressed intolerant attitudes H. The social cost
towards persons with HIV and AIDS was higher than
of discrimination
the proportion expressing intolerance towards
immigrant or foreign work-ers, or towards persons of The past 20 years have witnessed enormous
a different race (see figure 16). More tolerant leaps in scientific understanding of how discrimi-
attitudes were evident in high-income countries, in nation and stigma impact both physical and mental
Latin America and the Caribbean, and in selected health, as well as human performance. Such
countries in Africa and Asia. In more than a quarter research affirms the extent and manner by which a
of the countries, most of them located in Asia and climate of discrimination curtails the well-being and
Eastern Europe, more than 50 per cent of productivity of persons and nations.176
respondents expressed intol-erant attitudes. Several
such countries also scored high on intolerance A growing body of research from around the world
towards other population groups, suggesting that affirms that physical health, mental health and
intolerant attitudes tend to cluster around multiple productivity are not only compromised by physical
types of “difference”.164 harassment, bullying or violence; similar effects are
prompted by pervasive negative stereotypes,
Over the past two decades sex workers170 have been experience of stigma and fear of discrimination.177
the focus of many public health initiatives concerned The costs to society of having a substantial pro-
with the spread of HIV and AIDS, but rarely have their portion of citizens waging a sustained struggle
own rights to health been acknowledged, nor their for dignity and fundamental rights should concern
rights to social protection from poverty or violence.171 political leaders, given the evident losses in terms of
With 116 countries criminalizing some aspect of sex health, well-being and productivity and the potential
work,172 sex workers face deeply rooted stigma, as for increased social instability where human suffer-
well as institutionalized discrimination through legal ing is not addressed. New thinking on the “cost of
and policy environments that reinforce and inaction” estimates the significant, and often hidden,
exacerbate their vulnerabilities. Sex workers often live consequences of failing to take appropriate action to
in con-ditions of extreme structural poverty and are address injustices and inequalities and under-scores
highly vulnerable to often brutal violence, including the high toll that such inaction extracts from
sexual violence, without redress or protection.173 communities, as illustrated below.178
Violence is linked to other health vulnerabilities, with
female sex workers 13.5 times more likely to acquire In the area of women’s health, birth out-comes are
HIV than women aged 15-49 globally.171 increasingly recognized as being responsive to
Criminalization of sex work limits their political voice conditions of stress due to discrim-ination against the
and collective representation,174 thereby reducing their mother.179 A recent illustrative investigation of
chances to improve their living and working mothers in California compared birth outcomes
conditions, gain financial security, adequately protect before and after the terrorist attacks of 11 September
their health and expand opportunities for themselves 2001. Mothers with Arabic-sounding names had a
and their families.175 States should decriminalize significantly increased risk of preterm delivery and
adult, vol-untary sex work in order to recognize low birth weight over a six-month period after the
the right of sex workers to work without coercion, attacks compared to the same period a year earlier,
violence or risk of arrest; provide social while those with the most ethnically distinctive names
protection and mean-ingful employment had the greatest risk of poor birth outcomes. No
alternatives and opportunities for economic similar change in birth outcomes before and after 11
empowerment, so that individuals who wish to September was observed among mothers without
leave sex work have the ability to


Arabic-sounding names, providing strong evidence With regard to explicitly addressing discrimina-tion
that the stress of anti-Arab sentiment in the period against persons other than children, the propor-tion
following 11 September compromised birth out- of countries with policies, budgets and imple-
comes among mothers with Arabic names.180 mentation measures in place is not encouraging (60
per cent or less), depending on the groups ad-
Evidence of the effect of discrimination on dressed. For example, 57 per cent of countries have
performance and productivity is equally compelling. addressed the issue of “preventing discrimination
When middle-school boys in India were asked to per- against older persons, especially widows”, and 60
form a maze puzzle, there was no difference in per- per cent have addressed the issue of “guaranteeing
formance between boys of all castes; however, when to persons with disabilities equal and effective legal
the boys’ family name and caste were announced protection against discrimination on all grounds”.
before a second round of testing, there was a large
and significant performance differential by caste, with The same proportion of countries have addressed,
low-caste boys underperforming. The announcement budgeted and implemented the issue of “protecting
of caste in front of other boys had a debilitating effect migrants against human rights abuses, racism,
on the performance of lower-caste boys.181 ethnocentrism and xenophobia” (60 per cent).
Regionally, a higher proportion of countries
A daily struggle for dignity and against address this issue in Asia (71 per cent) and the
discrimination is a lived experience for millions of Americas (70 per cent) than in Europe (59 per
people around the world. Government support in cent), Africa (56 per cent) and Oceania (20 per
that struggle is manifest in reported policies, cent). With regard to the legal and practical
budgets and programmes to protect specific restrictions on the movement of people within
populations from abuse, neglect and violence, and countries, which include, among others, the need
also in laws that respect, protect and guarantee the for a work permit, proof of identity, proof of
human rights of these populations. The evidence employment or a legal address at the place of
from the global survey suggests a world in which destination, the requirement that women be
most countries recognize and protect their citizens, authorized by their husbands or legal guardians/
but not all countries, and not all population groups. tutors and restrictions based on HIV status, only
four countries reported legal restrictions (two in
The overwhelming majority of countries (87 per cent) Asia and two in Africa), four others reported practi-
reported that they have addressed the issue of cal restrictions (two in Asia and two in Africa), and
“preventing children’s abuse and neglect and [pro- nine reported both legal and practical restrictions
viding] assistance to [child] victims of abuse, neglect (three in Africa, three in Asia, two in the Americas,
or abandonment, including orphans” during the past and one in Oceania).
five years. Protecting children as they attend school
did not garner a similar level of support, with 59 per Unfortunately, only 40 per cent of countries have
cent of countries reporting that they had addressed addressed the issue of “facilitating school
the issue of “improving the safety of pupils, especially completion for pregnant girls” during the past five
girls, in and on their way to school”. A higher propor- years, a form of discrimination that is especially
tion of countries addressed this issue in Asia (66 per costly to society given the age of the young
cent) and Africa (63 per cent) than in Oceania (55 per women involved and the importance of their
cent), the Americas (54 per cent) and Europe (48 per education, not only to their own long-term pros-
cent). Similarly, actions “addressing gender-based pects but also to the well-being of their children.
vio-lence and bullying in schools” have been This proportion decreases to 29 per cent among
addressed, budgeted and implemented by almost two countries in Europe and 21 per cent in Asia,
thirds of countries (63 per cent); a larger share of while it increases to 67 per cent in the Americas.
countries in the Americas (83 per cent) have done so This may be linked to the fact that Latin America
than in Africa (62 per cent), Europe (61 per cent), Asia and the Caribbean have the second-highest rate
(53 per cent) and Oceania (50 per cent). of adolescent pregnancies in the world.


FIGURE 17 Dignity and human rights:
Percentage of governments addressing
key areas for future action
discrimination against migrants, disabled
persons, older persons and pregnant girls Despite significant gains in poverty reduction
70 and economic growth since the International
Conference on Population and Development,
50 economic inequalities have been increasing and
threaten further progress towards sustain-able
Per cent

development. Addressing these issues requires
30 increased efforts to eradicate poverty and
promote equitable livelihood opportunities.

10 Significant poverty reduction has occurred in the

last two decades, yet 1.2 billion people are still
living in extreme poverty, lacking fulfilment of basic
World needs, meaningful work, access to social
Migrants Older persons protection, or public services in health and
Disabled persons Pregnant girls
education. The current state of wealth inequality,
Source: Global survey on the International Conference on where almost 70 per cent of adults possess only 3
Population and Development beyond 2014. per cent of the world’s wealth, is unsustainable, as
Note: The commitments reported by Governments in the global it threatens future economic growth, the cohe-sion
survey do not necessarily reflect the extent to which relevant laws
are upheld or enforced. and security of societies and the capacity
of people to adapt and innovate in response to
Comprehensive measures are needed to changing environmental conditions. The principal
ensure non-discrimination, equality and the message of the International Conference — that
realization of human potential for all population the fulfilment of individual rights and capabilities is
groups. States should address the multiple and the foundation of sustainable development — is
overlapping forms of inequality, disempower-
even more relevant today, with ample evidence
ment and discrimination, through a commitment
that investments in substantive equality for all
to equality and non-discrimination for all
persons results in long-term development and
persons, without distinction of any kind, in the
population well-being.
exercise of their social, cultural, economic, civil
and political rights, including the right to gainful
The empowerment of women and girls and
employment, residence and access to services,
gender equality remain unfulfilled, requiring
as well as the need to promulgate and enforce
further actions to ensure women’s leadership in
laws that take active steps to protect people
public spheres, equality before the law and in
from discrimination, stigma and violence.
practice, elimination of all forms of violence, and
empowerment of women in exercising their
States should adapt necessary legal
sexual and reproductive health and rights.
frameworks and formulate policies, with the full
participation of those who are discriminated Discrimination against women is evident in all
against, including women, adolescents, older societies, and women continue to have fewer
persons, persons with disabilities, indigenous opportunities than men to define the directions of
persons, ethnic and racial minorities, migrants, their lives, exercise their human rights, expand
persons living with HIV, persons of diverse their capabilities and elaborate their chosen
sexual orientations and gender identities and contribution to society. Despite advances in
sex workers, and with the participation of civil legislation, harmful practices, such as child, early
society throughout the process of design, and forced marriage and female genital mutila-
implementation evaluation of those policies. tion/cutting, remain prevalent in many countries.


Despite gains in universal primary education for tion and the opportunities to define their futures, h
both sexes, adolescent girls are disproportion-ately secure their sexual and reproductive health and u
excluded from lower and higher secondary rights and delay the formation of their families, m
education. In the labour market, women continue jump-start economic growth and spur the innova- a
to be paid less than men for equal work and to be tions needed for a sustainable future. Safeguard- n
substantially overrepresented in vulnerable and ing the rights of young people and investing their
informal employment where jobs are less secure human capital in development deserve urgent
and provide fewer benefits. Women and girls bear attention, including access to quality education
a disproportionate share of unpaid household and training linked to expanding sectors of the
labour. Women also remain substantially under- economy; sexual and reproductive health infor-


represented in positions of power and decision- mation, education and services; and participation
making in politics, business and public life. in the design and evaluation of programmes for
which they are the intended beneficiaries.
Violence against women and girls continues to be
one of the most prevalent forms of human rights Active efforts are needed to eliminate
violations worldwide, creating extreme inse-curity discrimination and marginalization, and
with lifelong costs. United Nations agencies and promote a culture of respect for all.
researchers have made critical inroads into
measuring violence in the past decade, exposing the Many individuals and groups continue to be
startling extent to which sexual and domestic exposed to discrimination on the basis of
violence occurs, beginning early and affecting one in dimensions of their identity or circumstances. The
three women. Such efforts deserve all possible social cost of discrimination is high, with growing
support, within and across countries, to strengthen evidence that stigma and discrimination negatively
routine monitoring; extend research into important affect every aspect of the lives of those who are
unaddressed issues such as the number of people impacted, including mental and physical health,
living in conditions of sustained fear; violence within childbearing and productivity. Public opinion
schools, prisons and the military; the causes of research is a powerful instrument for advocacy,
violence; and the effectiveness of interventions and identifying where stigma and discrimination may be
of laws and systems for the protection and recovery most entrenched, and therefore where individuals
of victims and/or survivors. may be most vulner-able. With regard to public
discrimination against women and intolerance
Substantial investment is needed in the towards racial and ethnic minorities, immigrants
capabilities of children, adolescents and youth, and foreign workers,
while ensuring that every child and young and towards people living with HIV, the present
person, regardless of circumstances, has report highlights variations in stigma between
access to quality pre-primary, primary and sec- countries, and where trends are improving. The
ondary education and comprehensive sexuality United Nations System Task Team on the Post-2015
education holistically defined and consistent United Nations Development Agenda has
with their evolving capacities, and has a rapid, underscored the importance of public opinion data
safe and productive transition from school to on attitudes; regular monitoring, in national
working life and adulthood.
statistics, of public values regarding sexism, ageism,
racism and other forms of discrimination is
Adolescents and youth are central to the
recommended. The protection of the human rights
development agenda of the developing countries in
of all individuals is crucial, requiring an enabling
the coming two decades, because the propor-tion
of the population entering the productive and environment where people can exer-cise autonomy
reproductive years stands at the historically high and choice, with all individuals, particularly women,
level of over a quarter of the total population. adolescents and those belonging to other
These cohorts can, if provided with quality educa- marginalized groups, empow-ered to claim their


K. Elborgh-Woytek and others, “Women, work and the Presentation by Ernesto Mujica at the dialogue
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3 Health

Programme of Action, para. 7.3
“[R]eproductive rights embrace certain human rights that are already recognized in national
laws, international human rights documents and other consensus documents. These rights
rest on the recognition of 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.”

Programme of Action, para. 8.3

“The objectives [in the primary health care and the health-care sector] are: (a) to increase the
accessibility, availability, acceptability and affordability of health-care services and facilities to all
people in accordance with national commitments to provide access to basic health care for all;
to increase the healthy life-span and improve the quality of life of all people, and to reduce
disparities in life expectancy between and within countries.”

Key actions for the further implementation of the programme of action of

the International Conference on Population and Development (General
Assembly resolution S-21/2), annex, para. 85
“Implementation of key elements of the Programme of Action must be tied closely to a
broader strengthening of health systems.”

The changes in global population health over the past eases of poverty) in sub-Saharan Africa and South
two decades are striking in two ways: a dramatic Asia. Efforts to improve the quality and accessibility
aggregate shift in the composition of the global health of sexual and reproductive health care since 1994
burden towards non-communicable diseases and have led to significant improvements in many sexual
injuries, including those due to global ageing, and the and reproductive health indicators, with evidence of
persistence of communicable, maternal, nutritional stronger government commitments to policy,
and neonatal disorders (i.e., dis- budgeting and programmes for many


of the most pressing sexual and reproductive health participation, transparency, empowerment,
goals. Yet aggregate improvements mask signifi-cant sustainability, non-discrimination and international
inequalities both between and within countries, with cooperation”. As these principles were affirmed in
far too many countries exhibiting progress among the Programme of Action, the operational review
households in the upper household wealth quintiles, afforded the opportunity to address the question
while progress is flat or marginal among poor whether achievements in health since 1994,
households. The persistence of poor sexual and particularly the provision of services and underly-
reproductive health outcomes among the poor, ing social determinants affecting the sexual and
particularly in Africa and South Asia, under-scores the reproductive health of women and girls, reflect the
near impossibility of further progress expansion and strengthening of a human rights-
in the realization of health for all persons without based approach to health.
sustained attention to strengthening the reach,
comprehensiveness and quality of health systems. B. Child survival
The number and distribution of skilled health workers,
a vibrant knowledge sector and systems of public There have been significant improvements in the
accountability are among the prerequisites of a rights- survival of children since 1990. The global under-
based health system and pivotal to future sustainable five mortality rate has dropped from 90 deaths
gains in sexual and reproductive health. This thematic per 1,000 live births in 1990 to 48 in 2012. All
section celebrates progress in many sexual and regions made substantial progress, many by
reproductive health outcomes since the International percentage points or more. Sub-Saharan Africa
Conference on Population and Devel-opment, but has the highest child mortality rate (98 per 1,000
underscores the continuing fragility of health systems live births in 2012) and increasingly concentrates
for the poor and the unfulfilled right to sexual and the largest share of all under-five deaths (nearly
reproductive health. half of global under-five deaths). South Asia also
continues to have both a high rate of under-five
A human rights-based mortality (58 deaths per 1,000 live births) and a
large number of total deaths (nearly a third of the
approach to health
global under-five deaths).184
Numerous United Nations and bilateral
development agencies have defined a human Countries in all regions and all income levels
rights-based approach to health as one that have made progress in saving children’s lives.
aims to realize the right to the highest While low-income countries tend to have the
attainable standard of health based on “a highest rates of under-five mortality, a large
conceptual framework … that is normatively reduction in child mortality has been observed
based on international human rights standards recently for several low-income countries in-
and oper-ationally directed to promoting and cluding Bangladesh, Cambodia, Eritrea,
protecting human rights”.182 Ethiopia, Guinea, Liberia, Madagascar, Malawi,
Mozam-bique, Nepal, the Niger, Rwanda,
WHO has proposed that a human rights-based Uganda and the United Republic of Tanzania.185
approach to health is based on seven key
principles: availability, accessibility, acceptability, The proportion of neonatal deaths among total
quality of facilities and services, participation, under-five deaths has been increasing because
equality and non-discrimination, and accountabil- declines in mortality rates among neonates
ity.183 Further, the Human Rights Council, in reso- have been slower than those for older children
lution 18/2 on preventable maternal mortality and in all regions (see figure 18).184 Neonatal
morbidity, recognized that “a human rights-based survival is highly dependent on the overall
approach to eliminate preventable maternal mor- health and the continuity of clinical care of
tality and morbidity is an approach underpinned mothers in the preconception period, during
by the principles of, inter alia, accountability, pregnancy, at delivery and during the post-


partum period. To improve neonatal survival share of all child deaths (34 per cent),
women need access to good nutrition before, because of the still-high mortality rates for
during and after pregnancy; prevention and older children in sub-Saharan Africa.184

treatment of malaria during pregnancy; syphilis
screening and treatment; management of birth A significant proportion of under-five deaths are
complications; adequate treatment of infections due to preventable causes and treatable
in the neonate; and routine support throughout diseases.184 Although declining, infectious
the neonatal period.186 In 2012, 34 per cent of diseases and conditions still account for almost
neonatal deaths were caused by complications two thirds of the global total of under-five
of preterm birth, and a quarter by sepsis and deaths. Pneumonia and diarrhoea, followed by
meningitis (12 per cent), pneumonia (10 per malaria, remain the major causes of child death
cent) or diarrhoea (2 per cent).184 and account for 17 per cent, 9 per cent and 7
per cent respectively of all under-five deaths.188
In 2012 neonatal deaths represented 44 per cent
of under-five deaths at the global level.184 Sub- Children are at greater risk of dying before age 5 if
Saharan Africa maintains the highest neonatal they are born in rural areas, in poor house-holds,
mortality rate (32 deaths per 1,000 live births), and or to a mother without basic education185 In 2012 it
accounts for 38 per cent of global neonatal was estimated that undernutrition was a
deaths.184 The region also has the high-est contributing factor for approximately 45 per cent of
maternal mortality rate (500 maternal deaths per under-five deaths at the global level.184
10,000 live births), underscoring the close link
between maternal and neonatal survival.187 Yet some of these disparities are decreas-ing.
Neonatal deaths in the region represent a lower For example, evidence from selected

Global under-five, infant and neonatal mortality rates, 1990-2010

Under-five mortality rate
Infant mortality rate
Neonatal mortality rate
Per 1,000 live births



1990 1995 2000 2005 2010

Source: Childinfo database. Available from (accessed on 25 October 2013).


sub-Saharan African, Asian and Latin American disease, which is 14 per cent of all disability-adjusted
countries suggests that neonatal, post-neonatal life years lost, a proportion virtually unchanged in
and child mortality declined between the 1990s 2010.189 The burden has declined in most regions but
and early 2000s in both rural and urban areas, increased substantially in Africa (see figure 19),
including in urban slums, with the larger decline largely reflecting the added burden of HIV and AIDS
observed in rural areas. Also, under-five mortal-ity since 1990. The burden remains highest in Africa and
rates declined in both poorer and wealthier South Asia, and the degree to which these two
households, and disparities in under-five mortality regions lag behind the others in bearing the burden of
between the richest and the poorest households sexual and reproductive health conditions is larger in
have declined in most regions of the world. The 2010 than it was in 1990.
exception is sub-Saharan Africa, where disparities
in under-five mortality rates by household wealth There has been a significant change in the
quintile have increased slightly.185 composition of the sexual and reproductive
health burden over the intervening 20 years,
C. Sexual and reproductive with a decline in the disability-adjusted life years
health and rights lost to perinatal conditions, syphilis and mater-
nal mortality since 1990 compensated for by
In 1990, sexual and reproductive health increases in disability-adjusted life years lost to
represented 14.4 per cent of the global burden of HIV/AIDS in 2010.

Total disability-adjusted life years attributed to sexual and reproductive health
conditions among males and females (all ages), worldwide and by region, 1990-2010

25 12.3
1990 Males 1990 Females

20 9.6 2010 Males 2010 Females


15 7.1 7.2 7.1 7.0

Per cent

12.2 5.3 5.4 5.3

10.1 10.1
8.9 7.7 4.0 3.8 3.9 4.1
7.4 6.9 7.5
5 5.6 3.7
4.7 5.0
3.4 2.8 3.3 2.5

0 1.5
Global Sub-Saharan South Asia Latin America North Africa Southeast Asia, Central and High-income
Africa and the and East Asia Eastern Europe
Source: WHO, Global Burden of Disease database, 2013


The gains in maternal health and other national Conference, the escalation of incidents in
dimensions of sexual and reproductive health and which women’s rights were transgressed by family
rights during the past 20 years reflect ad-vances planning programmes suggested a sec-tor-wide

in many distinct goals of the Programme of subordination of women’s health and human rights
Action, for example, in technical advances to population control imperatives.190
relating to childbirth, access to contraception to
avert unwanted pregnancies, and proximate Disputes over Norplant, depot medroxy-
factors such as gains in women’s education and progesterone acetate (DMPA, branded as Depo-
social, legal and political empowerment. While Provera) and quinacrine are illustrative. In 1987,
many sexual and reproductive health rights the ministry of health in one country embarked
remain unfulfilled, the gains nonetheless under- upon a Norplant campaign, becom-ing the world’s
score the dramatic redirection of development largest contraceptive implant programme. In the
programmes that occurred at the International first year there were 145,826 new users, with the
Conference on Population and Development. number of insertions rising to 398,059 in 1989-
1990. By 1997, approximately
1. A troubled history million women in the country had had the six
A substantial proportion of sexual and rods of Norplant inserted, with 62 per cent of
reproductive health-related investments in the insertions done by mobile clinics. However, this
two decades preceding 1994 had focused on ambitious programme focused more on inser-
population control and contraceptive in- tions than on follow-up, failing to account for the
novations. Those investments had yielded an necessary staffing and training for removals. All
unprecedented expansion of new contraceptive too frequently, women had to make numerous
products, variations of which are now part of the removal requests before they were attended to,
modern contraceptive market: injectable Depo- and many women, suffering from side effects
Provera, Cyclofem and Mesigyna; low-dose about which they had not been counselled, were
combined oral contraceptives and the charged fees for early removals, in contrast to
progesterone mini-pill; improved copper- and the free, or highly subsidized, insertions.191
steroid-releasing intrauterine devices; an
entirely new delivery system through implants; The long-delayed United States Food and Drug
and a female condom. Combined injections for Administration approval of the three-month
men were under early development in 1994, and injectable contraceptive Depo-Provera reflected
a contraceptive vaccine was facing scientific another case of wide-scale institutional disregard
hurdles and resistance by women’s groups for the health, safety and reproductive rights
in almost equal measure. of poor women, in this case during the clinical trial
of DMPA at the Grady Medical Center in Atlanta,
The political atmosphere in 1994 was one of Georgia, from 1968 to 1979. While DMPA was
substantial mistrust on the part of women’s groups gaining approval in a growing number of countries
towards the agencies, private companies and worldwide, the trials conducted by the Food and
Governments developing and evaluating these Drug Administration were based on clinical data
new contraceptive methods, as well as those from 14,000 predominantly rural, African
delivering contraceptives and related ser-vices to American, low-income women.192 When reviewed
women. The provider-controlled nature of many by the Administration, the trial data showed
new products heightened the potential for coercion egregious misconduct by the presiding clinicians,
and involuntary fertility control, and women’s including enrolments without informed consent;
groups became increasingly adept enrolments of women with medical
at sharing information on a global scale about contraindications (e.g., cancer, type 2 diabetes,
cases of such human rights violations, some of obesity, hypertension); and inconsistent data
which were occurring systematically and on a collection with more than half the women lost to
national scale. In the decade prior to the Inter- follow-up. The Administration declined to give


its approval three times (1967, 1978 and 1983). In civil society organizations in family planning
1991, WHO completed a study that satisfied out- governance at both national and global levels
standing safety concerns and in 1992 the Food and ultimately reshaped research and development
Drug Administration approved DMPA.193 portfolios in notable ways, contributed to greater
investment in women-centred technologies and
In the case of quinacrine, the controversies were guidelines, and further contributed to a loss of
transnational. Quinacrine hydrochloride pellets investment for technologies that were regarded
inserted into the vagina dissolve into liquid, as potentially risky to women’s health and user
burning and scarring the fallopian tubes and control, such as the contraceptive vaccine.
leading to permanent sterilization. Although major
family planning organizations and govern-ment 2. Reproductive rights
agencies, including WHO, opposed the use of The troubled history of human rights viola-tions
quinacrine for sterilization, the procedure was leading up to the International Conference on
performed on more than 104,410 women by 2001, Population and Development shaped the
through a network mobilized by two doctors. The foundational emphasis on reproductive rights in
drug lacked approved testing for long-term side the Programme of Action.
effects or possible effects on foetuses. The United
States ordered an end Since the International Conference, countries have
to its production and export in 1998, and made progress in the promulgation and en-forcement
the product is banned in India and Chile.194 of national laws responding to the priority areas
related to sexual and reproductive health and rights
The political mobilization of women’s rights groups identified at the International Conference. Although
in response to such cases fuelled the demands for gaps remain in access to reproductive health and in
a human rights basis for health and the the accountability of Governments, including with
achievements of the International Conference in respect to recourse to justice, such legal instruments
that regard, and changed the criteria on the basis serve as the basis for respecting, protecting and
of which technological and service innova-tions guaranteeing reproductive rights.
were evaluated and received investment.
Numerous population and development agen-cies, In the area of sexual and reproductive health and
including the WHO Special Programme of reproductive rights, less than two thirds of
Research, Development and Research Training in countries (63 per cent) have promulgated and
Human Reproduction (now the Department enforced a law protecting the right to the highest
of Reproductive Health Research) and UNFPA, attainable standard of physical and mental health,
established gender or women’s advisory panels to including sexual and reproductive health (Asia:
ensure that future priorities and investments were per cent; Oceania: 62 per cent; the Americas:
women-centred and met more stringent criteria on per cent; Africa: 55 per cent); the percentage
side effects, user control and revers-ibility. WHO increases to 80 per cent in Europe.
pursued regional “common ground” dialogues
bringing women’s reproductive health advocates, The vast majority of Governments allow abor-tion on
activists, scientists, government min-isters and request or to save the life of the woman and for at
family planning leaders to a common table to least one other reason such as foetal anomaly, or to
establish collaborative agreement about family safeguard the woman’s health. As recognized in the
planning programme priorities. WHO also key actions for further imple-mentation of the
established an “introductory task force” to support Programme of Action, in all cases where abortion is
a more participatory process for selecting the not against the law, it must be safe (para. 63 (iii)).
contraceptive method mix within countries.195 The World Health Organization has, however, noted
that “the more restrictive legislation on abortion [is],
These new mechanisms for the participa-tion of the more likely abortion [is] to be unsafe and to
women’s health advocates and other result in death”.196 The


fundamental human rights to life, security of the Only 60 per cent of countries have promul-gated and
person, freedom from cruel and inhumane treat-ment enforced a national law protecting against coercion,
and freedom from discrimination, among others, including forced sterilization and forced marriage; this

mean that unnecessary restrictions on abor-tion proportion is lowest in the Americas (45 per cent).
should be removed and that Governments should
provide access to safe abortion services, both to
safeguard the lives of women and girls and as a If a composite indicator is computed for the
matter of respecting, protecting and fulfilling human dimensions of the above-mentioned five sexual
rights, including the right to health.197 and reproductive health and reproductive rights,
only 32 per cent of countries have promulgated
Globally, 73 per cent of countries have and enforced laws in all cases, although this
promulgated and enforced laws that ensure non-- percentage increases to 54 per cent in Europe.
discrimination in the access to comprehensive
sexual and reproductive health services, including Efforts to improve the quality and accessibility of
HIV services, and a similar percentage (70 per sexual and reproductive health services since 1994
cent) have promulgated and enforced a national have led to significant improvements in many sexual
law protecting the rights of people living with HIV. and reproductive health indicators, with evidence of
In the latter case, a higher proportion of countries strong government actions in terms of policies,
in the Americas have done so (76 per cent) than in budgets and implementation measures for some of
Africa (72 per cent), Europe (69 per cent), Asia (67 the greatest vulnerabilities; however, there has been
per cent) and Oceania (57 per cent). comparatively limited progress in other

Human rights elaborations since the International Conference

on Population and Development
BOX 12: Reproductive rights

Intergovernmental human rights outcomes: The Human Rights Council has recognized the
critical role of sexual and reproductive health contained in the right to health. In its reso-lution 6/29
on the right of everyone to the enjoyment of the highest attainable standard of phys-ical and
mental health (2007), the Council encouraged the Special Rapporteur “to continue to pay
attention to sexual and reproductive health as an integral element of the right of everyone to the
enjoyment of the highest attainable standard of physical and mental health”.

Other soft law: General comment No. 14 on the right to the highest attainable standard of health
(2000) adopted by the Committee on Economic, Social and Cultural Rights clarifies the normative
content of the right to the highest attainable standard of health: “The right to health contains both
freedoms and entitlements. The freedoms include the right to control one’s health and body,
including sexual and reproductive freedom, and the right to be free from interference, such as the
right to be free from torture, non-consensual medical treatment and experimentation”. Further,
general recommendation No. 24: on women and health (1999) adopted by the Committee on the
Elimination of Discrimination against Women elaborates measures that should be taken to ensure
equality for all women in the implementation of the right to health, “affirming that access to health
care, including reproductive health, is a basic right under the Convention on the Elimination of All
Forms of Discrimination against Women”.


areas. The following section highlights both areas of 15-24 years in 2008199 and high rates of sexually
progress and continuing challenges in fulfilling transmitted infections, including HIV. A 2012
sexual and reproductive health and rights. review of available international data on sexual
and reproductive health of young people (up to
Sexual and reproductive health age 24), underscored these numerous gaps.200
The operational review also emphasized the
and rights and lifelong health
paucity of comparable data on adolescent health,
for young people even in the areas with the greatest policy focus
The largest generation of adolescents in history is (such as HIV infection and maternal mortality). 201
now entering sexual and reproductive life. Their
access to sexual and reproductive health Based on the available evidence, the poorest
information, education, care, and family planning adolescent health profiles are in sub-Saharan Africa,
services and commodities is essential to achieving including the highest rates of mortality from both
the goals set out in the Programme of Action. maternity-related and infectious causes; the mortality
The Programme of Action requires that countries rate is higher for females than males (see figure 20).
ensure that health-care providers do not restrict There is a greater than seventy-fold variation in
the access of adolescents to services and infor- maternal mortality rates between coun-tries in the
mation, and that “these services must safeguard region, with the highest rates among
the rights of adolescents to privacy, confidentiality, 15- to 19-year-olds in Chad and the lowest in South
respect and informed consent, respecting cultural Africa.202 Deaths due to injury become increasingly
values and religious beliefs” (para. 7.45). States significant with age (that is, comparing the age
should review all such policies and remove legal, groups 10-14, 15-19 and 20-24 years), and by ages
regulatory and social barriers to reproductive 15-19 injuries account for more than 50 per cent of
health information and care for adolescents. deaths among males in the Americas and close to 50
per cent of deaths in all other regions (e.g., Europe,
Pregnancy has major consequences for a girl’s the Eastern Mediterranean, South-East Asia and the
health. About 70,000 adolescents in devel-oping Western Pacific), except for Africa.
countries die annually of causes related to
pregnancy and childbirth. Nine of 10 births to girls For females, adolescence and young adulthood
below age 18 occur within early marriage. are accompanied by acute needs for sexual and
Researchers have found that girls who become reproductive health services. Early childbirth
pregnant before age 15 in low- and middle-in-come (before age 18) is closely correlated with early
countries have double the risk of maternal death marriage. The country with the highest rate of early
and obstetric fistula than older women (including marriage (before age 18) is Niger, with 75 per cent;
older adolescents), in particular in sub-Saharan rates are high throughout sub-Saharan Africa.
Africa and South Asia. There are also significant Bangladesh has the highest rate in Southern Asia,
health risks to the infants and children of with 66 per cent.203 Sixteen million adolescent girls
adolescent mothers: stillbirths and newborn deaths aged 15-19 years and 2 million girls under 15
are 50 per cent higher among infants years give birth every year.204
of adolescent mothers than among infants of
mothers between the ages of 20 and 29. About Girls under age 15 are five times more likely to
million children born to adolescent mothers do die from maternity-related causes than women
not make it to their first birthday.198 over age 20, and pregnancy and childbirth are the
leading cause of death for women of child-bearing
The extent to which young people have access to age in Africa and South Asia205.
quality services is not well documented, but their poor
health outcomes point to significant gaps in coverage, From 2001 to 2012 HIV prevalence declined globally
for example, 8.7 million abortions under-gone by among young people, both females and males.206
adolescent girls and young women aged Across sub-Saharan Africa, the region with


Mortality (per 100,000) among young people from maternity-related
causes, communicable and non-communicable diseases and injury

A. 10-14 years
10 0,00 0

400 Non-communicable

M: Male

200 F: Female


600 B. 15-19 years







600 C. 20-24 years







World High- Lower- Africa Americas Eastern Europe South-East Western
income middle Mediterranean Asia Pacific
countries income

Source: G. C. Patton and others, “Global patterns of mortality in young people: a systematic analysis of population health data”, The
Lancet, vol. 374, No. 9693 (12 September 2009), p. 885.


the highest prevalence of HIV, prevalence declined per cent of new HIV infections worldwide,207 high-
by 42 per cent. Dramatic decreases have been noted lighting the urgency for renewed efforts towards
across all low- and middle-income countries. ensuring availability of targeted sexual and repro-
Variations are significant, however, with increases in ductive health information, education and services
HIV prevalence noted for male youths in Eastern that keep young people informed of their risks and
Europe and Central Asia, and increases noted for provide them access to condoms, screening and
both male and, in lesser proportion, female youths in treatment for sexually transmitted infections, and
the Middle East and North Africa.206 HIV testing and care. Regarding data cover-age,
29 countries, representing only 29 per cent of the
Furthermore, in regions where HIV is endemic, such adolescent population globally, collect data on HIV
as Africa, where almost three quarters of all people prevalence among youth aged 15-24, with data
living with HIV reside, female youth have higher collected predominantly from sub-Saharan Africa
prevalence rates of HIV than males,206 particularly at and parts of Central and Southern Asia, and a
the youngest ages, and males do not have selection of wealthy countries with com-paratively
comparable prevalence levels in many African lower HIV rates.208 HIV data on young adolescents
countries until age 30 or more. These patterns are aged 10-14 years old is very limited, hindering
reversed in regions where HIV is predominantly advancements towards the prevention of new
transmitted through men having sex with men or infections within this group.209
intravenous drug use, where young males are at
higher risk than young females.206 The 2013 UNAIDS report on the global AIDS
epidemic also reported that there are limited data
Despite progress, in 2009 young people aged 15- on rates of comprehensive knowledge of HIV
24 years accounted for approximately 41 transmission, with data available for only 35

Trends in the percentage of never married women aged 15-24 using a
condom at last sex
(Countries with at least 3 Demographic and Health Surveys or AIDS indicators survey since 1994)
100 Benin
90 Burkina Faso
80 Colombia
Dominican Republic
70 Ethiopia
60 Ghana
50 Malawi
40 Mozambique
30 Nigeria
20 Rwanda
United Republic of Tanzania
10 Uganda
0 Zimbabwe
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Source: Demographic and Health Surveys and AIDS indicators survey on 28 October 2013, available from
Note: All countries with available data for at least two time points.


per cent of the global adolescent population.210 trends in condom use are most likely
Knowledge levels are low in many countries contributing to the declining HIV incidence
with generalized HIV epidemics, generally among young people 15-24 years that has

falling below 50 per cent of the national been observed over the last decade.
adolescent population, and no country exhibited
comprehen-sive HIV knowledge among more 1. Targeted youth programmes
than 65 per cent of their adolescent population. Failures to recognize, prioritize and invest in
Significantly, females in sub-Saharan African adolescents and their sexual and reproductive
countries had lower knowledge levels than health have fatal consequences: high rates of HIV
males, which is alarming considering the high that can lead to early death; unplanned and
risk of HIV among young women. unwanted early pregnancies, with exacerbated
risks for maternal mortality and morbidity, such as
Demographic and Health Surveys data from obstetric fistula; and higher rates of infant and
countries with at least three surveys since 1994 child mortality.216 Furthermore, adolescents have
show that condom use at last sex among young limited life and work skills to care for their children,
men and women aged 15-24 has been on the rise and are often forced by schools or their
in most countries since 1994; however, condom circumstances to abandon their schooling.
use by females overall has been consistently lower Therefore, early parenthood can enhance the risk
than condom use by males (see figures 21 and of poverty.217 The need for greater invest-ments in
22). Self-reported condom use can vary by sex youth-friendly sexual and reproductive education
owing to sex differentials in multiple part-nerships and health services tailored to adolescents is
and to tendencies to report desirable behaviours, critical. Young people may
that is, social desirability bias. These be afraid of, or deterred by, intimidating

Trends in the percentage of never married young men aged 15-24 using a
condom at last sex
(Countries with at least 3 Demographic and Health Surveys or AIDS indicators survey since 1994)
100 Armenia
90 Burkina Faso
80 Dominican Republic
70 Ethiopia
60 Kenya
50 Malawi
40 Mozambique
30 Nigeria
United Republic of Tanzania
10 Uganda
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Source: Demographic and Health Surveys and AIDS indicators survey on 28 October 2013, available from
Note: All countries with available data for at least two time points.


Human rights elaborations since the International Conference
on Population and Development
BOX 13: Adolescent and youth health

Binding Instruments: Both the Ibero-American Convention on the Rights of Youth (2005; entry
into force 2008) and the African Youth Charter (2006; entry into force 2009) contain articles
elaborating the right to health for youth. The African Youth Charter encourages youth participation
in health, obliging States to “[s]ecure the full involvement of youth in identifying their reproductive
and health needs”. The Charter requires States to “provide access to youth-friendly reproduc-tive
health services including contraceptives, antenatal and post-natal services”, to “[i]nstitute
comprehensive programmes … to prevent unsafe abortion” and to “[t]ake steps to provide equal
access to health care services and nutrition for girls and young women”. The Charter also
devotes specific attention to HIV and AIDS, obliging States to institute programmes to address the
HIV and AIDS pandemic, including to “[e]xpand the availability and encourage the uptake of
voluntary counselling and confidential testing for HIV/AIDS” and to “[p]rovide timely access to
treatment for young people infected with HIV/AIDS”. The Ibero-American Convention on the
Rights of Youth recognizes “the right of youth to comprehensive, high-quality health”, including
“specialized health care … and promotion of sexual and reproductive health”.

Other soft law: Through general comments and recommendations, human rights treaty
bodies have recognized the evolving capacities of adolescents to make decisions about their
sexual and reproductive health, and have urged States to develop programmes to provide
such services to adolescents.211 General comment No. 15 on the right of the child to the
enjoyment of the highest attainable standard of health (2013) adopted by the Committee on
the Rights of the Child clarifies the normative content of the right of children and adolescents
to the enjoyment of the highest attainable standard of health, including health-care services,
as well as the binding obligations of States party to the Convention to respect, protect,
promote and fulfil the rights of the child to health. States are urged to ensure access to
sexuality education and information, not limiting access on the basis of third-party consent
(that is, parental or health authority),212 and to eliminate laws that act as barriers to accessing
sexual and reproductive health services.213 Treaty bodies have also emphasized that all
young people should have access to confidential and child-sensitive services, 214 and
adolescents who become pregnant should be able to remain in, and return to, school. 215

environments, including inflexible opening designs, but there are comparatively few at
hours, cost of services, resistant or national scale or with reliable periodic evalua-
unresponsive health-care providers and long tion.219 While programmes may benefit from local
distances to clinics, or be uncomfortable about tailoring, far greater attention should be given to
requesting as-sistance or resources; they may systematic interventions and evaluation of impact.
also be unaware of what services are offered.218
In 2006, WHO conducted a retrospective study
Globally, the number of adolescent sexual and of 16 interventions aimed at increasing young
reproductive health programmes docu-mented in people’s use of health services and their
the literature is substantial, with varied effectiveness.220 It evaluated these interventions


against the explicit targets set by the General targets and principles into their design and to
Assembly in its resolution S-26/2, adopted at its assess their strategies against these targets,
special session on HIV and AIDS in 2001, including including those listed in the WHO framework

that 90 per cent of young people aged 15-24 years for development of youth-friendly services.224
should have access to the necessary services to
decrease their vulnerability to HIV by 2005, and 95 States should fund and develop, in part-
per cent by 2010.221 nership with young people and health-care
providers, policies, laws and programmes that
The review concluded that there was sufficient recognize, promote and protect young
evidence of the effectiveness of com-ponents peoples’ sexual and reproductive health and
of these interventions to recommend the wide rights and lifelong health. All programmes
implementation of interventions that included serving adolescents and youth, whether in or
training for service providers, improve-ments out of school, should provide referral to reli-
for clinics so that they would be more youth- able, quality sexual and reproductive health
friendly, and community-based activities to counselling and services.
generate demand, with careful monitoring of
quality, impact and coverage of sexual and States should remove legal, regulatory and
reproductive health services.222 policy barriers to sexual and reproductive health
services for adolescents and youth, and ensure
The WHO review acknowledged that while the information and access to contracep-tive
use of health services had increased as a result technologies; prevention, diagnosis and
of these interventions, the evidence used to treatment for sexually transmitted infections and
assess impact was generally weak or mixed; HIV, including the HPV vaccine; and referrals to
that reporting lacked detailed descriptions in services dealing with other health concerns
some cases; and that there were difficulties such as mental health problems.
interpreting data, thereby limiting conclusions or
recommendations. The review therefore called 2. Comprehensive sexuality education
for more rigorous research and evaluation, The Programme of Action called on Gov-
particularly to determine the effectiveness of ernments to provide sexuality education to
involvement of other sectors in interventions.223 adolescents and to ensure that such
programmes addressed specific topics, among
A 2007 global assessment of youth-friendly them gender relations and equality, violence
primary care services that examined the benefits against adoles-cents, responsible sexual
and effectiveness of accessing youth-friendly behaviour, contracep-tion, family life, and
health services and facilities on health outcomes sexually transmitted infections, HIV and AIDS
drew further conclusions about the need for prevention (paras. 4.29, 7.37. 7.41 and 7.47). 225
stronger research and evaluation. The well-
documented barriers faced by young people in Recent findings from comprehensive
accessing services had not been addressed in a sexuality education evaluations
comprehensive way, and the evidence for the Numerous reviews of sexuality education
effectiveness of youth-friendly initiatives was evaluation studies have been conducted since
inadequately measured against young peoples’ 1994. These evaluations were of community-based
health outcomes. Although utilization had often and school-based programmes in both developing
increased, there was little clear evidence that and developed countries. The evidence from these
making services youth-friendly, and securing the reviews points to several findings and lessons:
investments required to do so, improved health
outcomes. The study called for systematic and Comprehensive sexual risk reduction interven-
well-designed interventions with regular as- tions do not lead to earlier sexual initiation or
sessments, and for interventions to incorporate greater sexual frequency;226


Most sexuality education programmes demon- ted infections and/or unintended pregnancy than
strate increased knowledge, and about two “gender-blind” curricula.231 This finding resonates
thirds of them demonstrate some positive with other evidence on the value of address-ing
impacts on behaviour;227 gender norms and relationship dynamics within
comprehensive sexuality education. For example,
Among comprehensive sexuality education studies have found that women and men with more
programmes that track health outcomes to equitable gender attitudes are significantly more
measure impact, there is little measurable likely to use contraception and/or condoms232 and
effect on rates of HIV, sexually transmitted significantly more likely to receive pre-natal care
infections and unintended pregnancy; and to deliver in a maternity facility.233 In five high-
fertility countries in East Africa, men who support
Efforts to link programme results with specific gender inequal-ity had higher fertility aspirations,
programme characteristics have been independent of education, income, or religion. 234
incon-sistent or lacked consensus.228

However, several reviews identified elements re- Relationship skills are necessary for many
lated to teaching methods: effective programmes young people, as not all children have had the
tend to incorporate skills building, especially mentoring to treat others with dignity, respect
condom-use skills, and interactive activities help and non-discrimination; schools can provide
students personalize information.229 values-based learning that will enhance human
relationships. States should guarantee for boys,
Reviewers recommended the use of biologi-cal girls, adolescents and young people the
health outcomes as a more reliable, objective opportunities, mentoring and skills to build
measure of programme efficacy than self-re-ported healthy social relationships, harmonious coex-
sexual behaviour.230 One recent review that istence and a life free from violence through
considered only studies that utilized health multisectoral strategies and education that
outcomes as a measure of impact found that engage peer groups and families, and promote
comprehensive sexuality education curricula that tolerance and appreciation of diversity, gender
emphasized gender and power were markedly equality, self-respect, conflict resolution
more likely to reduce rates of sexually transmit- and peace.

Human rights elaborations since the International Conference

on Population and Development
BOX 14: Comprehensive sexuality education

Binding Instruments: Binding instruments. The Ibero-American Convention on the Rights of

Youth (2005; entry into force 2008) recognizes that “the right to education also includes the right
to sexual education” and that “[s]exual education shall be taught at all educational levels”.

Other soft law: Human rights treaty bodies have recognized that the right to health includes
“underlying determinants of health, such as … access to health-related education and
information, including on sexual and reproductive health”, as well as the right to seek, receive and
disseminate health information.236 Treaty monitoring bodies have also highlighted that States
should ensure that all adolescents have access to information on sexual and reproductive health,
both in school and in other settings for adolescents who are not in school. 237


National leaders at the highest level, community and non-violence in relationships; and to plan
leaders, faith-based institutions and other their lives. States should design and implement
thought leaders are called upon to develop, comprehensive sexuality education programmes

creatively and publicly and in collab-oration with that provide accurate information, taking into
young people, media and com-munications that account scientific data and evidence about
address the negative social consequences of human sexuality, including growth and develop-
gender stereotypes, promote the values and ment, anatomy and physiology; reproduction,
practice of gender equality and honour non- pregnancy and childbirth; contraception; HIV
violent masculinities. and sexually transmitted infections; family life
and interpersonal relationships; culture and sex-
A 2012 review of curricula in 10 East and uality; human rights protection, fulfilment and
Southern African countries suggested that empowerment; non-discrimination, equality and
critical thinking about gender and rights was not gender roles; sexual behaviour; sexual abuse,
yet sufficiently implemented within gender-based violence and harmful practices;
comprehensive sexuality and HIV education.235 as well as youth-friendly programmes to explore
values, attitudes and norms concerning sexual
Support by Governments for youth sexual and and social relationships; promote the acquisition
reproductive health services in the global survey of skills and encourage young people to assume
varied starkly. Only 54 per cent of coun-tries in responsibility for their own behaviour and to
Africa addressed the issue of ensuring access by respect the rights of others; are gender-sensitive
adolescents and youth to sexual and reproductive and life-skills-based; and provide young people
health information and services that warrant and with the knowledge, skills and efficacy to make
respect privacy, confidentiality and informed informed decisions about their sexuality.
consent, compared with 96 per cent,
per cent and 80 per cent of countries in the
Americas, Europe and Asia respectively. Fertility, contraception and
family planning
As the evidence builds for a paradigm shift to- Globally, fertility fell by 23 per cent between
wards programmes that emphasize critical thinking 1990 and 2010.238 Falling fertility is largely the
about gender and power, a question arises about result of a desire for smaller families, coupled with
the extent to which this is being implemented. In better access to contraception. Aspirations for
the global survey 70 per cent of Governments smaller families are affected by many factors,
reported that the issue of “revising the contents of including improvements in child survival and
curricula to make them more gender-sensitive” expanded opportunities for women, especially
was being addressed, but the implications or thor- education. In Africa as a whole, and sub-Saharan
oughness of that effort was not questioned. The Africa in particular, fertility has fallen more slowly
regional reviews and outcomes stressed the im- than in other regions, and remains higher than in
portance of designing and implementing effective, any other region in the world.239
comprehensive sexuality education that addresses
the key elements linking the five thematic pillars of Globally, contraceptive prevalence among
the operational review. women aged 15 to 49 who are married or in
union and currently using any method of con-
States should recognize that comprehen-sive traception rose from 58.4 per cent in 1994 to
sexuality education, consistent with the evolving 63.6 per cent in 2012, a rise of approximately 10
capacities of young people both in and out of per cent.240 While contraceptive use increased
school, is essential to enable them to protect faster (from 40 to 54 per cent) over that period in
themselves from unwanted pregnancy, HIV and developing countries (excluding China), use in
sexually transmitted infections; to promote values developing countries remained much lower than
of tolerance, mutual respect in developed countries, where nearly 72


Human rights elaborations since the International Conference
on Population and Development
BOX 15: Contraceptive information and services

Other soft law: Article 12 of the Convention on the Elimination of All Forms of Discrimination
against Women (1979; entry into force 1981) provides that States “shall take all appropriate mea-
sures to eliminate discrimination against women in the field of health care in order to ensure, on a
basis of equality of men and women, access to health care services, including those related to
family planning” (art. 12 (1)). Further, article 16 (1) (e) protects women’s right “to decide freely and
responsibly on the number and spacing of their children and to have access to the information,
education and means to enable them to exercise” this right. Building on these standards, rec-
ognizing the correlation between unmet need for contraceptives and higher rates of pregnancy
among adolescents, abortion and maternal mortality, and that barriers to access to contraception
disproportionately affect certain populations, treaty monitoring bodies have urged States since
1994 to ensure access to medications on the WHO Essential Medicines List, including hormonal
contraception and emergency contraception. In elaborating State obligations under article 12 of
the International Covenant on Economic, Social, and Cultural Rights, the Committee on
Economic, Social and Cultural Rights, in general comment No. 14 on the right to the highest
attainable stan-dard of health (2000) urges that “States should refrain from limiting access to
contraceptives and other means of maintaining sexual and reproductive health, from censoring,
withholding or inten-tionally misrepresenting health-related information, including sexual
education and information, as well as from preventing people’s participation in health-related
matters”. Further, general comment No. 15 on the right of the child to the enjoyment of the highest
attainable standard of health (2013) adopted by the Committee on the Rights of the Child states,
“Short-term contraceptive methods such as condoms, hormonal methods and emergency
contraception should be made easily and readily available to sexually active adolescents. Long-
term and permanent contraceptive methods should also be provided.”

per cent of married or in-union women used con- Findings from the global survey indicate that
traception. Contraceptive prevalence increased approximately 8 out of 10 countries addressed
more rapidly in the 1990s than in the 2000s, and increasing women’s access to information and
in a number of extremely poor countries, preva- counselling on sexual and reproductive health (84
lence has remained below 10 per cent.241 per cent) and increasing men’s access to sexual
and reproductive health information, counselling,
Global unmet need for modern contraceptive and services (78 per cent) during the previous five
methods declined modestly, from 20.7 per cent in years. Similarly, 8 out of 10 countries reported
1994 to 18.5 per cent in 2012. Ninety per cent of having addressed the issue of increasing access to
women with unmet need today live in developing comprehensive sexual and reproductive health
countries, with the greatest need among women services for women (82 per cent) as well as for
and men in Africa. In 28 sub-Saharan African adolescents (78 per cent). However, this percent-
countries, including all countries in West Africa with age decreased in the case of providing sexual and
the exception of one, fewer than 25 per cent of reproductive health services to persons with
women of reproductive age used contracep-tion, disabilities (55 per cent) and indigenous peoples
with unmet need as high as 36 per cent. 243 and cultural minorities (62 per cent).


FIGURE 23 Benin 40 Burkina Faso
Trends in modern 30


prevalence rate in

Northern and Western 20

Africa, by household 10

wealth quintile 10 1996 2001 2006 0 1993 1998 2003 2006 2010

Richest 20%

Fourth 20%
40 Cote d’lvoire 40 Ghana
Middle 20%
Second 20% 30

Poorest 20% 30




1994 1998 0 1993 1998 2003 2008

40 Guinea

Mali 40 Niger

40 30


30 30

20 20


10 10
1996 2001 2006 0 1998 2006
0 0

1999 2006
40 Nigeria 40

Senegal 40 Sierra Leone


30 30

20 20


10 10
1997 2006 2010 0 2006 2008 2010
0 0

1990 2003 2008

Source: Demographic and Health Surveys, available from (accessed 15 June 2013); multiple indicator cluster surveys, available
from (accessed on 15 June 2013), all countries with available data for at least two time points.


(a) Contraceptive method mix distinct contraceptive method types is a
Over the past 20 years, the diversification of hallmark of safety and quality in human rights-
modern contraceptive method mix has been based family planning services, and additional
considerable, and the direction of product choices of method typically increase overall use.
innovations has been towards innovations that
ease administration (and removal), lower doses In 1994, the global contraceptive method mix was
and reduce side effects.244 Yet the current array of dominated by female sterilization and the
contraceptive products is not without risks of intrauterine device, which captured 31 and 24 per
failure and side effects, some of them serious, cent of overall contraceptive use, respectively,
and many women have clinical contraindications followed by pills at 14 per cent of global use. 245
for specific methods. Because clients differ in their Twenty years later, these three methods continue
method preferences and clinical needs, including to dominate, but they are accompanied by greater
over their own life course, a range of diversification of female methods, including

FIGURE 24 Burundi Cameroon

Trends in modern 80 80
60 60
contraceptive prevalence
rate in Eastern, Middle


40 40
and Southern Africa, by

household wealth quintile 20 20

0 2005 2010 0 1991 1998 2004 2006 2011

Richest 20%
80 Ethiopia 80 Kenya
Fourth 20%
Per cent

Middle 20%
Second 20%
Poorest 20%
60 60

40 40


20 20

0 2000 2005 2011 0 1993 1998 2003 2008

Rwanda United Republic of Tanzania

80 80

60 60
Per cent

Per cent

Source: Demographic and Health Surveys, 40 40

available from (ac-
cessed on 15 June 2013); multiple indicator
20 20
cluster surveys, available from www.unicef.
org/statistics/index_24302.html (accessed
on 15 June 2013), all countries with 0
0 2000 2005 2007 2010 1996 1999 2004 2010
available data for at least two time points.


increased use of injectables and implants, and a programmes are unable to respond to the varied
rise in the use of male condoms. Single methods needs of women for delaying, spacing and ending
that predominated in selected countries in the reproduction; the varying needs that women have

1990s continue to do so (see figure 27), suggest- for different contraceptive technologies for health
ing limited product choice and/or limited capacity reasons; or user preferences for distinct technical
among service providers in these countries. 246 attributes of methods at different phases of their
lives, such as for user-controlled and reversible
Programmes dominated by single methods may methods, among others.
reflect the legacy of past State family planning
policies, sustained through public choice and/or A criterion of quality family planning programmes is
routine commodity flows, provider bias, or technical the availability of a selection of methods with
training. Regardless of the reason for programmes distinct clinical features that can be safely and
dominated by use of a single method, such affordably offered to clients. Persistent

80 Chad 80 Democratic Republic of the Congo 80 Eritrea



60 60 60

40 40 40


0 20 20 20

0 0 0

1996 2004 2007 2010 1995 2002

80 Madagascar 80 Malawi 80 Mozambique

60 60 60
Per cent

Per cent

Per cent

40 40 40

20 20 20

0 1997 2003 2008 0 1992 2000 2004 2010 0 1997 2003 2008

80 Uganda 80 Zambia 80 Zimbabwe

60 60 60

40 40 40
Per cent

Per cent

20 20 20

0 2000 2006 2011 0 1996 2001 2007 0 1994 1999 2005 2010



dominance of a single method in countries (2012) found that where emergency contraception
highlights the trade-offs that country programmes is not registered, it is generally due to policies
make between mass provision of a familiar method conflating emergency contraception with abortion
versus investment in the health system and general opposition to contraception. 250 The
to diversify commodities and ensure the necessary Commission noted that restrictions on access are
provider expertise for safe delivery and informed often due to unnecessary requirements for
counselling for a range of methods. prescriptions or lack of provision by the public
sector, and emergency contraception remains little
(b) Emergency contraception known by health-care providers.
Emergency contraception has been includ-ed as
part of the WHO Model List of Essential (c) Male sterilization
Medicines248 since 1995; is included in norms, While the number of men using condoms has
protocols and guidelines issued by the Interna- increased where HIV is of concern, male
tional Federation of Gynaecology and Obstetrics; participation in modern family planning has
is registered in most developing and developed advanced very little since 1994, and there have
countries, and registered as a non-prescription been very few countries that report increases in
product in over 50 countries.249 Nevertheless, male sterilization over the past 20 years.
inadequate knowledge and information regarding
emergency contraception pose barriers to its use Of 92 countries with more than two data points
in most countries. A commission recently on the proportion of overall contraceptive

FIGURE 25 80 Bolivia (Plurinational State of) Colombia

Trends in modern

prevalence rate in 40
the Americas, by

household wealth


Richest 20% 1994 1998 2003 2008 0 1990 1995 2000 2005
Fourth 20%
Middle 20%
Second 20%
Poorest 20%
80 Guyana Haiti




Source: Demographic and Health Sur-

veys, available from www.measuredhs. 20
com (accessed on 15 June 2013); multiple
indicator cluster surveys, available from 20
html (accessed on 15 June 2013), all
0 2006 2009 0
countries with available data for at 1994 2000 2005
least two time points.


prevalence attributable to male sterilization,251 with men who relied on male sterilization.253 This
at least one data point during or since 2005, 38 disparity is especially striking given that
countries (41 per cent) reported no use of male female sterilization is more expensive, incurs

sterilization, and in only four countries (the United more health risks and is irreversible, in
Kingdom (21 per cent), the Republic of Korea (17 contrast to the relatively safe and reversible
per cent), the United States of Amer-ica (14 per procedure for males. Research into male
cent) and Bhutan (13 per cent)) did male hormonal contraception continues to
sterilization contribute to more than 10 per cent of advance, slowly.254
contraceptive prevalence. Twenty-seven countries
(29 per cent) have seen declines in the relative States must, as a matter of urgency, pro-vide
use of male sterilization since 1994, among them widespread and high-quality information and
Sri Lanka (-4 per cent), India (-2 per cent), counselling regarding the benefits and risks of
Thailand (-2 per cent), Myanmar (-1.4 per cent) a full range of affordable, accessible, quality
and the United States of America (-0.5 per cent), contraceptive methods, with special attention
suggesting either absolute declines in the use of to dual-method use with male or female
male sterilization or increased reliance on other condoms given the continuing risk of sexually
(largely female) contraceptive methods.252 transmitted infections and HIV, and ensure
access to both contraceptive knowledge and
In 2002, 180 million women relied on female commodities irrespective
sterilization, compared with 43 million of marital status.

80 Dominican Republic 80 Guatemala


60 60

40 40


20 20

0 0

1996 1999 2002 2007 1995 1998

80 Nicaragua 80 Peru

60 60


40 40


20 20

0 1998 2001 0 1991 1996 2000 2004 2007


FIGURE 26 80 Armenia 80 Bangladesh
Trends in modern 60 60

contraceptive prevalence


rate in Asia, by household
wealth quintile


20 20

0 2000 2005 2010 0 1993 1996 1999 2004 2007 2011

Richest 20% 80 Jordan 80 Kazakhstan

Fourth 20%
Middle 20% 60 60
Second 20%
Poorest 20%

40 40


20 20

0 1990 1997 2002 2007 2009 0 1995 1999 2006

80 Philippines 80 Uzbekistan

60 60



Source: Demographic and Health Surveys,


available from (ac-

cessed on 15 June 2013); multiple indicator 20 20
cluster surveys, available from www.unicef.
org/statistics/index_24302.html (accessed 0 1996 2006
on 15 June 2013), all countries with 0
available data for at least two time points. 1993 1998 2003 2008

Percentage distribution of women aged 15-49, according to contraceptive
method use, highlighting single-method dominance in selected countries
80 Injectables
Rate, Modern Methods Total Contraceptive Prevalence

70 Male Condoms
60 34.2%
Female Sterilization
30 92% 48.3% Male Sterilization
20 47.5%
10 52.9% Implants
South Africa Japan China India Kenya
2003–04 2005 2006 2007–08 2008–09

Source: South Africa, Demographic and Health Surveys 2003-2004, final report; Kenya, Demographic and Health Surveys, final report, 2008-2009;
Japan, Thirteenth National Fertility Survey, 2005; China, National Family Planning and Reproductive Health Survey, 2006; India, District Level
Household and Facil-ity Survey, 2007-2008. Quoted in United Nations, World Contraceptive Use 2011, available from contraceptive2011.htm (data downloaded and analysed 5 September 2013).
80 Cambodia 80 India 80 Indonesia


Per cent

Per cent

60 60

40 40

20 20 20
0 0
2000 2005 2010 1997 2002 2007
1992 1998 2005
80 Kyrgyzstan
80 Nepal 80 Pakistan

Per cent

Per cent
60 60

40 40

20 20

0 0
1997 2006
1996 2001 2006 2011 1990 2006
80 Viet Nam
80 Yemen

Per cent




1997 2002 2006 2011
1997 2006

4. Abortion The risk of death due to complications of unsafe

The use of abortion reflects many cir- abortion is decreasing at both global and
cumstances that can be difficult for women to regional levels.257 This improvement is widely
prevent, such as contraceptive failure, lack of attributed to improved technologies, increased
knowledge about the fertile period or how to use use of the WHO guidelines for safe abortion
contraception, shortfalls in access or affordability and post-abortion care, and greater access to
of contraceptives, changing fertility aspirations, safe abortion;
disparities in the desire for a pregnancy between
a woman and her partner, fear of asking a At 460 and 160 deaths per 100,000 unsafe
partner to use contraception, and unplanned or abortions,257 the death rates from abortion
forced sex.255 Rates of abortion vary dramatically in Africa and Asia respectively are still
between countries (see table 1)256 and recent shock-ingly high;
estimates suggest declines in both the rate of
abortion, and abortion-related deaths, with the The overall rate of abortions declined globally from
following trends: 35 abortions per 1,000 women aged 15-44


years in 1995 to 28 per 1,000 in 2003, and Governments committed themselves in the
remained stable at 29 per 1,000 in 2008;255 Programme of Action, as well as in the key actions
for the further implementation of the Programme of
The absolute numbers of estimated abortions the Action, to place the highest priority on
declined from 45.6 million in 1995 to 41.6 preventing unwanted pregnancies, and thereby
million in 2003, then increased to 43.8 million making “every attempt … to eliminate the need for
in 2008.255 This increase is attributable to abortion”. Key requirements for fulfilling that
stagnation in the rate of abortions from 2003 commitment are ensuring good public knowledge
to 2008 coupled with population growth over regarding the risk of pregnancy, strong gender
time; equality norms, and affordable access to a range of
safe contraceptive methods with different attributes
The highest subregional abortion rates were in that would enable most women and men to secure
Eastern Europe (43 per 1,000 women), the a method that conforms to their needs and any
Caribbean (39), East Africa (38) and South- contraindications. Increased use of contraceptives
East Asia (36); the lowest subregional rate was may sometimes correspond to a direct decline
in Western Europe (12);255 in the rates of abortion, as observed in Italy over a 20-
year period (see figure 28).258 While the interaction
An estimated 86 per cent of all abortions took between the rate of abortion and the use of modern
place in the developing world in 2008, the contraception is affected by other conditions, such as
last year of available estimates.255 fertility aspirations, when fertility

Rates of voluntary termination of pregnancy and use of oral contraceptives
among women of reproductive age, Italy, 1978-2002

Prevalence of TOP (%)





Prevalence of OC use (%)

1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2

Source: WHO, Women and Children’s Health: Evidence of Impact of Human Rights (Geneva, 2013), figure 2D.4. Available from
bitstream/10665/84203/1/9789241505420_eng.pdf.Abbreviations: TOP = termination of pregnancy; OC = oral contraceptive.


rates are held constant over time, increased use Low rates of abortion in Western Europe reflect
of effective modern contraception corresponds to widespread access to contraceptive knowledge
a reduction in the rate of abortions.259 and methods, including comprehen-sive sexuality

education for young people, as well as a high level
Gender equality can affect the risk of abortion by a of gender equality. These factors have created an
variety of means, for example, by shifting social enabling environment for the use of contraception,
expectations for more couple conversations about and lower abortion rates.
contraception,260 by the repeal of discrimina-tory
laws such as spousal notification/authorization States should strive to eliminate the need for
laws, or by adopting stronger laws that reduce the abortion by providing universal access to
threat of intimate-partner violence.261 comprehensive sexuality education starting in
adolescence, and sexual and reproductive
Although there were declines in abortion rates health services, including modern methods of
across all regions between 1996 and 2003, the contraception, to all persons in need; by
most significant decline was in Europe255 (see providing widespread affordable access to male
figure 29), reflecting relatively high rates of and female condoms, and timely and
abortion in Eastern Europe in 1996, and steep confidential access to emergency contracep-
declines in those rates by 2003. Abortion rates tion; by implementing school and media pro-
have been much lower and relatively stable over grammes that foster gender-equitable values
time in Western Europe. and couple negotiations over issues of sex and

Abortions per 1,000 women aged Abortions per 1,000 women aged
15-44 years, weighted regional 15-44 years in select European
estimates, 1995, 2003 and 2008 countries where abortion is
legally available, 1996 and 2003
50 100
Africa 90 Russian Federation
45 Asia Estonia
Europe 80 Bulgaria
40 Latin America
Northern America
70 Belgium
Oceania Netherlands
30 60 Finland

20 40

15 30

10 20

5 10

0 0 1996 2003
1995 2003 2008

Source: Figure based on data reported in G. Sedgh and others, Source: Figure based on data reported in G. Sedgh and others,
“Induced abortion: incidence and trends worldwide from 1995 to “Induced abortion: incidence and trends worldwide from 1995 to
2008”, The Lancet, vol. 379, No. 9816 (18 February 2012). 2008”, The Lancet, vol. 379, No. 9816 (18 February 2012).


Table 1. Measures of legal abortion where contraception; and by respecting, protecting
reporting is relatively complete, 2001-2006 and promoting human rights through the en-
Number of Number of
forcement of laws that allow women and girls
Year of last abortions per abortions to live free from gender-based violence.
available 1,000 women per 100
Country/territory estimate aged 15-44 live births
Cuba 2004 57 109 The decline in abortion rates in Eastern Europe
Russian Federation 2003 45 104
reflects increasing availability and use of modern
family planning services and commodities after the
Estonia 2003 36 82
break-up of the Soviet Union. However, the persis-
Belarus 2003 35 91 tence of comparatively higher estimated rates of
Latvia 2003 29 69 abortion for the period 2001-2005 (Russian Feder-
Hungary 2003 26 57 ation (45 per 1,000 women), Estonia (36), Belarus
Bulgaria 2003 22 52 (35), Bulgaria (26) and Latvia (29)),256 coinciding with
rates of modern contraception use that are
United States 2003 21 31
comparable to those in Western Europe (contracep-
New Zealand 2003 21 33
tive prevalence rates for any year available from 2000
Australia 2003 20 34 to 2006 are: Russian Federation (64.6 per cent of
Sweden 2003 20 34 women aged 15-49), Estonia (57.9 per cent), Belarus
Puerto Rico 2001 18 28 (56 per cent), Bulgaria (40.1 per cent) and Latvia
(55.5 per cent)),262 suggest a lag in effective use
England and Wales 2003 17 29
behaviour, or possible contraceptive failure. A similar
France 2003 17 26
discordance is evident in Cuba, which has among the
Slovenia 2003 16 40 highest abortion rates in the world (57 per 1,000
Lithuania 2003 15 38 women aged 15-44),256 and yet compara-tively high
Denmark 2003 15 24 reported rates of modern contraceptive use; its
contraceptive prevalence rate was 72.1 per cent in
Norway 2003 15 25
2000 and 71.6 per cent in 2006.262 These cases
Canada 2003 15 31
underscore that access to contraception
Singapore 2003 15 31 is necessary, but may not be sufficient, to reduce
Israel 2003 14 14 abortion, and that other cultural behaviours may
Czech Republic 2003 13 29 demand understanding and intervention, including

Slovakia 2003 13 31
the social and symbolic meaning associated with the
use of contraception in certain relationships, norms
Scotland 2003 12 23
for communication between partners, social
Italy 2003 11 25
expectations of sexual practice, the local meaning
Finland 2003 11 19 associated with abortion, and the risk of forced sex.
Netherlands 2003 9 14

Germany 2003 8 18
Important gains have been made in reducing deaths
due to unsafe abortion since 1994, most notably in
Belgium 2003 8 14
countries that have undertaken comple-mentary and
Switzerland 2003 7 15
comprehensive changes in both law and practice to
Tunisia 2000 7 9 treat abortion as a public health concern (see the
South Africa 2003 6 6 case study of Uruguay, below). Nonetheless, the
Nepal 2006 5 4 number of abortion-related deaths has held steady in
recent years even as maternal deaths overall have
continued to fall. As of 2008, an estimated 47,000
Source: Data compiled from G. Sedgh and others, “Induced
abortion: incidence and trends worldwide from 1995 to 2008”, The maternal deaths were attributed to unsafe abortion, a
Lancet, vol. 379, No. 9816 (18 February 2012). decline from 69,000 deaths in 1990.263 But given that
the number of deaths due to



Eliminating maternal deaths resulting

from unsafe abortions

Since 2001 Uruguay has achieved important progress in the reduction of maternal deaths
resulting from unsafe abortions through the implementation of the Modelo Uruguayo de
Prevención de Riesgo y Daño. The model is based on commitments to fulfil the Programme
of Action of the International Conference on Population and Development. It aims to reduce
the risks and morbidities caused by unsafe abortions, which accounted for 42 per cent of
maternal deaths in 2001, 28 per cent in 2002 and 55 per cent in 2003.

The model is based on three pillars: respect for a woman’s decision; confidentiality and
com-mitted professional practice; and treating abortions as a public health issue rather
than a legal or criminal matter. All women, including adolescents, have access to a
multidisciplinary team of gynaecologists, midwives, psychologists, nurses and social
workers who provide pre- and post-abortion information, counselling and care, including
information on alternatives to abor-tion, existing abortion methods and their risks, within a
comprehensive health-care approach that includes the management of complications,
rehabilitation and access to contraception. A key to success is the fact that all sexual and
reproductive health professionals are trained to provide pre- and post-abortion counselling.

Encouraging results were observed shortly after the implementation of the model. From
2004 to 2007 Uruguay registered a maximum of two cases of maternal deaths from unsafe
abortion, and from 2008 to 2011 reached zero maternal deaths from unsafe abortion.
According to WHO, this model can be adapted and replicated in other countries.

In 2012 Uruguay became the third country in Latin America, after Cuba and Guyana, to decrim-
inalize abortion, through the Law on the Voluntary Termination of Pregnancy, which guarantees a
woman’s right to safe abortion during the first 12 weeks of pregnancy, and 14 weeks in case of
rape. Adolescents are included in this law under the notion of “progressive autonomy”, based on
article 8 of the Child and Adolescent Code, which refers to the development process of the
evolving capacities of each individual to enable the fulfilment of all rights.

These initiatives, together with the Law on the Protection of the Right to Sexual and Reproduc-
tive Health Care (2008), which requires public and private health providers to provide compre-
hensive sexual and reproductive health services, including private and confidential counselling
and access to free, quality contraception in public services, and the Sexuality Education Act
(2009), which institutionalizes sex education at all levels of formal education, from kindergarten
to teacher training, have contributed to Uruguay’s attainment of the lowest maternal mortality
rate in Latin America and the third lowest in the Americas. In the last year for which data are
available, 2012, the maternal mortality ratio in Uruguay was 10.3 per 100,000 live births.

ICPD BEYOND 2014 101

unsafe abortion has declined more slowly than complications; the latter was of particular relevance
the overall number of maternal deaths, unsafe to countries where abortion was not legal. In 1999,
abortions appear to account for a growing with the five-year review of the Programme of
proportion of maternal deaths globally. 264 Action WHO began a series of consultations that
resulted in the publication of Safe Abortion:
Nearly all (97 per cent) abortions in Africa (outside of Technical and Policy Guidance for Health Systems,
Southern Africa) and in Central and South America which was approved in July 2003 and issued in the
remain unsafe.255 But this figure masks dramatic official and numerous non-official WHO languages.
differences between the regions in the risk of death Several agencies attribute the recent decline in
due to abortion, which is 15 times higher in Africa than abortion-related case fatalities to the growing use
in Latin America and the Caribbean.263 It is also Africa of the guidelines contained in this publication.
that has seen the least decline in the number of
deaths due to unsafe abortion since 1990.265 The States should take concrete measures to urgently
estimated decline in deaths in Latin America was from reduce abortion-related compli-cations and deaths
80 to 30 per 100,000 abortions, whereas in Africa the by increasing access to non-discriminatory post-
number of deaths declined from the staggering rate of abortion care for all women suffering from
680 deaths per 100,000 abortions to 460 (520 in sub- complications of unsafe abortion, and ensure that
Saharan Africa).265 all providers take action as indicated in the WHO
The Programme of Action acknowledged that unsafe Safe Abortion: Technical and Policy
abortion was a major public health concern, and that Guidance for Health Systems, to deliver
Governments had a responsibility to provide for post- quality care and remove legal barriers to
abortion care and counselling. services. States should remove legal barriers
In 1995, WHO developed technical recommen- preventing women and girls from access to safe
dations to improve the quality of abortion-related abortion, including revising restrictions within
services where such services were legal, and the existing abortion laws, in order to safeguard the
urgent care of women arriving with post-abortion lives of women and girls and, where abortion is

Human rights elaborations since the International Conference

on Population and Development
BOX 16: Abortion

Other soft law: Since 1994 human rights standards have evolved to strengthen and expand States’
obligations regarding abortion. In a series of concluding observations, treaty monitoring bodies have
highlighted the relationship between restrictive abortion laws, maternal mortality and unsafe
abortion;269 condemned absolute bans on abortion;270 and urged States to eliminate punitive measures
against women and girls who undergo abortions and providers who deliver abortion services.271
Further, treaty monitoring bodies have emphasized that, at a minimum, States should decriminalize
abortion and ensure access to abortion when the pregnancy poses a risk to a woman’s health or life,
where there is severe foetal abnormality, and where the pregnancy is the result of rape or incest.272
However, the Human Rights Committee noted that such exceptions might be insufficient to ensure
women’s human rights, and that where abortion is legal it must be accessible, available, acceptable
and of good quality.273 Regardless of legal status, treaty bodies have highlighted that States must
ensure confidential and adequate post-abortion care.274


legal, ensure that all women have ready access When grouping countries by the current status of
to safe, good-quality abortion services. their abortion laws (most, less and least restric-
tive),268 the proportion of countries that addressed

The global survey found that only 50 per cent of the issue of “prevention and management of the
countries addressed the issue of access to “safe consequences of unsafe abortion” was lowest (72
abortion to the extent of the law” during the previ- per cent) among countries with the most restrictive
ous five years. A larger proportion of countries (65 laws. Likewise, only 48 per cent of countries with
per cent) did, however, address the issue of “pre- the most restrictive laws addressed the issue of
vention and management of the consequences of access to “safe abortion to the extent of the law”.
unsafe abortion”. The proportion of Governments
addressing this issue was inversely proportional to Abortions among young women
the wealth of the countries. Thus, while 69 per In 2008, 41 per cent (8.7 million) of all unsafe
cent of the lowest-income countries addressed this abortions occurred among young women aged
issue via policy, budget and concrete actions, only 15-24 years in developing countries; of this number
29 per cent of the wealthiest did the same. This 3.2 million unsafe abortions were undergone by
may reflect the higher prevalence of unsafe 15-to 19-year-olds275 Young adolescents face a
abortions in low-income countries. higher risk of complications from unsafe abortions,
and women under the age of 25 account for almost
Access to safe and comprehensive abortion half of all abortion deaths.257 Evidence points to the
services and to management of the complica- fact that adolescents are more likely to delay
tions of abortion varies widely across and seeking an abortion and, even in countries where
within countries and regions. Regarding abortion may be legal, they resort to unsafe
management, evidence based on data from the abortion pro-viders owing to fear, lack of
Maternal and Neonatal Program Effort Index knowledge and limited financial resources.275
underscores that women living in rural areas
have significantly less access to such services Governments committed themselves in the
across most developing countries.267 Programme of Action to place the highest priority


Effective family planning strategies result in very

low abortion rates

The Netherlands
The Netherlands provides an excellent example of a country where a pragmatic and compre-
hensive approach to family planning, especially for young people, has resulted in one of the
lowest abortion rates worldwide. By the late 1960s family doctors in the Netherlands offered
family planning services. In 1971 family planning was included in the national public health
insurance system, providing free contraceptives. Sexual education is universal and comprehen-
sive, and based on common United Nations indicators, Dutch women are the most empowered in
the world.276 Sexually active young people display some of the highest rates of contraceptive use
of any youth population and, as a consequence, the Dutch abortion rate fluctuates be-tween 5
and 9 per 1,000 women aged 15-44, one of the lowest rates in the world. Abortion in the
Netherlands is legal, safe, easily accessible and rare.277

ICPD BEYOND 2014 103

Maternal mortality ratio by country, 2010
(Deaths per 100,000 live births)

20–99 ≥1000
100–299 Population <100 000 not included in assessment
300–549 Not applicable

Source: Trends in Maternal Mortality 1990 to 2010: WHO, UNICEF, UNFPA and The World Bank Estimates (Geneva, WHO, 2012).
Note: Forty countries had high maternal mortality ratios in 2010. Of these countries, only Chad and Somalia had extremely high ratios, at 1,100 and 1,000,
respectively. The other eight countries with the highest ratios were: Central African Republic (890), Sierra Leone (890), Burundi (800), Guinea-Bissau (790),
Liberia (770), Sudan (730), Cameroon (690) and Nigeria (630). Although most sub-Saharan African countries had high ratios, Mauritius (60), Sao Tome and
Principe (70) and Cabo Verde (79) had low maternal mortality ratios while Botswana (160), Djibouti (200), Namibia (200), Gabon (230), Equatorial Guinea
(240), Eritrea (240) and Madagascar (240) had moderate ratios. Only four countries outside the sub-Saharan African region had high maternal mortality ratios:
Lao People’s Democratic Republic (470), Afghanistan (460), Haiti (350) and Timor-Leste (300).

on preventing unwanted pregnancies, thereby globally.278 Women in the developed world have
making “every attempt … to eliminate the need for only a 1 in 3,800 lifetime risk of dying of causes
abortion”. Closer examination of policy and practice related to maternity, while the lifetime risk for
in countries with a low number of abortions such as those in developing regions is 1 in 150, and in
the Netherlands may offer valuable lessons on sub-Saharan Africa, the lifetime risk is 1 in 39.278
reducing unwanted pregnancies in other countries. While still short of reaching target 5.A, “Reduce
by three quarters the maternal mortality ratio”, of
5. Maternal mortality Millennium Development Goal 5 globally, by
Of all sexual and reproductive health indi-cators, 2010, 10 countries had reached this target, with
the greatest gains since 1994 have been made in another 9 on track to reach it by 2015.279 How-
the maternal mortality ratio. In 1994, more than ever, 26 countries have experienced an
half a million women died each year from largely increase in maternal deaths since 1990, in large
preventable causes related to pregnancy and part due to deaths related to HIV, and in sub-
childbirth, and by 2010 the maternal mortality ratio Saharan Africa, HIV and maternal causes are
had declined by 47 per cent, from 400 deaths per now the two predominant causes of women’s
100,000 live births in 1990 to 210.278 premature death.278

However, an estimated 800 women in the world Countries with unacceptably high maternal
still die from pregnancy or childbirth-related mortality ratios remain concentrated in develop-
complications each day, and the differ-ences ing regions, predominantly sub-Saharan Africa,
between developed and developing re-gions where numerous factors, including poverty and
remain stark. In 2010, developing countries fragile health systems, perpetuate higher rates
accounted for 99 per cent of all maternal deaths of maternal death.278


Human rights elaborations since the International Conference on
Population and Development

Box 17: Maternal mortality

Intergovernmental human rights outcomes: The Human Rights Council has adopted multiple
resolutions declaring that maternal mortality violates human rights, including resolution 18/2 on
preventable maternal mortality and morbidity and human rights (2011), in which the Council recognized
that “a human rights-based approach to eliminate preventable maternal mortality and morbidity is an
approach underpinned by the principles of, inter alia, accountability, participation, transparency,
empowerment, sustainability, non-discrimination and international cooperation”, and encouraged
“States and other relevant stakeholders, including national human rights institutions and non-
governmental organizations, to take action at all levels to address the interlinked root causes of
maternal mortality and morbidity, such as poverty, malnutrition, harmful practices, lack of accessible
and appropriate health-care services, information and education, and gender inequal-ity, and to pay
particular attention to eliminating all forms of violence against women and girls”.

Post-partum haemorrhage, sepsis, ob-structed quality prenatal care, skilled attendance at

labour, complications of unsafe abortion and birth, emergency obstetric care and postnatal
hypertensive disorders — all preventable care for all women, including those living in
— are among the leading causes of maternal rural and remote areas.
deaths.280 Wealth and spatial inequalities in
wom-en’s access to adequate emergency (a) Maternal morbidity and reproductive cancers
obstetric care for the management of these For every woman who dies of pregnancy-related
conditions abound within countries, highlighting causes, an estimated 20 others experi-ence a
the inade-quate reach of skilled providers and maternal morbidity,282 including severe and long-
quality health services for many poor women, lasting complications. The underlying causes of
especially in rural or remote areas. maternal morbidity are the same as the
underlying causes of maternal death,283
Gains in maternal survival over the past 20 years including poverty and lack of skilled care. Most
can be attributed in part to advances in the use of of them, including obstetric fistula, are entirely
antenatal care, skilled attendance at deliv-ery, preventable with skilled care at birth, and
emergency obstetric care and family planning emergency obstetric care as a back-up.
among select sectors of society, yet the majority of
developing countries are not on track to achieve Obstetric fistula represents the face of failure as a
Millennium Development Goal 5 (improv-ing global community to protect the sexual and
maternal health), with its targets of reducing the reproductive health and rights of women and girls,
maternal mortality ratio by three quarters and and to achieve equity in the distribution and
achieving universal access to reproductive health access to comprehensive sexual and reproductive
by 2015; in no region is the gap more pronounced health services. An estimated 2-3.5 million women
than in sub-Saharan Africa.281 live with obstetric fistula in the developing world,
mostly in sub-Saharan Africa and Asia where
States should eliminate preventable maternal adolescent births are highest and access to emer-
mortality and morbidity as urgently as possible gency obstetric care is low, and between 50,000
by strengthening health systems and thereby and 100,000 new cases occur each year. All but
ensuring universal access to eliminated from the developed world, obstetric

ICPD BEYOND 2014 105

fistula continues to affect the poorest of the poor: advancing technology has significant promise
women and girls living in some of the most under- for curtailing cervical cancer.287
resourced regions in the world.284 States should
implement measures to ensure the elimination of Breast cancer was, and remains, the most
obstetric fistula through the provision of high- common cancer among women in high-income
quality maternal health care to all women, and countries, currently affecting 70 out of 100,000
provide for the rehabilitation and reintegra-tion of women. Incidence is less than half in low-income
fistula survivors into their communities. countries, but because of poor access to diag-
nosis and treatment, mortality in the developing
385. Maternal morbidity should be utilized as world is similar to that in developed countries.285
an indicator of quality sexual and reproductive
health services and the progressive realization States should recognize and address the rising
of women’s right to health. burden of reproductive cancers associated with
rising life expectancy, especially breast and
386. The Programme of Action included com- cervical cancer, by investing in routine screening
mitments to address infertility and cancers of the at primary care, and referral to skilled cancer
reproductive systems. Infertility is not only a great providers at higher levels of care.
personal sadness for many women and couples, but
in many parts of the world, a woman’s inability to (b) Antenatal care
become pregnant is cause for social exclusion and The percentage of pregnant women who had at
even divorce. The Programme of Action called for least one antenatal care visit increased globally
prevention and treatment of sexually trans-mitted from 63 per cent in 1990 to 80 per cent in 2010,
infections, a leading cause of secondary infertility, as an overall improvement of approximately
well as for treatment of infertility where feasible. per cent. Again, such accomplishments mask
About 2 per cent of women globally are unable to
conceive (primary infertility) and nearly 11 per cent
are unable to conceive another child after having had
at least one (secondary infertility). In FIGURE 32
low-income countries, infertility is often caused by Trends in skilled Bolivia (Plurinational State of)
sexually transmitted infections and complications attendance at birth 100
from unsafe abortion. Infertility is highest in some
in the Americas, by
countries of South Asia (up to 28 per cent) and sub- 60
household wealth
Per cent

Saharan Africa (up to 30 per cent), but primary

quintiles 40
infertility has declined in South Asia and both types
of infertility have declined in sub-Saharan Africa. 20

Owing to population growth, the number of couples Richest 20% 0

affected by infertility globally rose from 42 million in Fourth 20% 1994 1998 2003 2008
1990 to 48.5 million in 2010.286 Middle 20%
Second 20%
387. More than half a million women each year Poorest 20%
develop cervical cancer, the second most
common cancer among women aged 15 to 44 100
worldwide. More than 275,000 women die of the
Source: Demographic and Health
disease each year, the great majority (242,000) in Surveys, all countries with available 60
Per cent

developing regions, especially sub-Saharan data for at least two time points.
Available from www. 40
Africa. While the global survey was carried out (accessed on 15
June 2013); Multiple indicator clus- 20
before widespread appreciation of the impact of
ter surveys, available from www.
the human papilloma virus vaccine, and there- 0
fore did not include questions on that topic, this html (accessed 15 June 2013).
2006 2009


regional disparities: Southern Africa had achieved for the “provision of adequate food and nutrition
94 per cent coverage of antenatal care by 2010, to pregnant women” (71 per cent) during the
whereas in West Africa only 67 per cent of previous five years, and even fewer reported

pregnant women had at least one antenatal care addressing the issue of “providing social
visit. In Latin America, nearly all women now have protection and medical support for adolescent
at least one antenatal care visit (96 per cent) and pregnant women” (65 per cent).
88 per cent have at least four.288
(c) Skilled attendance at birth
According to the global survey, 88 per cent of The proportion of deliveries attended by skilled
countries had addressed the issue of “access to health personnel rose in developing coun-tries,
antenatal care” in the previous five years. On aver- from 56 per cent in 1990 to 67 per cent in 2011.
age, countries that addressed this issue had Despite the positive trends, access to good
mater-nal mortality rates higher than countries that maternal health care remains highly inequitable
did not report addressing it, suggesting targeted across regions, and within countries between poor
attention by Governments with higher maternal and wealthier women. The likelihood of having
mortality rates at the time of the survey. skilled attendance at birth is most cor-related with
Furthermore, we can associate greater government wealth, as illustrated by the differen-tial progress
attention with a steeper decline in maternal within countries when stratified by household
mortality rates; this is most apparent in low-income wealth quintiles (see figures 32 to 35).
Comparing figures 32 to 35 with figures 23 to
In spite of a high proportion of countries reveals that the distribution of the contraceptive
reported to have addressed the issue of antenatal prevalence rate by household wealth quintiles is
care, a reduced proportion of countries had adopt- more equitable than the distribution of skilled birth
ed policies, budgets and implementation measures

100 Colombia Dominican Republic 100 Guatemala

Per cent

80 80 80
Per cent
Per cent

60 60 60

40 40 40

20 20 20

0 0 0

1990 1995 2000 2005 2010 1996 1999 2002 2007 1995 1998

100 Haiti 100 Nicaragua 100 Peru

80 80 80
Per cent

60 60 60
Per cent

40 40 40

20 20 20

0 2000 2005 0 2001 0 1996 2000 2004 2007

1994 1998 1991

ICPD BEYOND 2014 107

attendance, with greater outreach to the poor. women much less likely than urban women to have
Indeed, contraception is operationally far easier for a skilled attendant during delivery. This is driven in
weak health systems to offer than skilled birth part by a profound health worker shortage in the 58
attendance, as pill or condom distribution does not countries in which 91 per cent of maternal deaths
rely on the availability of skilled health workers to occur. In the aggregate, little progress was seen in
respond urgently to a woman in need, and can be skilled birth attendance in sub-Saharan Africa as a
passively provided long in advance of actual need. region, where fewer than half of all births are
Disparities in skilled attendance highlight the attended by skilled personnel.289
limited capacity of many existing health systems to
provide fundamental sexual and reproductive The availability and accessibility of skilled at-
health care to poor women. tendance at birth provided by adequately trained
health-care personnel ensures a safe, normal
Differences in access among urban and rural delivery for every woman, significantly reducing
women are also strikingly inequitable, with rural the risks of delivery complications and thus the

Trends in skilled attendance
at birth in Asia by household
wealth quintiles
Per cent



Richest 20% 0
Fourth 20%
Middle 20%
Second 20%
Poorest 20%
Per cent


Philippines Uzbekistan
100 100
Per cent

Per cent

Source: Demographic and Health Surveys, all

countries with available data for at least two
time points. Available from www.measuredhs.
com (accessed on 15 June 2013); multiple
indicator cluster surveys, available from
1993 1998 2003 2008 0
(accessed on 15 June 2013).
1996 2006
need for emergency obstetric care. For this women died from complications of pregnancy, 291
reason, the use of skilled birth attendance is not with millions more women suffering chronic mor-
only cost-effective, but also a valuable indicator bidities, testimony to the lack of equitable access

of the maturity and sophistication of a health to emergency obstetric care for women.292
system, indicating its accessibility and
responsiveness to all, particularly the poor. All five of the major causes of maternal mortality
— post-partum haemorrhage, sepsis, unsafe
(d) Emergency obstetric care abortion, hypertensive disorders and obstructed
Even in the context of skilled attendance at birth, labour — can be managed when well-trained
delivery complications arise in approxi-mately 15 staff with adequate equipment are available to
per cent of all pregnancies, a majority of which can provide the necessary emergency obstetric
be managed if quality emergency ob-stetric care is care.292 Basic emergency obstetric care services
available and rapidly accessible to all women.290 include the ability to: administer paren-teral
Yet in 2010 approximately 287,000 antibiotics, uterotonic drugs and parenteral

Cambodia India Indonesia

100 100 100
Per cent

Per cent

80 80

Per cent
60 60 60

40 40 40

20 20 20

0 0 0

2000 2005 2010 1997 2002 2007

1992 1998 2005

Kyrgyzstan Nepal Pakistan

100 100 100
Per cent

80 80
Per cent

Per cent

60 60

40 40 40

20 20 20

0 0 0

1997 2006 1996 2001 2006 2011 1990 2006

Viet Nam Yemen

100 100
80 80
Per cent

Per cent

60 60

40 40

20 20

0 0

1997 2002 2006 2011 1997 2006

ICPD BEYOND 2014 109

FIGURE 34 100 Burundi 100 Cameroon
Trends in skilled attendance

Per cent

Per cent
at birth in Eastern, Middle
and Southern Africa, by 40
household wealth quintiles 20
Richest 20% 100
2005 2010 1991 1998 2004 2006 2011
Fourth 20%
Middle 20% 100 Democratic Republic of the Congo Eritrea
Second 20% 80

Per cent
Poorest 20%

Per cent
Source: Demographic and Health Surveys, all 40
countries with available data for at least two 20
time points. Available from www.measuredhs. 20
com (accessed 15 June 2013); multiple 0
indicator cluster surveys, available from
0 statistics/index_24302.html
(accessed 15 June 2013). 2007 2010 1995 2002

100 Lesotho Madagascar

Per cent

Per cent


Per cent
60 60
40 40
20 20
0 0
1993 1998 2003 2008 2004 2009 1997 2003 2008
100 Mozambique Rwanda

100 Namibia
Per cent
Per cent

80 80
Per cent

60 60
40 40
20 20
0 0
100 1992 2000 2005 2007 2010
1997 2003 2008 1992 2000 2006
100 United Republic of Tanzania
100 Zambia
Uganda 80
Per cent
Per cent

80 80
Per cent

60 60
40 40
20 20
0 0

1996 1999 2004 2010 1996 2001 2007

1995 2000 2006 2011


100 Chad anticonvulsants for pre-eclampsia and eclampsia;
remove placenta and retained products; and
Per cent
provide assisted vaginal delivery and basic neo-

natal resuscitation. Comprehensive emergency
obstetric care services also include surgical skills
to perform caesarean sections and blood trans-
fusions. A minimum of five facilities, including at
0 least one that provides comprehensive emer-gency
1996 2004 obstetric care, per 500,000 population is
Per cent recommended for adequate coverage.293
100 Ethiopia

80 Since 1994 emergency obstetric care has

become a key component of global maternal
mortality reduction initiatives. Yet in developing
40 countries emergency obstetric care coverage
remains inadequate, with an insufficient number
of basic emergency obstetric care facilities in
Per cent countries that have high and moderate levels of
2000 2005 2011
maternal mortality. Further, a majority of
facilities that offer maternal care are unable to
provide all services required to be classified as
80 an emer-gency obstetric care facility.
Figure 36 highlights the relationships between
maternal mortality and density of emer-gency
Per cent 20 obstetric care facilities when measured per
20,000 births. The authors of the analysis advo-
1992 2000 2004 2010 cate for the value of this measure of emergency
obstetric care facility density.
100 Swaziland
While emergency obstetric care is unavail-able for
many women, caesarean sections that are
60 possibly medically unnecessary appear to
Per cent
command a disproportionate share of global
economic resources and an “excess” number of
20 caesarean sections have important negative
implications for health equity, both within and
2006 2010 across countries. A study undertaken by WHO on
the number of caesarean sections performed in
100 Zimbabwe 137 countries, accounting for approximately
per cent of global births for that year, found that a
total of 54 countries showed underuse of
caesarean sections (rates below 10 per cent of
deliveries), whereas 69 countries showed over-use
(rates above 15 per cent), with the rest of the
countries falling in between. The study estimated
0 that in 2008, over 3.1 million additional caesar-ean
1994 1999 2005 2010 sections were needed, while at the same time 6.2
million unnecessary caesarean sections

ICPD BEYOND 2014 111

100 Burkina Faso
FIGURE 35 100 Benin

Trends in skilled attendance

Per cent
80 80

at birth in Northern and

Per cent
60 60
Western Africa, by 40 40
household wealth quintiles
20 20
Richest 20% 0
Fourth 20%

Per cent
Middle 20%
1996 2001 2006 1993 1998 2003 2006 2010
Second 20%
Poorest 20% Mali

100 Mauritania Niger

Per cent


60 40
60 60
Per cent

40 20
0 0

1995 2001 2006 2000 2007


Source: Demographic and Health Surveys, all countries with available data for at least two time points. Available from (accessed on 15
June 2013); multiple indicator cluster surveys, available from (accessed on 15 June 2013).

Fitted regression line (blue):
Association between MMR = 733–68* EMOC
emergency obstetric 1200 Chad Evidence against null hypothesis
care facility density Niger
of no association: P=0.007

per 20,000 births and Guinea-Bissau Correlation coe„cient r= –0.44

maternal mortality Mali
Source: S. Gabrysch, P. Zanger P and Tanzania Mozambique
O. M. R. Campbell, “Emergency contraceptive
care availability: a critical assessment of the 800
current indicator”, Tropical Medicine and Guinea Sudan Rwanda
International Health, vol. 17. Cameroon
Abbreviations: MMR = maternal mortality Mauritania
rate; EmOC = emergency obstetric
care.No. 1 (January 2012), pp. 2-8.
Zambia Lesotho
Notes: Figure The figure was created by the Uganda Senegal Gambia
authors using data from Trends in Maternal Benin
Madagascar India Ghana
Mortality 1990 to 2010: WHO, UNICEF, UNFPA 400
Pakistan Nepal Bhutan
and The World Bank Estimates (Geneva, WHO,
2012) and maternal mortality rates are from that
Djibouti Gabon
Yemen Bangladesh
publication; emergency obstetric care facility
200 Bolivia
estimates were calculated from UNICEF,
Honduras El Salvador Peru Morocco
Tracking Progress in Maternal, Newborn and
Child Survival: The 2008 Report and A. Paxton
Nicaragua EmOC facilities
Sri Lanka
and others, “Global patterns in availability Tajikistan per 20 000 births
of emergency obstetric care”, International
Journal of Gynaecology and Obstetrics, vol. 0 1 2 3 4 5 6 7 8 9 10
93 (2006) using national crude birth rates from
UNdata ( Benchmark of five
EmOC facilities per 20,000 births represented Benchmark
by the vertical line.


100 Cote d'Ivoire 100 Ghana 100 Guinea
Per cent

Per cent

Per cent
80 80 80

60 60 60

40 40 40

20 20 20

0 0 0

1994 1998 1993 1998 2003 2008 1999 2005

Nigeria 00 Senegal 100 Sierra Leone


Per cent
80 80 80
Per cent

Per cent

60 60 60

40 40 40

20 20 20

0 0 0

1990 2003 2008 1997 2005 2010 2006 2008 2010

had been performed. The cost of the global to bring skilled care and emergency
“excess” caesarean sections was estimated to obstetric services to women in need.
amount to approximately US$ 2.3 billion in
health-care costs, while the cost of the global Although 79 per cent of countries reported in the
“needed” caesarean sections was global survey that they had addressed the issue of
approximately US$ 432 million.294 providing “referrals to essential and
comprehensive emergency obstetric care”, the
Where emergency obstetric care facilities are percentage of countries that reported having an
available, sociocultural factors, geographic and adequate geographic distribution of emergency
financial accessibility of care and quality of service obstetric care facilities ranged from 40 per cent in
issues continue to act as barriers to emergency Africa to 97 per cent in Europe. Hence, actions fell
obstetric care.292 The uneven distribution of emer- short where health systems were most fragile, and
gency obstetric care facilities between rural and where the numbers of skilled personnel were
urban areas exacerbates disparities experienced inadequate and poorly distributed in countries.
by rural women, who are more likely to give birth at
home and have long distances and poor roads to Distribution of health-care services is strongly
travel should complications occur.295 Data on the associated with maternal mortality ratios, in that
proportion of women with access to services for 96 per cent of countries with the lowest maternal
the management of post-partum haemorrhage in mortality ratios reported having an adequate
2005 highlight these disparities in access between geographic distribution of emergency obstetric
rural and urban women (see figures 37 to 39) and care facilities in the global survey, but this drops
the high variability between countries.296 to 29 per cent in the case of countries with the
highest maternal mortality ratios.
These persistent barriers and gaps in coverage
illustrate the investments needed to realize the 6. Sexually transmitted infections
life-saving reproductive health care for women in New cases of sexually transmitted infections
many developing countries in order appear to have increased significantly since 1994,

ICPD BEYOND 2014 113

driven in part by population growth among limited success, other than for syphilis. Wide-
young people in areas of high incidence, spread promotion of syndromic algorithms to
including the Americas and sub-Saharan Africa. diagnose sexually transmitted infections
The highest rates of sexually transmitted among women with vaginal discharge has not
infections are generally found among urban proven reliable and instead led to
men and women between 15 and 35 years, the overtreatment; these methods have been far
ages of greatest sexual activity.297 more successful with men.301 Overall, because
sexually transmitted infections are more
In 1995, WHO estimated that there were 333 symptomatic in men, diag-nostic screening and
million cases of the four major curable sexually treatment for males is a more cost-effective
transmitted infections among 15- to 49-year-olds: means of controlling sexually transmitted
syphilis, gonorrhoea, chlamydia and trichomonia- infections and warrants further investment.302
sis. By 2008, this figure had grown to nearly half a
billion (499 million) cases, largely due to a major Polymerase chain reaction technologies have
rise in cases of trichomoniasis, from 167 million to vastly improved sexually transmitted infection
276.4 million cases (an increase of 65 per cent), diagnostics, but their expense limits widespread
and a rise in gonorrhoea from 62 million to use. Inexpensive and accurate rapid diagnostic
million cases (a 71 per cent increase). These tests would be helpful in low resource settings, but
increases coincided with a 12 per cent decline in rapid diagnostic tests for syphilis are not yet widely
syphilis, from 12 million to 10.6 million cases.297 available and a test for chlamydia is still under
development.303 Well-equipped laboratory systems
While the decline in syphilis is notable, the are a critical component of referral-level health
remaining 10 million cases are a major reproduc- systems, valuable for sexually transmitted
tive health burden: when syphilis in pregnant infections and a range of other conditions, and
women (it occurred in an estimated 1.3 million warrant further investment. The human papilloma
pregnancies in 2008) is left untreated, 21 per cent virus vaccine has proven highly effective and offers
of those pregnancies will result in stillbirth and 9 considerable promise for curtailing certain strains
per cent in neonatal death.298 Many sexually trans- of the virus.
mitted infections contribute to infertility in both
women and men, and untreated gonorrhoea and WHO undertakes global efforts to aggregate the best
chlamydia in pregnant women can lead to severe available reporting of data on sexually transmitted infections
neonatal morbidities, including blindness. Further, from countries, but the data reflect widespread weaknesses
co-infection with sexually transmitted infections in surveillance out-side select wealthy countries, and
(including gonorrhoea, chlamydia, syphilis, and therefore global summary data must be interpreted
herpes simplex virus) increases susceptibility to cautiously.
HIV infection and likewise increases the infectivity
of people living with HIV. Human papilloma virus is In two recent reviews304 WHO emphasized the
the principal cause of cervical cancer, which poor quality and limited coverage of data on
causes the deaths of approximately 266,000 sexually transmitted infections. There are no
women annually, over 85 per cent of whom live in sentinel surveillance systems for collecting data
resource-poor countries.299 Human papilloma virus on sexually transmitted infections globally. Data
has also been linked to cancers of the anus, mouth on syphilis and, to a lesser extent, drug-resistant
and throat.300 gonorrhoea are collected through the Global
AIDS Response Progress Reporting, a collab-
Not all post-1994 investments to address sexual orative effort of WHO, UNAIDS and UNICEF.
and reproductive health needs have been Figure 40 depicts both the paucity of available
successful. Low-cost diagnostic interventions for data on sexually transmitted infection screening
sexually transmitted infections among women of pregnant women, a necessary first step for
were a widely promoted intervention that yielded sexually transmitted infection case identification


Estimated coverage of women with access to management of post-
partum haemorrhage, urban-rural, selected African countries, 2005

90 Urban
80 Rural 82

70 76 67 67 72 75 69
60 65 62
60 57
55 50 51
40 42 38 40 40

28 31 29 36 33 34
20 24 20 25
12 17 14
Benin Congo Ethiopia Madagascar Ghana Mozambique Kenya Nigeria Rwanda Senegal South United Uganda Zambia Zimbabwe
Africa Republic of

Source: Analysis based on data from the Maternal and Neonatal Program Effort Index, available from

Estimated coverage of women with access to management of post-
partum haemorrhage, urban-rural, selected Asian countries, 2005
80 Rural 79 80 81
70 69
58 60 65 60
52 49 54
40 44

19 22 19 24
10 11

Bangladesh China India Indonesia Myanmar Nepal Pakistan Philippines Viet Nam

Source: Analysis based on data from the Maternal and Neonatal Program Effort Index, available from

Estimated coverage of women with access to management of post-partum
haemorrhage, urban-rural, select Latin American and Caribbean countries, 2005
90 Urban 89
80 Rural 83

70 69 69 67
60 60 61
60 57 56
40 40 44 39
30 33 30 29
25 21 19
10 13
Bolivia Dominican Ecuador El Guatemala Haiti Honduras Mexico Nicaragua Paraguay
Republic Salvador

Source: Analysis based on data from the Maternal and Neonatal Program Effort Index, available from

ICPD BEYOND 2014 115

and management, and, where data are available, of sexually transmitted infections, support the
these highlight the low levels of screening at first development and widespread use of
antenatal visit across several countries in Africa, accurate and affordable diagnostic tests for
South America, the Middle East and parts of sexually transmitted infections, and promote
China. This may be reflective of insufficient sexual greater access to quality diagnosis and
and reproductive health services in some of these treatment of sexually transmitted infections,
regions; it is worthwhile to note that countries in including for men and boys.
North America and Europe have separate and
more sophisticated surveillance systems which are 7. Prevention of HIV
not reflected. New HIV infections have declined globally by 33
per cent, from a high of 3.4 million per year in
In the light of current needs, WHO and its partner 2001 to 2.3 million in 2012. In 26 low- and middle-
agencies are calling for a much-needed concerted income countries new HIV infections decreased by
global effort to build systematic surveil-lance for more than 50 per cent between 2001 and 2012.
sexually transmitted infections, including screening New HIV infections among adults in sub-Saharan
and effective case management. Urgent Africa, where 70 per cent of all new infections
implementation of this proposal is necessary if we occur, have decreased by 34 per cent since 2001.
are to strengthen public health systems with However, the number of new infections has risen
improved data for estimations of sexually transmit- in Eastern Europe and Central Asia in recent
ted infection, and ultimately control the spread of years, despite declines in Ukraine, and new
sexually transmitted infections and limit the resul-tant infections continue to rise in the Middle East and
morbidities.305 North Africa.306

States and global health partners should commit Declines in the rates of new HIV infections among
to strengthening national and global surveillance adults largely reflect a reduction in sexual
of the incidence and prevalence transmission. However, regional achievements

Percentage of antenatal care attendees tested for syphilis at first visit, latest
available data since 2005

Source: WHO, Global Health Observatory map gallery, available from


in HIV prevention mask critical disparities within all those living with HIV”.306 Preventing HIV among
and between countries. For example, throughout people who inject drugs and their sexual partners
Southern Africa, new HIV infections are occurring is a key priority in Eastern Europe and Central

despite widespread knowledge about the disease Asia, where people who inject drugs account for
and good access to condoms. In South Africa, the more than 40 per cent of new infections in some
country with the highest absolute number of people countries. In countries where the incidence of HIV
living with HIV, the annual number of new is closely related to intravenous drug use, Govern-
infections declined rapidly after peaking in 1998, ments have yet to show a strong political commit-
but the pace of decline slowed between 2004 and ment to address the problem and lack adequate
2011, and HIV incidence remains high even after a data systems for monitoring the epidemic.306
substantial decline from 2011 to 2012.307
Globally, female, male and transgender sex workers
While “people who inject drugs account for an are at a higher risk of contracting HIV, with female
estimated 0.2-0.5 per cent of the world’s popula-tion, sex workers 13.5 times more likely to be living with
they make up approximately 5-10 per cent of HIV compared with other women. Yet

Human rights elaborations since the International Conference

on Population and Development
BOX 18: HIV and AIDS

Intergovernmental human rights outcomes: Since 1994 there have been considerable
elaborations of human rights protections as they relate to persons living with HIV and AIDS.
The General Assembly has adopted three declarations on HIV and AIDS, including the Polit-
ical Declaration on HIV and AIDS: Intensifying our Efforts to Eliminate HIV/AIDS, annexed to
resolution 65/277 (2011), in which the Assembly reaffirmed “that the full realization of all
human rights and fundamental freedoms for all is an essential element in the global
response to the HIV epidemic”. The Commission on Human Rights adopted a series of
resolutions on protecting the human rights of persons living with HIV, including resolution
2005/84 on the protection of human rights in the context of human immunodeficiency virus
(HIV) and acquired immunodefi-ciency syndrome (AIDS) (2005).

Other soft law: In 1997, the International Guidelines on HIV/AIDS and Human Rights pre-sented
a framework for promoting the rights of persons living with HIV and AIDS. Since the International
Conference on Population and Development, human rights treaty bodies have increasingly
addressed the rights of people living with HIV, including in general comments and concluding
observations. Treaty bodies have established that States must guarantee people living with HIV
equal enjoyment of their human rights,308 and that antiretroviral therapy should be available,
affordable, and accessible,309 and that States must take action to eradicate barriers to access. 310
Appropriate resources must be allocated to HIV and AIDS programmes, 311 and monitored for
effectiveness.312 States are also urged to take action to counter stigma and discrimination related
to HIV and AIDS.313 States should ensure that people living with HIV can make informed and
voluntary decisions about reproduction.314 Treaty monitoring bodies have also advised States to
address certain populations such as young women, people in rural areas, ethnic minority groups,
older persons, and other groups facing vulnerabilities. 315

ICPD BEYOND 2014 117

funding for HIV prevention among sex workers world, and among different population groups;
remains disproportionately low, given the level of their undertake research to understand the under-
risk. Men who have sex with men are also at lying causes of such disparities; and share
increased risk of contracting HIV, accounting for a proven policy lessons to reduce HIV infections
disproportionate number of new infections in the in high-incidence populations.
Americas and Asia; among men who have sex with
men, the young and homeless are at greatest risk.
Sex workers, men who have sex with men and other HIV and AIDS-related treatment,
key populations at higher risk of contracting HIV care and support
continue to face stigma, discrimination and, in many What was soon to become an HIV pandemic had
cases, punitive laws that compound vulnera-bilities not fully emerged at the time of the Interna-tional
and serve as a barrier to critical prevention, Conference on Population and Development in
treatment, care and support efforts.306 1994. In 1993, an estimated 14 million people were
living with HIV, but it was only after the Conference
Ninety-two per cent of Governments participat-ing in that the pandemic exploded. Within a decade
the global survey reported having addressed the (2003), an estimated 31.7 million people were
issue of “increasing access to [sexually trans-mitted living with HIV, with three quarters of them residing
infection]/HIV prevention, treatment and care services in Africa.316 The response of Governments and aid
for vulnerable population groups and populations at institutions followed, but not before deaths from
risk” in the previous five years, but with varying AIDS had reached a peak of 2.3 million per year in
degrees of success. 2005.306 In terms of the global burden of disease,
HIV rose from the thirty-third largest cause of
Preventing new HIV infections depends to a disability-adjusted life years lost in 1990 to the fifth
considerable extent on behavioural change. The largest in 2010. And while deaths due to AIDS
effectiveness of approaches to bringing about have declined sharply, for an estimated 1.6 million
such change has differed from region to region. In people in 2012,306 AIDS remains the leading cause
several countries across Africa, sexually risky of death in women of reproductive age (15-49
behaviours increased from 2000 to 2012, with years) worldwide.317 In sub-Saharan Africa, deaths
evidence of significant increases in the number of due to AIDS and those resulting from maternity-
sexual partners (in Burkina Faso, the Congo, Côte related causes are leading causes of death in
d’Ivoire, Ethiopia, Gabon, Guyana, Rwanda, South women of reproductive age.318
Africa, Uganda, the United Republic of Tanzania
and Zimbabwe), and declines in condom use (in Under the newly revised (2013) WHO treat-ment
Côte d’Ivoire, the Niger, Senegal and Uganda).306 guidelines, the 9.7 million people receiving
Understanding and addressing the persistence of antiretroviral therapy in 2012 represented only
sexual risk-taking in the face of widespread knowl- per cent of persons eligible for treatment.306
edge about and access to condoms and its links to Changes in treatment guidelines were made in
gender norms and structural inequality is a major response to new evidence on the benefits of
public health challenge for the coming decade. beginning antiretroviral therapy earlier in the
There is the need for a major United Nations natural history of HIV infection. Consequently,
meeting of Governments, experts and civil society despite expanding access to antiretroviral ther-
organizations to address this uneven success, the apy, the proportion of eligible persons receiving it
failure of behaviour change in some parts falls far short of the Millennium Development Goal
of the world, and the evidence that preventive 6 target of universal access to antiretroviral
behaviour is declining in many high-risk countries. therapy by 2015.306 While treatment programmes
have been successfully rolled out in many coun-
States and global health partners should tries, delivery remains challenging where health
address the stark disparities in the success of systems are weak and understaffed, and stigma
HIV prevention in different parts of the creates obstacles to testing and care. Notably,


antiretroviral therapy coverage reached fewer shortest time possible, universal access to
children eligible for treatment than adults glob- antiretroviral therapy with the aims of elim-
ally, and scale-up continues to favour adults.306 inating mother-to-child transmission of HIV,

ensuring follow-up of infants exposed to HIV,
The percentage of pregnant women living with HIV improving the life expectancy and quality of life
who have access to antiretroviral thera-py has of mothers and all people living with AIDS, and
risen dramatically owing to the sustained scale-up protecting all people living with HIV from stigma,
of vertical transmission programmes, with discrimination and violence.
coverage reaching 63 per cent globally in 2012.
There is, however, considerable variation in the 428.Regarding the “eliminating mother-to-child
coverage of prevention of mother-to-child transmission of HIV and treatment for
transmission of HIV programmes between regions, improving the life expectancy of HIV-positive
with coverage exceeding 90 per cent in Eastern mothers”, the global survey shows that 86 per
and Central Europe and the Caribbean, while cent of countries reported addressing this issue
remaining at less than 20 per cent in the Pacific, during the previous five years; among the 38
the Middle East and North Africa. Among countries countries that UNAIDS identifies as suffering
with generalized epidemics, 13 coun-tries provided from a “high impact” of HIV and AIDS, 97 per
antiretroviral therapy to less than cent reported addressing this issue during the
per cent of pregnant women living with HIV, while same time period. Although goals are not yet
13 countries reached prevention of mother-to-child met, this indicates a greater concentration of
transmission coverage levels of 80 per cent.306 efforts in the countries of greatest need.
Differentials in prevention of mother-to-child
transmission coverage among countries with a E. Non-communicable diseases
generalized epidemic do not appear
to reflect differences in underlying national Since the International Conference on Population
HIV prevalence.319 and Development, the contribution of non-
communicable diseases to the burden of disease
While prevention of mother-to-child trans- in the developing world has become far more
mission has increased access to treatment prominent. There was a 30 per cent increase in the
among pregnant women, pregnant women still number of deaths related to non-communicable
receive antiretroviral therapy for their own health diseases (most significantly, car-diovascular
at lower levels than the general population.306 diseases, cancers, chronic respiratory diseases
Additionally, sex differentials persist in access to and diabetes) globally between 1990 and 2010.322
and use of HIV testing and counselling ser- In all regions except Africa, deaths from non-
vices,320 as well as treatment.321 Gains in preven- communicable diseases exceed those caused by
tion of mother-to-child transmission coverage maternal, perinatal, communicable and nutritional
have translated into decreased transmission of disorders combined.323 The mortality rates from
HIV from mothers to their children, preventing non-communicable diseases are higher in the more
more than 670,000 children from acquiring HIV. developed regions, especially Eastern Europe,
In 2012, 260,000 children were newly infected in where older persons represent a higher proportion
low- and middle-income countries, representing of the population. However, age-standardized
a 35 per cent decline since 2009. death rates from non-communicable diseases
show that people living in Africa
States should ensure universal access to HIV have the highest risk of death due to non-
information, education and counselling communicable diseases than in any other
services, including voluntary and confiden-tial region.324 Deaths from non-communicable causes
HIV testing, with a particular focus on young are expected to increase by 44 per cent between
persons and persons with increased risk of 2008 and 2030 worldwide, with the burden of
HIV; and commit to providing, in the disease highest among low- and middle-income

ICPD BEYOND 2014 119

Prevalence of obesity, ages 20 and over, age standardized, both sexes, 2008

Source: WHO, Global Health Observatory map gallery, available from (accessed 25 October 2013).

countries where population growth rates In all regions, women are more likely to be obese
are higher and longevity is increasing.323 than men.327 Obesity among young children has
increased in all regions, but is rising most rapidly
About half of all non-communicable diseases can in low- and middle-income coun-tries, where it is
be attributed to high blood pressure (13 per cent of projected to double by 2015 from its level in
global deaths), tobacco use (9-10 per cent), 1990.328 The poor may be pre-disposed to non-
elevated cholesterol and glucose (6 per cent), communicable diseases from such factors as low
physical inactivity (6-7 per cent) and obesity (5-7 weight at birth, poor nutrition during childhood and
per cent).325 It is therefore important to reach exposure to second-hand smoke. Non-
young people early in life by educating communicable diseases are largely chronic
adolescents, youth and parents about the diseases that affect work attendance, remove
importance of a healthy diet and exercise, and the people from the labour force and take an
risks of harmful alcohol use and smoking. economic toll in terms of lost economic
productivity as well as health-care costs.
Non-communicable diseases
In the developing world, illness and deaths from
and inequity
non-communicable diseases are occurring at
While behaviours and risk factors related to non- earlier ages and affecting adults in their prime
communicable diseases are commonly associated income-generating years.329 A much greater
with those living in higher-income countries, a proportion of deaths related to non-communi-
“globalization of unhealthy lifestyles” is taking cable diseases occur among people younger
place.326 For example, the worldwide prevalence of than 60 years of age in low- and middle-income
obesity almost doubled between 1980 and 2008, countries (29 per cent) compared with high-
and is high in countries from both developed and income countries (13 per cent), and the poor
less developed regions (see figure 41). are more likely to die prematurely than those
who are better off.323


2. Mental illness Lifelong health education should begin with
Mental illness is a key non-communicable disease young people, both within the school curricula
affecting hundreds of millions of people globally, and in concert with comprehensive sexuality

and is the leading cause of disability-adjusted life education, as many life habits relating to long-
years lost from non-communicable diseases.326 term health are initiated and formed at young
Depressive disorders account for about a third of ages and are intertwined with aspects of identity
this toll, affecting 154 million people globally, and formation and aspirations for adulthood.
are measurably more common among women,
especially young women. Accord-ing to States should reduce risk factors for non-
Alzheimer’s Disease International, 44 million communicable diseases through the promotion
people currently live with the disease, a number of healthy behaviours among children and ad-
that will grow to 135 million by 2050. In addition, by olescents through school programmes, public
2050, 71 per cent of the cases will be in low- and media, and within comprehensive sexuality
middle-income countries.330 education, including skills to resist tobacco use
and other substance abuse, healthy eating and
Mental illness and poverty are mutually reinforcing: nutrition, movement and exercise, and stress
the conditions of poverty increase exposure to management and mental health care.
stress, malnutrition, violence and social exclusion,
while mental illness increases the likelihood of Changing patterns of
becoming or remaining poor.331 Mental health life expectancy
conditions, along with cardiovascular diseases,
account for 70 per cent of lost economic output, At the global level, life expectancy at birth for
and the global economic burden of non-- both sexes increased from 64.8 years from 1990
communicable diseases is expected to double to 1995 to 70 years in the period 2010-2015, a
between 2010 and 2030.326 Although the highest gain of 5.2 years, reflecting changes in female
economic toll will occur in high-income countries, life expectancy at birth from 67.1 to 72.3 years
improving mental health in low- and middle-income and in male life expectancy from 62.5 to
countries should be a development priority. 332 8 years over the same period.336

All regions of the world experienced gains in life

Preventing non-communicable
expectancy, and progress has been steady in
diseases: start in adolescence
almost all of them except Africa and Europe. In
Most non-communicable diseases, and about 70 Africa, life expectancy had a slow increase in the
per cent of premature deaths among adults, are 1990s, as mortality in a number of countries
strongly associated with four be-haviours that soared owing to HIV/AIDS and conflict, but
begin or are reinforced in adoles-cence: smoking, regained momentum in the 2000s. As a result, in
harmful alcohol use, inactivity and overeating or the last two decades Africa gained 6.5 years in life
poor nutrition.333 For example, smoking is typically expectancy. Similarly, in Europe, the increase in life
begun in adolescence and is responsible for one expectancy in the 1990s was slow, owing to rising
in six deaths related to non-communicable mortality in a number of successor States of the
diseases.334 Reducing both the supply and the former Soviet Union, but it also accelerated again
demand for tobacco would avert an estimated 5.5 in the 2000s. Currently, sub-Saharan Africa has the
million deaths over 10 years in 23 low- and lowest life expectancy, 56 years, 14 years less than
middle-income countries with a high burden of the world average. In fact, all the countries of the
non-communicable dis-eases.334 Furthermore, world with a life expectancy lower than 60 years (a
evidence from Europe and low- and middle- total
income countries suggest that there is rising of 30 countries) are in Africa, including six with
alcohol consumption among youth, beginning at a levels below 50 years: Sierra Leone, Botswana,
young age.335 Swaziland, Lesotho, the Democratic Republic of
the Congo and the Central African Republic.336

ICPD BEYOND 2014 121

While aggregate analysis highlights the well-known smoking in the preceding decades. The con-
view that women, on average, live longer than traction of the gender gap seen in recent years
men, national, subnational and trend analyses is attributed, in part, to the decrease in smoking
show that this pattern is hardly fixed, as the extent among males over the past 20 years.341
of the gender gap varies significantly between
populations and has been changing over time. 337 Inequalities in life expectancy are dynamic
Countries at early stages of their de-mographic — they change over time — both within and
and epidemiological transitions have life between populations, reflecting variable political,
expectancy differentials favouring women by economic and epidemiological contexts. Because
approximately 2-3 years. In these contexts, a central obligation of States is to respect, pro-
unclean water, infections, inadequate nutrition, lack mote and protect the human rights of its people,
of access to health care and other structural life expectancy is an aggregate indicator of the
conditions cause high mortality across all age extent to which States fulfil this obligation, and
groups, in particular during childhood. These same invest adequately in the capabilities, health, social
conditions make women vulnerable during protection and resilience of its citizens.
pregnancy and childbirth and drive higher rates of
fertility as a means of protection against high infant Unfinished agenda of health
and child mortality, which in turn increase women’s
system strengthening
lifetime maternal mortality risk.337
Despite decades of unprecedented medical
The growing HIV epidemic reversed gains advances and innovations in health care, stark
in life expectancy seen in many African countries in inequalities in the accessibility and quality of
the 1970s,338 with a greater impact on women. This health systems persist across and within coun-
is due in part to women’s higher AIDS-related tries. Sub-Saharan Africa and, to a lesser extent,
mortality, which reflects women’s higher risk South Asia continue to have some of the least
of contracting HIV sexually because of greater accessible and most fragile health systems, as
biological risk, as well as disempowerment in measured by operations indicators such as health
sexual relationships.339 In certain countries in worker density, coverage of critical services,
Africa men currently have greater life commodity stock-outs and record keeping, or by
expectancy than women.337 health outcomes. Within selected middle- and
high-income countries, pockets of weak and poor
Women have a marked advantage over men in health system coverage or quality abound for
life expectancy (10 years or more) in former selected areas or populations, such as for indig-
Soviet republics, reinforced as male life enous peoples, urban slums, the uninsured and
expectancy declined in the late 1980s and the undocumented groups.
beginning of the 1990s.340 Life expectancy among
males increased marginally, but has since
Impact of HIV and AIDS on
stagnated. The causes of men’s decline in life
health systems
expectancy are debatable, but are attributed,
in part, to increased stress, heart disease, and International aid for HIV was largely di-rected
alcohol-related causes of death associated with towards developing vertical HIV-specific
political turmoil. These changes in life programmes rather than building services into
expectancy illustrate the influence of social and existing health systems. That approach was meant
political contexts on health and longevity.337 to allow for the rapid and urgently needed roll-out
of HIV services, while ideally causing spillover
In high-income, industrialized countries women effects that would strengthen health systems more
have a higher life expectancy (4-7 years) than broadly. However, vertical structures that did not
men. These gender differentials peaked in the integrate HIV and AIDS within broader health
1970s, owing largely to men’s high rates of systems have been faulted for diverting


resources, crowding out other services from the had little impact on rates of maternal health ser-
health system and compromising overall health vice provision (mothers reporting antenatal care
system strengthening in favour of a single-disease visits or skilled attendance at birth). However, in

approach.342 While urgent, potentially fatal health areas with low health worker density and low HIV
emergencies require priority action and resource prevalence, HIV funding had a stronger effect on
mobilization, there is nevertheless a need to maxi- building maternal health services, suggesting that
mize benefits and strengthen health systems to AIDS dollars have multiplier effects on the more
provide long-term and far-reaching health preven- underresourced health systems, especially where
tion and care throughout the life course. HIV and AIDS are less acute.345

HIV and sexual and reproductive health are States should implement full integration of HIV and
intimately related, with 80 per cent of HIV cases other sexual and reproductive health services by
transmitted sexually and 10 per cent transmitted greatly expanding access to quality services for
during pregnancy, childbirth or breastfeeding.343 Yet diagnosis and treatment of sexually transmitted
in the years following the International Conference infections, including HIV testing; integrating HIV
on Population and Development, funding for sexual counselling within better sexual and reproductive
and reproductive health remained stagnant in many health counselling for all people, including for
countries while HIV aid increased dramatically.344 adolescents and youth; strengthening continuity of
care from pre-pregnancy, prenatal to post-natal
There has been much debate, but little decisive and child health for all women and children,
evidence, indicating whether increased funding irrespective of HIV status; and addressing the
and scale-up of HIV programmes have had contraceptive needs of all persons, including HIV-
spillover effects on service delivery for sexual and positive persons.
reproductive health care. However, a recent
economic analysis used demographic and 2. Human resources for health
household surveys and OECD Creditor Reporting According to the latest numbers from the recent
System data to investigate the impact of donor aid WHO and Global Health Workforce Alliance
for HIV per capita on maternal health service publication A Universal Truth: No Health Without
provision across sub-Saharan Africa from 2003 to a Workforce, the 2013 global health workforce
2010. Comparing annual health outcomes with HIV shortfall stood at 7.2 million, a figure estimated to
aid disbursements from the previous year, the reach 12.9 million by 2035.346 This is a marked
study showed that HIV development assistance increase from the 2006 estimated

Table 2.
Estimated critical shortages of doctors, nurses and midwives by region, 2006

Number of countries In countries with shortages

WHO region Total With shortages Total stock Estimated shortage increase required
Africa 46 36 590,198 817,992 130
Americas 35 5 93,603 37,886 40
South-East Asia 11 6 2,332,054 1,164,001 50
Europe 52 0 NA NA NA
Eastern Mediterranean 21 7 312,613 306,031 98
Western Pacific 27 3 27,260 32,560 119
World 192 57 3,355,728 2,358,470 70

Source: WHO, The World Health Report 2006: Working Together for Health, table 1.3, available from

ICPD BEYOND 2014 123

FIGURE 42 Using estimated thresholds of 22.8,
Density of physicians, nurses 5 and 59.4 of skilled health professionals
and midwives, urban-rural, (midwives, nurses and physicians) per 10,000
selected countries, 2005 populations, developed to demonstrate global
availability patterns, the WHO report cited above
Uganda 6.4 13.8 Rural
reveals the following findings:346
United Republic Urban
of Tanzania 3.0 “83 countries fall below the threshold of 22.8
Rwanda 2.1 15.4 skilled health professionals per 10,000 pop-
ulation”; this represents the lowest numbers of
Pakistan 6.4 22.1
doctors, nurses and midwives needed to
provide basic health services;
Niger 0.7 10.6

Iraq 15.2 “100 countries fall below the threshold of 34.5

19.7 skilled health professionals per 10,000
Guinea-Bissau 5.7 13.0 population”;

Côte d’Ivoire 1.5 12.4

“118 countries fall below the threshold of
59.4 skilled health professionals per
Cameroon 15.4
10,000 population”;
Brazil 9.0 52.8
“68 countries are above the threshold of 59.4
Benin 7. 3 skilled health professionals per 10,000
7.0 population”.
0 10 20 30 40 50 60
Physicians, nurses and midwives These findings highlight the continued imbal-
per 10,000 population ance in the distribution of health workers across
countries; further, health worker shortfalls
remain most acute in sub-Saharan Africa and
Source: Source: WHO, Department of Human Resources for Health,
“Monitoring the geographical distribution of the health workforce in parts of Asia.346
rural and underserved areas”, Spotlight on Health Workforce
Statistics, Issue 8 (October 2009), available from spotlight_8_en.pdf. The global distribution of health workers is such
that countries with the greatest need and highest
disease burdens have the lowest absolute
workforce shortfall of roughly 4.3 million workers
numbers of health workers and health worker
across 57 countries facing critical shortages. 347 At
densities (i.e., health workers per unit of
that time, health worker shortfalls were most
population). Europe has a health worker density of
serious in 36 countries in Africa and in South-East
18.9 health workers per 1,000 population, which is
Asia, dominated by the needs of Bangladesh,
roughly eight times that of Africa, where the health
India and Indonesia (see table 2). The mix of
worker density is 2.3 per 1,000.347 The Americas
countries identified as having low human-
bear roughly 10 per cent of the global burden of
resource-for-health density and/or low service
disease and have 37 per cent of the world’s health
coverage has since changed. Of the original
workforce, while Africa bears over 24 per cent of
57 countries facing critical shortages, 46 have
the global burden of disease and has 3 per cent of
available data that show increases in the
the global workforce. Among the 49 countries with
numbers of physicians, nurses and midwives.
the lowest per capita income (according to the
However, these net gains are outpaced by
World Bank), only 5 meet the minimum WHO
population growth over time, which further
threshold of 23 doctors, nurses and midwives per
exacerbates the health worker shortfalls.346
10,000 population.347


Percentage of births assisted by professionals, select regions, 2000, Lay person

2005, and 2015 (projected) Traditional
birth attendant
100 Midwives/





2000 2005 2015 2000 2005 2015 2000 2005 2015 2000 2005 2015
Sub-Saharan South and Middle East, Latin America
Africa South-East Asia North Africa and the Caribbean
and Central Asia

Source: Adapted from WHO, The World Health Report 2005: Make Every Mother and Child Count, in UNFPA, The State of the World’s Midwifery 2011:
Delivering Health, Saving Lives, figure 1.2, available from

Beyond the shortfall in overall health worker to reach the WHO target of providing 3 million
numbers in many countries, shortages are exac- people with antiretroviral therapy by 2005.350 At the
erbated by spatial maldistribution within countries, same time, poor working conditions created risks
with a greater proportion of health workers, for occupational transmission, and increased
especially the most highly skilled, concentrated in workload, poor compensation and extremely
urban centres.348 Many countries, wealthy and limited access to essential medicines contributed to
poor, have incentive programmes to address low morale and high rates of attrition. Some health
maldistribution, with varying degrees of success. workers transitioned to the private sector, which
India, for example, is currently experimenting with many have argued siphoned critical human
a rural service programme wherein doctors are resources away from public sector programmes 351.
rewarded with post-graduate training opportuni-ties However, the human resource crisis has generat-
following service in a remote or rural area.349 ed political will to train and retain health workers
and led to the implementation of strategies to
The HIV epidemic placed enormous strain on relieve pressures on the health workforce, such as
weak health systems, highlighting and exacer- task-shifting and scaling up community health
bating critical shortages of health workers at the worker programmes.352
very time that human resources for health were
most desperately needed. The HIV epidemic The evidence illustrates a strong correla-tion
increased the need for health workers to rapidly between low health worker density and poor
scale-up treatment, with upper estimates of health outcomes, including the inability to
approximately 120,000 health workers needed achieve the Millennium Development Goals.353

ICPD BEYOND 2014 125

While most regions have seen significant Health worker assessments, country by
advances in the professionalization of birth-ing country, are sorely needed to provide human
care since 2000, the least progress has been resources for health policy diagnostics and the
made in sub-Saharan Africa (see figure 43), opportunity for scaled planning and redressing
where laypersons and traditional birth health worker shortfalls, and to improve the
attendants attend the majority of births. Less equitable distribution of care.
than 55 per cent of women in Africa deliver with
a skilled birth attendant, compared with more States should urgently undertake the neces-sary
than 80 per cent of women in the other long-term investments in training, recruiting and
regions,354 with Africa falling far short of the rewarding health-care workers to increase their
targets set for the proportion of births assisted numbers and strengthen their capacity, with a
by skilled attendants in the key actions for the focus on ensuring that human resources are
further implementation of the Programme of available to provide universal access to quality
Action (1999).355 A study of 58 countries in which sexual and reproductive health services, including
91 per cent of all maternal deaths occur found by conducting national appraisals and, if neces-
an acute shortage of health workers, and that sary, strengthening health training institutions to
nine countries needed to increase their address the full range of needed sexual and repro-
midwifery workforce by 6-15 times to meet the ductive health services; improving health worker
Millennium Development Goal target. If the capacity, retention and supervision; investing in
number of trained midwives were doubled in mid-level cadres with sexual and reproductive
those 58 countries, an estimated 20 per cent of health skills, such as midwives; and improving
maternal deaths could be averted.354 compensation and career incentives to address
geographic maldistribution of health workers.
Many poor countries have responded to the
shortage of health workers by “task-shift-ing”, Health management information
that is, training lower-level staff to assume systems
higher-level functions.356 Analysts have also Another persistent shortfall in the health systems
increasingly recognized that the adequacy of of poor countries is the management information
any national health workforce is a legacy of systems that maintain patient records, health
long-standing dynamics, including the capacity, statistics and operational data on occu-pancy
traditions and adaptability of training institutions, rates, outpatient demand, stock flows and
professional incentives and licensing regulations reimbursements, enabling managers to evaluate
that may be outdated, country-to-country part- interventions and provider performance, and
nerships that may facilitate brain drain, and the ultimately ensure an evidence base for planning,
institutional culture of health staff. managing and improving the health system.358

National in-depth and comparative assess-ments As wealthier countries with extensive computer and
of human resources for health are proving valuable web access have progressed from paper or e-
and are reflected in recent work by WHO, the based management information sys-tems, most
World Bank and UNFPA, each of which have been poor countries rely on paper-based information
working on the subject in selected high burden systems, interrupting the continuity of care for
countries. The H4+ High Burden Countries patients and reducing the efficient use of data. One
Initiative is embarking on a series of assessments of the notable changes in health systems since
in eight countries to analyse the midwifery work- 1994, particularly in the last decade, has been the
force, with the ultimate goal of enhancing access to rapid evolution of Internet capability, making the
and quality of midwifery services at the community possibility for a major shift from paper-based to
level in a bid to accelerate progress towards electronic medical record systems, or e-based
the Millennium Development Goals and health management infor-mation systems,
achieve sustainability of health systems.357 increasingly feasible.359


Several recent investments in electronic medical Rapid advances in mobile technology since
records in poor countries were prompted by HIV 1994 include global mobile cell coverage of 85.5
and AIDS. The number of untraceable HIV- per cent in 2011364 and emerging new opportuni-

affected patients highlighted the extreme ties for integration of mobile health information
weakness of health information and medical systems have potential for linking and improving
records systems in many countries. A study care in remote settings. With 70 per cent of all
of prevention of mother-to-child transmission mobile phone users in low- and middle-income
programmes in 18 countries found that only 9 per countries, the possibilities of reaching the most
cent of infants born to mothers living with HIV were remote and rural parts of the globe via mobile
identified at their first immunization visit.360 As the health information systems holds promise. Multiple
global community scaled up efforts to deliver initiatives are under way, from weekly maternal
antiretroviral therapy in poor countries, HIV and death reporting in Cambodia using mobile systems
AIDS programmes received targeted investments to monitoring stock-outs of reproductive
to track those enrolled in treatment, in order to commodities, and using mobile phones to conduct
ensure adherence.361 Thus, specialized HIV verbal autopsies in countries with high maternal
surveillance and adherence monitoring death rates. There remains a substantial need for
are contributing to the expansion of electronic standardization and estab-lished guidelines to
medical records systems in Africa, but with limited enhance interoperability across e-health systems,
evidence as to whether such developments but the growth in technology offers a genuine
are being translated across the health sector.362 possibility for health systems to make major
States should reorient the health system to advances in both the operations and utility of their
enable continuity of care, through the devel- health management information system in the
opment of health management information coming decade.365
systems that facilitate the mobility of health
records and reliable integration of community- 4. Reproductive health commodity security
based, primary and referral care, with adequate Indeed, the poor operational systems for health
regard for confidentiality and privacy. management information systems and overall
management inefficiencies cause routine
Recognizing the potential of electronic medical bottlenecks that limit chances for quality health
records for the health sector more broadly, service delivery, whether for sexual and reproduc-
selected countries are working to integrate tive health or other health needs. Commitments to
these systems beyond HIV monitoring, but family planning, screening for sexually transmitted
challenges include lack of qualified technical infections and maternal health tend to assume the
personnel, sustained Internet coverage and availability of necessary supplies and technolo-
power outages. gies, yet in conditions of constrained resources,
inefficient health management information sys-
Paper and non-Internet computer-based health tems and weak programme management, many
management information systems, while less countries and health systems lack steady funding
efficient in many cases, can still have sub-stantial for supplies and experience poor planning that
value for health system improvements and leads to stock-outs of reproductive health com-
accountability. For example, the maternal death modities.366
surveillance response links health in-formation
systems with quality improvement efforts. The In the mid-1990s United Nations agencies,
implementation of maternal death surveillance government ministries and donors recognized the
response depends heavily on a functioning need to adopt a developmental approach to
management information system, but has the supply chain and commodity security for family
potential to reduce maternal mortality irrespective planning and reproductive health, and institu-
of the form through which such infor-mation tionalized their shared concern for reproductive
systems are collected or summarized.363 health commodity security. This is achieved when

ICPD BEYOND 2014 127

all individuals can obtain and use affordable, significant disease burdens the challenge of
quality reproductive health commodities of their sustainably financing universal health coverage
choice, whenever they need them. A series of schemes appears daunting.371
targeted initiatives were launched, including the
Supply Initiative in 2001, the establishment and Discussion of what will constitute the pack-age of
subsequent expansion in 2004 of the Repro- sexual and reproductive health services that would
ductive Health Supplies Coalition, the UNFPA need to be covered in selected settings is
Reproductive Health and Commodity Security increasingly urgent given the emerging global
Thematic Fund of 2004 and its Global Programme policy interest in universal health coverage. It is
to Enhance Reproductive Health and Commodity necessary to identify the core components of
Security of 2007.367 Additionally, the United Nations essential rights-based sexual and reproductive
Commission on Life-saving Commodi-ties for health services, both in total, and what might be
Women and Children368 and the Family Planning included in stages, through the progressive reali-
2020 initiative369 will continue to address zation of universal health coverage, as affirmed by
reproductive health commodity security issues in a the expert meeting on women’s health convened,
coordinated and coherent manner. in the context of the review process beyond 2014,
in Mexico City in 2013.
The principal focus in commodity security ef-forts
has been on the supply side, encompassing There is widespread understanding that health
forecasting and procurement and extending to resources go further in a context where both the
infrastructure, including vehicles and trained and financing mechanisms and the provision of
motivated personnel. Despite increasing recogni- services prioritize prevention and primary care. And
tion of the need to increasingly stimulate demand given that much of sexual and repro-ductive health
for commodities and improve indicators thereof, a is best located within prevention and primary care,
clear strategy is yet to be implemented. namely comprehensive sex-uality education,
contraception, antenatal care and skilled delivery,
among others, prospects are good for universal
5. Universal health coverage health coverage to include and promote universal
An estimated 150 million people suffer financial access to key elements of sexual and reproductive
catastrophe and another 100 million fall under health. The role of NGO providers may
the poverty line each year as a result of out-of- nonetheless be crucial to the provision of
pocket spending on health care. Even worse, comprehensive coverage of sexual and
high rates of maternal and infant mortal-ity as reproductive health, to ensure the provision of key
well as deaths and disabilities from other services such as abortion. As such, it
preventable causes persist because people are will be important to ensure the availability of
unable to access health care.370 evidence-based assessments of effectiveness,
costs and feasibility of all sexual and reproduc-
Universal health coverage has garnered tive health-related dimensions of care,
increasing international support in recent years. In especially in a diverse range of settings.372
2005, the World Health Assembly adopted a
resolution encouraging countries to transition to Success stories of universal health coverage
universal health coverage. The 2010 World Health schemes in poor countries include the roll-out of
Report focused on financing alternatives to the Community Based Health Insurance (mutuelle)
achieve universal health coverage, and in 2013, scheme in Rwanda. Utilizing bottom-up and top-
the spotlight was on research around universal down financing arrangements that are tailored to
health coverage. Most developed nations (the the specific needs of the country has resulted in
notable exception being the United States of marked improvements in health insurance
America) have universal health cover-age; coverage, concurrent with a 50 per cent reduc-tion
however, among developing nations with in under-five mortality and a rise in the use


of modern contraceptive methods from 10 per sary) all components of the health system at all
cent to 45 per cent. Similar examples suggest levels of service delivery. Quality assurance is
enhanced use of sexual and reproductive health also an essential component of the WHO Health

services after the removal of user fees in for All strategy. Prior to 1994, Bruce377 proposed
Burundi, Ghana, Nigeria and Mexico.375 seven elements of quality in family planning
programmes, highlighting the urgent need for
In establishing universal health coverage client-centred counselling and services at a time
schemes, States should ensure mechanisms when many family planning programmes were
for: (a) the fair and affordable participation of all still structured to meet contraceptive targets. The
potential beneficiaries in their country; (b) the two decades since the International Conference
inclusion of essential sexual and reproduc-tive on Population and Development have generated
health services within universal health coverage numerous frameworks, many of which build on
packages and the realization of comprehensive Bruce’s proposal, through which the quality of
sexual and reproductive health care, especially sexual and reproductive health services can be
for young people and the poor; and (c) the conceptualized, measured and monitored.378 For
assurance of fairness and equality through the example, networks of providers and ben-
participation of civil society, inde-pendent eficiaries undertake peer-like reviews of other
commissions and advocacy groups in the comparable facilities at their level of care, often
oversight of allowable procedures, provid-ers with excellent results at low cost and
and reimbursements. measurable improvements in health worker
motivation, a significant factor in the quality of
Although challenges remain, useful lessons care.379 The Programme of Action placed due
learned from new country roll-outs of universal emphasis on the formal engagement of civil
health coverage schemes include the need to society in ac-countability systems, which may
ensure that the elaboration of service packages extend to quality assurance.
are localized, target the poor but monitor the
situation of all, pay close attention to the spatial A patient’s experience while receiving care is an
demands of care, and include the anticipation of important predictor of the future utilization of such
human resources, infrastructure and commodity services and has an impact on the care-seeking
needs and of gender inequality and other forms of behaviour of other members of her family and
discrimination. The importance of closely linking community.376 Numerous studies undertaken on
sound evidence on population dynamics, including sexual and reproductive health services report
population health data and factors that limit that women place high value on feeling
access to health care, to universal health-care comfortable and respected over other aspects of
planning cannot be overemphasized.375 care, such as convenience or waiting times.380
Client characteristics, including differ-ences in
6. Quality assurance socioeconomic status, were associated with levels
Globally, there is greater recognition of the of client satisfaction; for instance, a study in
linkages between the quality of health services, Argentina reported substantial variation in
utilization rates and health outcomes, as well as satisfaction rates among native residents and
the economic returns from upgrading quality376. immigrants in all clinics surveyed.381
While variations in health-care quality exist within
and across regions, the comparatively worse Low-quality care in poorer countries is often
sexual and reproductive health indicators in low- attributed to a lack of resources, yet research
and middle-income countries underscore the need shows that high-quality care can be achieved in
to focus urgently on quality in these regions. resource-constrained settings. Notably, a study in
Indonesia attributed only 37 per cent of perinatal
Quality assurance systems measure, mon-itor, deaths to low resources and over 60 per cent to
control, optimize and modify (where neces- poor process of service delivery, while another

ICPD BEYOND 2014 129

study in Jamaica revealed that improvements by crises. In the same year the specific repro-
in process alone, without added funding, were ductive health needs of refugees and internally
significantly linked to increased birth weights.382 displaced persons were recognized in the
Programme of Action, the Inter-Agency Working
Numerous studies emphasize the need for Group on Reproductive Health in Crises was
effective and ongoing quality assurance formed to strengthen access to quality sexual and
systems, particularly where resource reproductive health services for persons affected
constraints, health-worker shortages and by humanitarian crises such as conflicts and,
infrastructural limitations exacerbate the strain increasingly, natural disasters.384
on health systems. A strategy that maximizes
resources with sys-tematic quality assurance A review undertaken from 2002 to 2004 by the
can break through to new performance levels in Inter-Agency Working Group found that
health quality and management. significant progress had been made in raising
awareness and advancing sexual and reproduc-
There do not appear to be “magic bullets” to tive health for populations affected by conflict,
assure equity and quality in service delivery. In particularly in stable refugee camp settings.
order to produce lasting and sustainable im- Nonetheless, critical gaps were noted,
provements, particularly in regions of the world especially for gender-based violence and HIV
with the worst health outcomes, transformational and AIDS, and sexual and reproductive health
investments in systems-level approaches are services for internally displaced persons were
needed. Health systems must be holistically severely lacking.
strengthened, and founded on the right to quality
care. Standardized tools now provide norma-tive
guidelines for sexual and reproductive health
States should give the highest priority to programming in crises, including the Inter-
strengthening the structure, organization and Agency Field Manual on Reproductive Health in
management of health systems, including the Humanitarian Settings385 and the Minimum Initial
development and maintenance of necessary Service Package for Reproduc-tive Health,
infrastructure, such as roads, electricity, clean which was integrated into the 2004 and 2011
water, facilities, equipment and commodities, to Sphere standards that provide universal
ensure fair and equal access by all persons to minimum standards for humanitarian response.
comprehensive, integrated and quality primary The Minimum Initial Service Package is now part
care that includes sexual and repro-ductive of the numerous high-level policy documents
health care and proximity to referral centres of and guidelines for crisis settings,386 and a 2013
excellence for higher levels of care, with a assessment of the Package in Zaatri refugee
commitment to providing universal access to camp and Irbid city in Jordan suggests that pri-
quality health care to all rural, remote and poor ority reproductive health services are integrated
populations, indigenous peoples, and all those into the response to the crisis in the Syrian Arab
living without adequate health care today. Republic.387

Need has not abated. An estimated 44 mil-lion

Sexual and reproductive health services people worldwide are currently displaced by
and rights for refugees and internally conflict, and an additional 32 million are
displaced persons displaced by natural disasters. Today, more than
half of the refugees served by the Office of the
In 1994, the Women’s Commission for Refu-gee United Nations High Commissioner for Refu-
Women and Children383 published a report gees (UNHCR) live in urban areas, as opposed
documenting the lack of sexual and reproductive to camp settings, and internally displaced
health services for refugees and others affected persons often live in host communities or are


dispersed over large geographical areas. Such Government priorities: sexual and
changes in the spatial distribution of internally reproductive health and rights
displaced persons raise new service chal- per cent of

lenges, prompting a recent review to advise on Global governments
future programming. Sexual and reproductive health services 56%
for adolescents and youth
Maternal and child health 51%
Lack of integration or mainstreaming of sexual
HIV- and sexually transmitted infection- 43%
and reproductive health into acute emergency related services
responses remains a challenge. In complex Family planning services 38%
emergencies, sexual and reproductive health Reproductive cancers 36%
African Region
often takes a back seat, and the quality and
range of sexual and reproductive health Maternal and child health 71%
HIV- and sexually transmitted infection- 56%
services suffers. While the latest review by the
related services
Inter-Agency Working Group finds services Sexual and reproductive health services 56%
more available today than 10 or 20 years ago, for adolescents and youth
Family planning services 46%
the services are often not comprehensive, and
Reproductive cancers 42%
selected components of the Minimum Initial Americas Region
Service Package are implemented rather than
Sexual and reproductive health services 74%
the comprehensive package. There are gaps in for adolescents and youth
the availability of contraceptive methods, with Maternal and child health 42%
no long-term or permanent methods or no HIV- and sexually transmitted infection- 42%
related services
contraceptive services available for adolescents Maximize social inclusion, equal access 42%
or unmarried people, while services addressing and rights to sexual and reproductive
gender-based violence, safe abortion care, health
Family planning services 32%
post-abortion care, sexually transmitted infec-
Asia Region
tions and adolescent sexual and reproductive
Sexual and reproductive health services 56%
health are still limited.
for adolescents and youth
Maternal and child health 54%
Global efforts are necessary to ensure that Family planning services 46%
sexual and reproductive health services for Reproductive cancers 37%
Maximize social inclusion, equal access 27%
refugees and internally displaced persons and rights to sexual and reproductive
comprehensively respond to identified gaps, health
including services to address gender-based HIV- and sexually transmitted 27%
infection-related services
violence, greater access for unmarried and Europe Region
young people, and the provision of multiple
HIV- and sexually transmitted infection- 55%
types of contraception.
related services
Maximize social inclusion, equal access 48%
A stronger evidence base is needed. In and rights to sexual and reproductive
addition, increased and enhanced monitoring is health
Sexual and reproductive health services for 45%
needed to document the outcomes and impact adolescents and youth
of existing programmes. Preliminary results Maternal and child health 39%
from a recent study by Research for Health in Reproductive cancers 35%
Oceania Region
Human-itarian Crises, funded by the United
Kingdom (Department for International Family planning services 58%
Development) and the Wellcome Trust, found Sexual and reproductive health services 42%
for adolescents and youth
that existing evidence on health needs and Violence 33%
services in crisis settings is generally weak, Maximize social inclusion, equal access 33%
including for sexual and repro-ductive health. and rights to sexual and reproductive
Develop sexual and reproductive health 33%
policies, programmes and laws

ICPD BEYOND 2014 131

Notably, the most frequently mentioned sexual and blocks of strong health systems, which are neces-
reproductive health priority (by 57 per cent of sary for the provision of basic maternal and child
Governments worldwide) was “sexual and health services. This is evident in the persistently
reproductive health services for adolescents and high maternal and infant mortality and morbidity
youth”. Given that today’s youth cohort far exceeds rates seen in these countries. The survey results
those of previous generations, it is critical that their highlight the recognition by Governments of
needs, particularly their sexual and reproductive the necessity of prioritizing those dimensions of
health needs, be addressed. The second most sexual and reproductive health services for
frequently mentioned priority, “maternal and child which there is the greatest need.
health”, was largely driven by the numbers of
African and Asian countries where maternal H. Health: key areas
mortality remained markedly prevalent and
constituted significant health concerns.
for future action
Interestingly, reproductive cancers, which in-cludes Accelerate progress towards universal
breast and cervical malignancies, in fifth place access to quality sexual and reproductive
globally, was highlighted by comparatively more
health services and fulfilment of sexual
high-income non-OECD countries (50 per cent)
and reproductive rights.
and low-income countries (41 per cent) than
countries in other income groupings. An alarmingly high proportion of people continue to
live without access to sexual and reproductive
When countries were grouped by income, health services, particularly the poor. Economic
“sexual and reproductive health for adolescents growth, by itself, is insufficient to ensure universal,
and youth”, “maternal and child health” and equitable coverage, and therefore countries must
“family planning” were more frequently dedicate resources to ensure that all persons have
mentioned as priorities by Governments of low- access to affordable, quality care. Current
and lower-middle-income countries, whereas discussions give considerable weight to “universal
“social inclu-sion, equality of access and rights” health coverage” as a means to assure that all
and “HIV- and sexually transmitted infections- persons have access to health care without
related services” stood out as a priority among financial hardship.
high-income OECD countries, mentioned by 58
per cent of their Governments. The highest priority should be to strengthen
primary health-care systems to make integrated,
The patterns described above reiterate the comprehensive, quality sexual and reproductive
inextricable linkages between health and wealth. health services, with adequate referrals, acces-
Developing countries still lack essential building sible to where people, especially rural, remote

Priorities of civil society organizations regarding sexual and reproductive health and
reproductive rights

A recent (2013) survey among 198 civil society organizations in three regions that work in sexual and
reproductive health and reproductive rights showed that in Africa, 26 per cent of civil society orga-
nizations identified the “development of programmes, policies, strategies, laws and the creation of
institutions” as the one top priority issue for public policy for the next 5-10 years. In contrast, “abortion”
was the most frequently cited issue by civil society organizations in the Americas (29 per cent) and
Europe (25 per cent). In the latter region, 20 per cent of civil society organizations identified “targeted
sexual and reproductive health for adolescents and youth”, that is, information, counselling and
services, as the one top priority issue for public policy in the near future.


and resource-limited populations, including the ity in education, adopting and enforcing a legal
urban poor, live. These efforts should ensure the minimum age of marriage of 18 years, eradicating
availability of the widest range of technologies female genital mutilation/cutting and other harmful

and commodities, as well as the strengthening of practices, and eliminating all forms of discrimina-
health management information systems. tion and violence against girls. Such protections of
adolescents and youth are essential in order to
Special attention should be directed towards create a society in which they can build their
ensuring that human resources are available and capabilities, expand their education and enter
accessible to provide comprehensive, quality freely into marriage and childbearing.
sexual and reproductive health services, including
by investing in the capacity of health workers, To realize sexual and reproductive health and
particularly mid-level cadres such as midwives, rights, adolescents and youth, both in and out of
addressing maldistribution and strengthening school, should receive comprehensive sexuality
health training institutions. education that emphasizes gender equality
and human rights, including attention to gender
Improved availability and accessibility must be norms, power and the social values of equality,
coupled with improved quality of sexual and non-discrimination and non-violent conflict resolu-
reproductive health services to support each tion. Such programmes can also empower young
person in a holistic and integrated way, protect people to adopt healthy behaviours, with lifelong
the human rights of all persons, and ensure the benefits for themselves and for society at large.
privacy and confidentiality of services and infor-
mation regarding patient rights. All programmes serving adolescents and youth,
in and out of school, must provide referral to
Protect and fulfil the rights of reliable, quality sexual and reproductive health
adolescents and youth to accurate counselling and services, as well as other health
services including mental health. Legal,
information, comprehensive sexuality
regulatory and policy barriers limiting young
education and health services for their
people’s access to sexual and reproductive
sexual and reproductive well-being and
health services should be removed.
lifelong health.
Rates of sexually transmitted infection and HIV Strengthen specific sexual and
infection and AIDS-related mortality, abortion- reproductive health services.
related deaths and maternal deaths among young
people reveal the urgent need to address the Contraception
inadequate access to information and services The availability and accessibility of the widest
currently experienced by the largest generation of possible range of contraceptive methods, including
adolescents and youth in history. emergency contraception, with adequate
counselling and technical information, to meet
Greater investment must be made in in- individuals’ and couples’ contraceptive needs and
formation and services so they are accessible preferences across the life course, are essential
and acceptable to adolescents and youth. for reproductive health and reproductive rights. Yet
Programme monitoring and evaluation should some countries provide only a few methods, or do
explicitly assess the extent to which not make options or information widely available
adolescents are being reached, and which that would enable individuals to exercise free and
interventions bring the greatest long-term informed choice, especially where health systems
health and well-being for young people. are weak, for example in rural areas. Decisions
about what contraceptive mix to provide must be
The sexual and reproductive health of adolescent calibrated to the capacity of health service provid-
girls requires ending gender inequal- ers, while also building the health system and the

ICPD BEYOND 2014 133

capacity of health workers to provide a range of suffer serious and often lifelong morbidities such
methods to meet the needs and preferences for as obstetric fistula, uterine prolapse, inconti-
everyone across the life course. nence or severe anaemia. Maternal morbidity
and case fatality rates should be increasingly
Abortion utilized as indicators of the quality of sexual and
With increasing access to safe abortion and post- reproductive health services and the progressive
abortion care, abortion rates as well as rates of realization of women’s right to health.
abortion-related deaths have decreased global-ly,
with significant regional variation. However, Sexually transmitted infections, including HIV
progress is inadequate as death rates resulting Evidence suggests a 40 per cent increase in the
from unsafe abortion remain unacceptably high in annual incident cases of sexually transmitted
Africa and South Asia, with more than half of these infections since the International Conference on
deaths occurring among young women under 25 Population and Development, yet data reflect
years. Concrete measures are urgently needed to: widespread weakness in surveillance. Despite the
facts that sexually transmitted infections have
Reduce unplanned pregnancies by increasing serious consequences for women’s health and
access to contraception and fulfilling the rights fertility, contribute to miscarriage and low birth
of women and girls to remain free from forced weight and can cause congenital disor-ders, these
or coerced sex and other forms of gender- infections remain among the most poorly
based violence; monitored, diagnosed or treated sexual and
reproductive health conditions worldwide.
Ensure access to quality post-abortion care for Enhanced global commitment towards strength-
all persons suffering from complications of ening sexually transmitted infection surveillance
unsafe abortion; and increasing access to effective prevention,
diagnosis and treatment of sexually transmitted
Take action as indicated in the WHO publi- infections for all persons, particularly young people,
cation Safe Abortion: Technical and Policy is sorely needed.
Guidance for Health Systems, to remove
legal barriers to services; Continued investment is also required to achieve
universal access to HIV prevention, treatment and
Ensure that all women have ready access to care, and to accelerate full inte-gration of HIV and
safe, good-quality abortion services. other sexual and reproductive health services in a
manner that will holistically strengthen health
Maternity care systems. Further, it is nec-essary to scrutinize and
Ninety per cent of maternal deaths are pre- address the structural conditions that may be
ventable, and the elimination of all preventable contributing to the persis-tence of new HIV
deaths requires a well-functioning and integrated infections in Southern Africa.
primary health-care system that is close to
where women live; effective referral mechanisms Non-communicable diseases, including
to respond to complications of pregnancy and reproductive cancers
delivery; and the availability and accessibility of The prevalence, and attendant mortality and
functioning basic and comprehensive emergency morbidity resulting from reproductive cancers
obstetric care. To achieve universal availability further highlight the inadequacy and inequalities in
and accessibility of quality maternity care re- access to sexual and reproductive health
quires strengthening the health system, particu- information, education and services globally.
larly in sub-Saharan Africa and South Asia.
More than half a million women each year
For each woman who dies of a pregnancy-related develop cervical cancer, which is responsible for
complication, an estimated 20 women the death of over half that number of women,


predominantly in developing countries, and disease reflects significant changes in tobacco
which is preventable through screening and the use, harmful use of alcohol, insufficient physical
human papilloma virus vaccine. Despite lower activity and unhealthy diet/obesity.

incidence of breast cancer in developing
countries, mortality rates are higher owing to a It is critical to address the rising burden of
lack of access to screening and treatment. reproductive cancers, including breast, cervical
and prostate cancers, by investing in prevention
In all regions of the world except Africa, where there is a strategies including the human papilloma virus
double burden, deaths from non-com-municable vaccine and routine screening, early treatment at
diseases exceed those caused by maternal, perinatal, the primary care level and reliable referrals to
communicable and nutritional disorders combined, and higher levels of care.
related mortality is occurring at earlier ages in developing
countries. Cardiovascular diseases, cancers, diabetes, It is also necessary to reduce risk factors for non-
depression and chronic respiratory diseases are communicable diseases through the promo-tion
responsible for the majority of non-communicable of healthy behaviours and lifestyle choices,
illnesses and deaths. This changing burden of particularly among children, adolescents and

Concept of a human rights-based approach adopted by “An assessment of Norplant® removal in the Committee of the initial report of Nicaragua
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Programmatic Support for Newborn Care in Africa the war in women’s wombs: a bioethical analysis of AIDS Epidemic 2013, pp. 16-17
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See UNICEF, Childinfo database (www.childinfo. Planning Perspectives, vol. 20, No. 4 (1994); Strategic Information on HIV and Young People
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that offers us a chance to estimate Newsletter, May/June 1999. cents: a synthesis of internationally
— with reasonable confidence — the relative “Creating common ground in the Eastern Mediterranean
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UNAIDS, Global Report: UNAIDS Report on the
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Ibid., Patton and others, “Health of the world’s
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Germaine and L. C. Chen, eds. (Cambridge, Harvard Committee on the Elimination of Discrimination against
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policymakers, held at Manila from 5 to 8 October
article 12 of the Convention on the Elimination of All
Ninuk Widyantora, “The story of Norplant® implants in 1992 (World Health Organi-zation, document
Forms of Discrimination against Women on women
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3 (May 1994), pp. 20-28; J. Tuladhar, P. J. Meeting of the Committee on Economic Social and
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Family Planning, vol. 29, No. 3 (September 1998), Center for Reproductive Rights, “Whose right to life:
Committee on Economic, Social and Cultural Rights
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A. A. Fisher and others, Torture following the consideration by
See concluding observations of the Commit-tee on the
Rights of the Child following the

ICPD BEYOND 2014 135

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(CRC/C/15/Add.166, para. 42). sub-Saharan Africa: a systematic review and meta- cluding observations of the Committee on the
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Committee on the Rights of the Child, general comment Population Conference, Busan, Republic of Korea,
Dick and others, “Review of the evidence for interventions No. 4 (2003) on adolescent health and development August 2013; model-based estimates based on, inter
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Tylee and others, “Youth-friendly primary-care concluding observations of the Committee on the and unmet need for family planning between 1990
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See also Commission on Population and Devel-opment (CRC/C/ AUS/CO/4, para. 67); concluding
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Emerging Answers 2007: Research Findings on general recommendation 24, concerning article 12 of India, District Level House-hold and Facility Survey
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E. E. Seiber, J. T. Betrand and T. M. Sullivan,


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int/hrh/statistics/spotlight_8_en.pdf; N. Dreesch and through Mobile Phone Technologies:
Implementation of the Health Cluster (World Health
others, “An approach to estimating human resource Second Global Survey on eHealth, Global
Organization, 2009).
requirements to achieve the Millen-nium Observatory for eHealth series, vol. 3
UNHCR, Inter-Agency Working Group on Repro-ductive
Development Goals”, Health Policy and Planning, (Geneva, World Health Organization, 2011).
Health in Crises, Reproductive Health Services for
vol. 20, No. 5 (2005), pp. 267-276. UNFPA, The Global Programme to Enhance Re-
Syrian refugees in Zaatri Refugee Camp and Irbid
L. R. Hirschhorn and others, “Estimating health productive Health Commodity Security: Annual
City, Jordan: An Evaluation of the Minimum Initial
workforce needs for antiretroviral therapy in Report (New York, 2010); available from www.
Service Package — 17-22 March 2013 (2013).
resource-limited settings”, Human
Resources for Health, vol. 4 (2006).

ICPD BEYOND 2014 139


Place and



Programme of Action, principle 2
“[Human beings] have the right to an adequate standard of living for themselves and their
families, including adequate food, clothing, housing, water and sanitation.”

Programme of Action, principle 12

“Countries should guarantee to all migrants all basic human rights as included in the
Universal Declaration of Human Rights.”

Key actions for the further implementation of the Programme of Action, para. 31
“Governments should improve the management and delivery of services for the growing urban
agglomerations and put in place enabling legislative and administrative instruments and
adequate financial resources to meet the needs of all citizens, especially the urban poor, internal

The importance of place to human security to one other. And place includes the village,
coincides with impressive evidence of our very municipality, state and country we call our
human relationship with migration. We are neither own, embedding us within a shared
migratory nor sedentary; we do not routinely or environmental niche and political structure.
instinctively change our habitation with the sea-
sons, but carry within us the uniquely human ca- A secure place is essential for human de-
pacity for both deep attachment to place and the velopment, as human security — that is, freedom
impulse to seek new and better places to make from hunger, fear, violence and discrimination
our homes. Our public policies, therefore, need to — is a precondition for the development of
accommodate human needs for both a secure children and the creative growth of all persons.
place and mobility. The foundational human rights instruments protect
rights related to human security through the “right
Place is both social and spatial.388 It includes our of everyone to an adequate standard of living …
family, household and community, which provide including adequate food, clothing and housing,
the moveable social fabric linking us and to the continuous improvement of

ICPD BEYOND 2014 141

living conditions”, as well as to mobility, including prospects, as well as to urbanization as the
a person’s “right to liberty of movement and free- dominant spatial transition currently under way in
dom to choose his residence” and the freedom much of the world. It highlights some of the most
to “leave any country”.389 vital threats to place, such as homelessness,
displacement, and lack of access to land.
Increasing numbers of people around the world are
moving, both within national borders and The changing structure of
internationally. A secure place for people on the
move is essential, underscoring the impor-tance of
planning for rapidly growing cities that can integrate The Programme of Action of the International
and support rural-urban migrants as well as the Conference on Population and Development called on
urban poor. States to develop policies to provide better social and
economic support to families, acknowledge the rising
Yet the scale of the human population living day to cost of child-rearing, and provide assistance to the
day without a safe or reliable home underscores rising number of single-parent households. The
the urgency of enhanced global attention to human Programme of Action recognized that the family could
security. At the end of 2012, there were at least take various forms. However, little mention was made
15.4 million refugees,390 28.8 million internally of prevailing trends in family or household structures
displaced persons391 and an estimated 863 million at the time, other than the noted rise in single-parent
persons living in slums,392 with a large but house-holds. It did not anticipate the growing
ultimately unknown population completely instability of marital unions in many societies, or the
homeless. These challenges demand cooperative growing heterogeneity of household structures and
partnerships between Governments for inclusive living arrangements, including the one-person, single-
land-use planning, linked urban and rural health parent, child-headed and grandparent-headed
systems, and commitments to fulfil the need for households that characterize many families today.
safe and secure housing.

This section reviews emerging changes Hence, the principal objectives of the Pro-gramme
in the structure of households, people’s most of Action — to ensure that families and
immediate place. It gives prominence to internal households have secure homes and that parents
and international mobility as they define people’s have the opportunity to give due attention to the

Human rights elaborations since the International Conference

on Population and Development
BOX 19: Freedom of movement

Other soft law: General comment No. 27 on freedom of movement (1999) adopted by the
Human Rights Committee states, “Liberty of movement is an indispensable condition for the
free develop-ment of a person.” The general comment clarifies rights related to liberty of
movement; the free-dom to choose one’s place of residence; the freedom to leave any
country, including one’s own; the right to enter one’s own country; and the exceptional
circumstances under which the State can restrict these rights, noting that the “application of
the restrictions permissible under article 12, paragraph 3 [of the International Covenant on
Civil and Political Rights], needs to be consistent with the other rights guaranteed in the
Covenant and with the fundamental principles of equality and non-discrimination”.


well-being of their households, especially their several converging social trends, such as the rise


children — needs to be reaffirmed in 2014, given in age at marriage, rates of divorce and proportions
that households are growing increasingly more of persons who never marry, along with medical
di-verse in structure, that a rising number of innovations, have led to increases in the number of
persons live alone, and that children worldwide one-person households, especially in European
are more likely to be raised by a single parent.393 and other developed countries394, in a wide range
of Latin American and Caribbean countries, and
1. The rise in one-person households in selected countries in Asia, notably the Republic of
In the two decades since the International Korea, the Philippines, Singapore, Indonesia,
Conference on Population and Development, Thailand and Viet Nam (see figure 44). There is

Trends in the proportion of one-person households, by region

Africa Asia
50 50
45 45
40 40
35 35

30 30
25 25

20 20
15 15
10 10
5 5
0 0
1985 1990 1995 2000 2005 2010 1985 1990 1995 2000 2005 2010
Census round Census round

50 Latin America and the Caribbean 50 Europe and other developed countries

45 45
40 40
35 35


30 30
25 25


20 20
15 15
10 10
5 5
0 0
1985 1990 1995 2000 2005 2010 1985 1990 1995 2000 2005 2010
Census round Census round

Source: United Nations, Demographic Yearbook, table 2, Households by type of household, age and sex of head of household or other reference member,
1995-2013, available from (accessed on 26 September 2013);
United Nations Statistics Division, special data request/interagency communication, June 2013; Minnesota Population Center, Integrated Public Use
Microdata Series, International: Version 6.2 [Machine-readable database], University of Minnesota, 2013 (data retrieved on 23 September 2013); Socio-
Economic Database for Latin America and the Caribbean (Centro de Estudios Distributivos, Laborales y Sociales (Argentina) and World Bank), 2013, table,
Household structure, in “Statistics by gender”, available from; Eurostat, 2013, Statistics on
Income and Living Conditions Database, table, Income and living conditions/private households/distribution of households by household type, 1997-2001 and
2003-2011, available from

Note: Data from censuses are organized in time periods centred on census rounds (plus/minus two years around 1985, 1990, 1995, 2000, 2005,
2010); data from surveys are averaged within each of the time periods.

ICPD BEYOND 2014 143

very little evidence of a measurable rise in Females are more likely than males to live in one-
single-person households in African countries, person households in Europe and other devel-oped
outside of Kenya. The rise in single-person countries, but the reverse is true in countries in
households has far-reaching implications for Africa and in Latin America and the Caribbean.
patterns of consump-tion, housing, long-term Women form the majority of persons living in one-
care of the elderly and intergenerational person households among older persons and
support and, therefore, demands on the State. among the widowed. On the other hand, in most
countries men constitute the majority of persons
The rise in one-person households reflects who were never married living alone. Women
social changes under way across the life course, remain underrepresented among young persons
among both young adults and older persons, living alone, especially in the less developed
which shape the rise in single-person regions. Only a small increase in their proportion
households to greater or lesser degrees in was noted for countries in both developed and less
different regions. Figure 45 shows that Spain, developed regions.
Hungary and Bulgaria have a relatively higher
proportion of older persons (over 60 years) in A selection of 21 countries have data on
one-person households (as a proportion of total one-person households by place of residence
households), which may reflect long-term health (urban/rural) and age of the household member.
and independence, but may also foreshadow a Among the seven African countries, one-person
future need for assisted living. Austria, Japan, households are more common in urban areas,
Kenya and the Republic of Korea, by contrast, especially those composed of young adults (20-39
have a relatively higher proportion of one-person years). In the Latin American, Asian and the three
households among 20- to 39-year-olds, European countries, the pattern is mixed regarding
suggesting delayed marriage, or bachelor-hood, whether one-person households are predominant in
with heightened demand for single-unit housing, rural or urban areas but, as in Africa, one-person
entertainment and certain consumer goods. households composed of young adults are more

Trends in the proportion of one-person households, by age category

60+ years
30 40-59 years
Per cent of total households

25 20-39 years




1991 2010 1985 2005 1989 2009 1991 2001 1986 2011 2005 2010 1990 2001 2001 2011 2000 2010 1991 2001
Brazil Colombia Kenya Spain Ireland Republic Hungary Bulgaria Japan Austria
of Korea

Source: United Nations, Demographic Yearbook, table 2, Households by type of household, age and sex of head of household or other
reference member, 1995-2013, available from
(accessed on 26 September 2013); United Nations Statistics Division, special data request/interagency communication, June 2013; Minnesota
Population Center, Integrated Public Use Microdata Series, International: Version 6.2 [Machine-readable database], University of Minnesota,
2013 (data retrieved on 23 September 2013).


common in urban areas. Only in Argentina are FIGURE 46
young people living alone equally likely to live in Singulate mean age at marriage by
either urban or rural areas. Conversely, older one- sex, 1970-2005
person households are more common in rural
than in urban areas in the majority of countries.

2. Delayed marriage Men

Among young adults, the rise in one-person

households reflects, in part, the contin-uing global
rise in the age of first marriage (see figure 46). The 27
singulate mean age at marriage for women and
men has increased in both more developed and 25
less developed regions for the past 50 years, but
more in the former.395 When combined with an 23
especially large cohort of young adults (15-24
years old) in Asia and the Americas (18.3 and 18.0
per cent of total pop-ulation, respectively),396 this
contributes to an overall rise in single-person
households in young adulthood. And while young 17
adult cohorts are
a smaller proportion of the overall population in 15
Europe (12.8 per cent in 2010),396 there too there 1970 1985 1995 2000 2005

has been a measurable rise in the likelihood that

young adults will form independent and shared- Source: United Nations, World Marriage Data 2012 (POP/DB/Marr/
Rev2012), available from
peer households prior to marriage,397 although publications/dataset/marriage/wmd2012/MainFrame.html.
many remain in their parents’ home.398

Younger cohorts of adults (20-39 years old)

partners.399 Looking exclusively at the proportion
represent the dominant group of one-person
of women aged 45-49 who have never married,
households in less developed countries. In fact, the
census-based trends of the past 40 years
small increase in the proportion of one-person
suggest a persistent rise across a majority
households seen in Kenya is due to an increase in
of countries in Europe, Africa, Oceania and the
one-person households among young adults. But
Americas,400 most of which were not
the rise in single-person households also reflects at
experiencing war or sustained conflict. Only in
least three other social trends: a decline in the
Asia is there a uniformly sustained low rate of
proportion of persons who have “ever married”, a
never-married middle-aged women. Statistics on
rise in divorce occurring in all regions, and gains in
non-marriage may reflect a competing rise in
life expectancy that increase the probability that all
less formal unions such as cohabitation, which
older persons, and elderly women in particular, will
look very much like marriage (including lifetime
spend more years living alone, whether after
security and raising a family), thereby
divorce or widowhood.
suggesting greater changes to the social fabric
than is actually occurring. The trends are
Rise in the proportion of the notable nonetheless, contributing, in part, to the
population who never marry more significant rise in one-person households.
Historically, a rise in the proportion of persons In Africa, an analysis of nine countries, with trend
who never marry has been observed among data drawn from censuses, shows that the
cohorts coming of age in wartime, owing to
percentage of never-married women aged
the shortage of prospective marriage

ICPD BEYOND 2014 145

45-49 remains low (less than 10 per cent), but has in Europe (29 of 43 countries); 45 per cent in the
increased significantly in the last two decades in six Americas (19 of 42 countries); 41 per cent in Africa
countries — Lesotho, Liberia, Libya, Mozambique, the (19 of 46 countries); and only 11 per cent in Asia (5
Niger and the Sudan — but not in three countries — of 43 countries). Even in many countries where
Burkina Faso, Egypt and Ethiopia.401 proportions are low (affecting less than 5 per cent
of middle-age persons), recent trends are
In the Americas, the percentage of never-married upwards, and steep. For example, while only 2.1
women aged 45-49 exceeds 10 per cent in all 12 per cent of those 45-49 years old are divorced or
countries where trend data are available, separated in China, this represents a five-fold
although it has remained constant in most increase over the past 20 years. Similar increases
countries for the past two or three decades. in Eastern Europe and South Asia suggest a fairly
recent loosening of historic restrictions (legal or
In Asia the percentage of never-married women social) on divorce, with rapid increases from zero
aged 45-49 tends to be lower (about 5 per cent), or near zero in the last 10 to 20 years.
with a few exceptions in countries such as Kuwait,
Qatar and Singapore, where it exceeds In summary, the observed rise in one-person
per cent and has seen steep increases over households globally reflects numerous social
the past 20 years. changes, including delayed marriage, non-
marriage, divorce and widowhood. Overall, more
Within the 25 European countries with
countries have had an increase in the propor-tion
trend data available, close to or over 20 per cent of
of one-person households due to a rising
women aged 45-49 have never married in Denmark,
proportion of never-married persons, young and
Finland, France, Germany, Ireland, the Netherlands,
old (23 of 52 countries with available data, from
Norway and Sweden; this proportion has increased
developed and less developed regions). Far fewer
steadily since the 1980s or 1990s. The proportion of
countries have observed a rise in one-person
never-married women has been increasing for 20
households due to divorce or separation (14
years in Austria, Belgium, Iceland, Latvia and
countries, mostly from developed regions). Still
Switzerland, and is now between 10 and 20 per cent.
fewer countries (seven countries, five of which are
The proportion ranges from 5 to 10 per cent in
in Latin America and Asia) have seen a rise in their
Albania, Belarus, Hungary and the Russian
proportion of one-person households due to
Federation, and has remained relatively constant
widowhood. There is a very small proportion of
over the past three decades.
one-person households composed of married
individuals or individuals in union (suggesting sus-
Finally, in Oceania (Australia, New Zealand,
tained separation, possibly due to migrant labour),
Palau and Tonga), the proportion of never-
which has nevertheless increased in Senegal,
married women aged 45-49 has increased
Colombia, Chile, the Plurinational State of Bolivia,
rapidly over the past 30 years, and is now
the Republic of Korea, Bulgaria and Switzerland.
approximately 10 per cent.
5. Single-parent households
4. Rise in divorce
The proportion of persons divorced or sepa-rated has Single parents with children represent a significant
also increased in the last two decades,401 and is proportion of all households in countries in all
evident in all regions to varying degrees. The regions. The highest prevalence is observed in
proportion of women and men aged 45-49 who are
Latin America and the Caribbean. Among the
currently divorced or separated is highest in
countries with available data, over 10 per cent of
European and other high-income countries, and has
households are composed of single parents with
increased the most in the past 20 years. The
children in 7 of 12 countries in Latin America and
the Caribbean, 5 of 17 countries in Europe and 3
proportion of countries in which at least 10 per cent
of 11 countries in Africa. However, these
of the population aged 45-49 (male and female) are
proportions are likely to be underesti-
divorced or separated is 67 per cent


mates, as they do not include families of single Austria, Ireland, the United States of America, the
parents with children who may co-reside with Plurinational State of Bolivia, Colombia, Ecuador,
other family or non-family members in non- El Salvador, Jamaica, Panama and Peru. In Africa,
nuclear households (i.e., extended or trends have been mixed. For example, in Rwanda
composite households). and the United Republic of Tanzania, the
proportion of children living in single-parent
Trends in the proportion of single-parent households has increased, reaching about 15 per
households have been mixed. In Latin America cent. On the other hand, the proportion has de-
and the Caribbean, almost all countries experi- creased but remained high in Kenya and Malawi,
enced an increase, the largest being observed in at 16 per cent and 9 per cent, respectively. In Asian
Colombia, Ecuador and El Salvador. Increases countries, the proportion of children in single-
were also observed in some European countries parent households has changed the least, and
(the Russian Federation and Ireland) and in some remained the lowest.
African countries (Cameroon, Rwanda and the
United Republic of Tanzania). Decreases in the As the world grows increasingly more urban, and
proportion of single-parent households were ob- the proportion of older persons in the global
served in some countries in different regions, the population increases, the proportionate increase
highest being in Cambodia, the Czech Republic, in one-person households is likely to continue.
Malawi, South Africa and Viet Nam. Likewise, as trends in divorce are upward in
several demographically large countries (India,
The most recent data available show that the China), and as the social acceptance of unmarried
majority of single parents living with their children childbearing appears to be increasing, it is difficult
are women, ranging from slightly less than three to anticipate a forthcoming decline in the propor-
quarters in the Philippines (2000), Bermuda tion of single-parent families.
(2010), the Republic of Korea (2010), Turkey
(2000) and Japan (2010) to more than 90 per States, including through local municipali-ties,
cent in Rwanda (2002) and Malawi (2008).402 should take into consideration the growing
diversity of household structures and living
The proportion of single-parent households is arrangements, and the corresponding needs for
higher in urban than in rural areas for about half of housing and communal social spaces for one-
countries with available data, most of them located person households among both young and older
in Latin America and the Caribbean and in Europe, people in order to reduce social isolation.
while it is higher in rural areas for about one fifth of
countries, most of them located in sub-Saharan The global survey showed that three as-pects of
Africa.402 The increases observed for some social protection systems relevant to the well-
countries in the proportion of single-parent being of families and households were addressed
households are due to changes in both urban and in the previous five years by close to 80 per cent
rural areas, but mainly in urban areas. of countries: increasing efforts to ensure health,
education and welfare services (85 per cent);
Children living in single-parent households may supporting and assisting vulnerable families (84
more often experience economic poverty and per cent); and providing effective assistance to
limited access to basic services of edu-cation and families and individuals (82 per cent). The
health. In the last two decades, the proportion of proportions vary if examined by region or income.
0- to 14-year-old children living in single-parent Likewise, assisting families caring for family
households has increased in most countries of members with disabilities and family members
Europe and other more developed regions, and living with HIV was reported to have been
Latin America and the Caribbean (see figure 47). addressed by 79 per cent of Governments in the
Among the countries with the highest current past five years, although to a lesser extent in
values (over 10 per cent) are Oceania (33 per cent).

ICPD BEYOND 2014 147

Trends in proportion of children (0-14 years old) living in single-parent
households by region

Africa Asia
20 20

15 15
Per cent

Per cent
10 10

5 5

0 0
1985 1990 1995 2000 2005 2010 1985 1990 1995 2000 2005 2010
Census round Census round

Europe and other developed countries Latin America and the Caribbean
20 20


Per cent


0 1990 1995 2000 2005 2010 0 1990 1995 2000 2005 2010

1985 1985
Census round Census round

Source: Minnesota Population Center, Integrated Public Use Microdata Series, International: Version 6.2 [Machine-readable database],
University of Minnesota, 2013 (accessed on 23 September 2013).
Note: Data refer to census data organized in time periods centred on census rounds (plus/minus two years around 1985, 1990, 1995, 2000,
2005 and 2010).

However, the global survey also indicated that maintain, a family. Mobility, and safety and
providing financial and social protection schemes secu-rity during internal migration, are central
to single-parent families was less likely to have to the opportunity for people to secure new
been addressed by Governments in the previous and better capabilities, work and livelihoods.
five years (61 per cent), despite the rise in the
proportion of such households. While estimates of internal migration are very
challenging to obtain, analysis suggests that
B. Internal migration 740 million people worldwide live in their home
and urbanization country but outside their region of birth,403 a
measurement that vastly outnumbers interna-
1. Internal migration tional migration (232 million),404 even as the
Whether people move within or between great majority of global attention to mobility has
international borders, be it permanently, temporar- been drawn to the international dimension.
ily or cyclically, their underlying motivations remain
the same: to improve their well-being and life Increasingly, women are migrating on their own
circumstances; to seek employment; to form, or or as heads of households and principal


wage earners.405 Moreover, because migration The most significant trend in internal migration is
requires a range of resources, migrants do not urbanization, including both cir-cular and
generally come from the poorer strata of rural permanent movements from rural areas into
society,406 except in movements forced by urban settings large and small. In fact, urban
severe push factors such as famine, war or areas are expected to absorb all population
natural disasters. growth over the next 40 years (see table 3),
making this the most important spatial
Mobility occurs on a continuum from voluntary population trend for the coming decades. Along
migration to forced displacement. The history of with migration from rural to urban areas, natural
severe environmental crises shows that any increase (the difference between births and
associated mobility is often short-term and deaths) in urban areas themselves is the other
local,407 while displacement due to political crises main source of urban growth.409 The relative
or conflict may be sustained, transnational and contribution of each factor varies considerably
even permanent.408 Short- or long-term with time and place owing to varying levels of
movements, whether voluntary or not, demand fertility and urbanization rates. The one factor
resources, leaving the poor more likely to be that unites them is that increasing urbanization
caught without resources for relocation,406 in levels are associated with an elevation of the
conditions of forced displacement or trapped in contribution of natural increase to urban growth,
refugee sites without resources to return home. since urbanization reduces the number of poten-
States should support people’s right to move tial rural-to-urban migrants while also increasing
internally as a means of improving their lives, the proportion of children born in cities, despite
adapting to changing social, economic, politi-cal universal lower fertility in urban areas.
and environmental conditions and avoiding
forced displacement, and should promote, The scale and pace of urbanization
protect and provide all internal migrants with In 2008, for the first time, more than half of the
equal opportunities and access to social world’s population lived in the city. Between 1990
protection. and 2010, 90 per cent of the growth in the urban

Table 3. Trends and projections in urban-rural population by development group, 1950-2050

Population (billions) Average annual rate of change (percentage)
Development group 1950 1970 2011 2030 2050 1950-1970 1970-2011 2011-2030 2030-2050
Total population
World 2.53 3.7 6.97 8.32 9.31 1.89 1.55 0.93 0.56
More developed regions 0.81 1.01 1.24 1.3 1.31 1.08 0.51 0.23 0.06
Less developed regions 1.72 2.69 5.73 7.03 7.99 2.23 1.85 1.07 0.65

Urban population

World 0.75 1.35 3.63 4.98 6.25 2.98 2.41 1.66 1.13
More developed regions 0.44 0.67 0.96 1.06 1.13 2.09 0.89 0.52 0.29
Less developed regions 0.3 0.68 2.67 3.92 5.12 4.04 3.33 2.02 1.34

Rural population

World 1.79 2.34 3.34 3.34 3.05 1.36 0.87 -0.01 -0.44
More developed regions 0.37 0.34 0.28 0.23 0.18 -0.48 -0.48 -0.92 -1.14
Less developed regions 1.42 2.01 3.07 3.11 2.87 1.74 1.03 0.07 -0.4

Source: United Nations, World Urbanization Prospects: The 2011 Revision (ST/ESA/SER.A/322), table 1, available from FINAL-FINAL_REPORT%20WUP2011_Annextables_01Aug2012_Final.pdf.

ICPD BEYOND 2014 149

population occurred in developing countries, where with Asia projected to see its urban population in-
the urban-dwelling population increased from 35 per crease by 1.4 billion, Africa by 900 million, and Latin
cent to 46 per cent. During this period, the size of the America and the Caribbean by 200 million. The sheer
urban population in the least developed countries scale of new urban residents in the coming decades
more than doubled, from 107 million to 234 million. is without parallel in human history, usher-ing in
Though developed countries experienced this unprecedented opportunities and challenges and
transition earliest, Latin America also underwent a requiring new and visionary responses.410
surprisingly rapid and early urban transition.410
Today’s 3.6 billion urban dwellers are distributed
The world’s urban areas (towns and cities) are unevenly among urban settlements of varying size.
projected to gain 2.6 billion people by mid-cen-tury, As seen in figure 48, over half of the world’s 3.6
growing from 3,630,000,000 people in 2011 to billion urban dwellers (51 per cent) still live in cities
6,250,000,000 in 2050 (see table 3). However, or towns with fewer than half a million inhabitants.
while the scale of this growth is enormous, the rate To date, the absolute growth of these smaller cities
is actually declining. Between 1950 and 2011, the has been considerably greater than that of cities of
world urban population grew at an average rate of larger size.
2.6 per cent per year and increased nearly fivefold.
In contrast, from 2011 to 2030, the world urban In 2011, 23 urban agglomerations qualified
population is projected to grow at an average as megacities, being home to at least 10 million
annual rate of 1.7 per cent.410 inhabitants. Despite their visibility and dynamism,
megacities account for a small, though increasing,
Meanwhile, the world rural population is pro-jected proportion of the world urban population: just 9.9
to start decreasing in about a decade, with an per cent in 2011, and an expected 13.6 per cent in
expected 300 million fewer rural inhabitants in 2025. Furthermore, megacities are experiencing
2050 than today. Most of the anticipated popula- varying rates of growth, growing at higher rates in
tion growth in urban areas will be concentrated in Africa and South Asia (e.g., Lagos, Dhaka and
the cities and towns of the less developed regions, Karachi) and more slowly in Latin America.

Distribution of world urban population by city size class, 1970-2025

2,000 1,966
1,849 1970

1,500 1990
Total population (millions)

1,333 2011
1,129 2025

833 776

500 516 456 402

365 244 283 359
206 145
0 128 109 142 39

Fewer than 500,000 to 1 to 5 to 10 million

500,000 1 million 5 million 10 million or more

Source: United Nations, World Urbanization Prospects: The 2011 Revision (ST/ESA/SER.A/322), figure II, available from


Urbanization and opportunity for all desired fertility. In conjunction with greater
The Programme of Action recognized the role of access to sexual and reproductive health
cities in economic and social development, as do services, the result has been significantly
many of the people who are moving to urban areas in reduced fertility, which has changed the
search of opportunity. Young adults account for a trajectory of overall population growth in all
large proportion of urban growth. Re-search on countries experiencing the urban transition.418
urbanization in China and Bangladesh411 highlights
the appeal that urban contexts hold The shape of urban growth impacts sus-tainability
for young people, especially young women, who across all its dimensions. The rise of urban
regard the move to urban areas as an opportunity inequality has increased social exclusion and
to escape traditional patriarchy and experience marginalization in cities and exacerbated urban
new freedoms.412 Even when urban housing and sprawl. Along with poor public transpor-tation
employment fall short of expectations and they infrastructure, sprawl has undermined the
eventually return to village life for marriage, many resource efficiencies of urban living as well as
of these young women speak of their urban increased the marginalization of the poor in
working experiences as a vital period of freedom remote or peripheral parts of cities, often in
and autonomy.413 extremely dense informal settlements with little or
no open and public space.419 The poorest urban
There is a strong correlation observed between women are often unable to access services, and
the level of urbanization and economic growth. 414 may live within urban cultural enclaves in which
While in some countries urban poverty is growing, their marital and reproductive lives, and fertility
particularly with the arrival of migrants from rural rates, are closer to those of rural women.420 How
areas, rural poverty remains higher universally. 415 urbanization meets the needs and aspirations
Towns and cities are responsible for over 80 per of urbanizing populations, particularly the poor,
cent of gross national product worldwide, a is therefore greatly dependent on the choices
function of advantages of proximity, Governments make regarding urban population
concentration, economies of scale and increased growth, land, housing and infrastructure.
access to services and information technology,
which create opportunities for work and entre- Though Governments in 1994 recognized the
preneurship. They also provide the essential importance of urbanization and cities, half of
transport, trade and information linkages between them considered the spatial distribution in their
rural, regional and global markets. In addition, countries to be unsatisfactory and in need of
demographic concentration helps reduce energy modification, particularly to address rapid
demand per capita, and makes it easier and urban-ization and excessive concentration of
cheaper for the State to provide basic health, popula-tions in large cities. Many Governments
welfare and education.416 continue to have these concerns today.421

Cities also offer increased autonomy, with In the global survey, when Governments were
greater opportunities for social and political asked about urbanization issues that they had
participation and new paths to empowerment, addressed in terms of policies, budgets and
as evidenced by the rise of women’s implementation in the preceding five years, the
movements, youth groups, political and highest proportion of countries mentioned
community associ-ations and organizations of decentralization (74 per cent). This issue is of
the urban poor in developing world cities.417 particular relevance to African countries, of which
per cent had committed to the implementation of
Conditions in urban areas — including greater decentralization policies, as well as to countries in
access to education, higher aspirations for Asia (9 per cent) and the Americas (73 per cent).
children, reduced living space, and other factors Decentralization can have spatial, fiduciary and/or
favouring smaller families — contribute to lower administrative aspects; each can be appropriate

ICPD BEYOND 2014 151

in the right context, though the latter two are While these challenges may affect all residents of
usually considered to be two essential aspects of a given city, they cause the greatest burden for the
good governance. For many cities the decentral- urban poor, who face enormous challenges in
ization of decision-making and budgeting can go a locating and maintaining secure housing,
long way towards resolving urban dysfunction and accessing work or public resources and achieving
providing urban residents with a stronger voice in quality of life, as recognized by the Commission on
local governance. However, decentraliza-tion can Population and Development at its forty-sixth
also place significant added governance session in 2013, when it adopted resolution 2013/1
responsibilities in the hands of secondary and on new trends in migration: demographic aspects.
tertiary cities, which are home to the large major-
ity of urban residents globally yet often lack the The total estimated number of global slum
capacity, resources and local tax bases of primary dwellers has risen from over 650 million in 1990
cities or megacities. Governments identified this in to about 820 million in 2010.422 Almost 62 per
their responses to the global survey, with 71 per cent of the urban population in sub-Saharan
cent reporting having addressed the growth of Africa lived in housing designated as slums in
small or medium-sized urban centres. 2010, the highest of any region in the world by a
large margin.
Among the most highly urbanized countries,
Governments were far more likely to address But slum growth should not be conflated with
“land, housing, services and livelihoods of urban urbanization, as urban population growth and
poor” (71 per cent) and to report that they had urban slum growth are two distinct phenomena.
been addressing “environmental management of The majority of evidence suggests that global
urban agglomerations” (67 per cent) in the previ- urbanization is an inevitable trend, though it takes
ous five years. These issues had been addressed place at different rates in distinct places. Slum
by only 40 per cent of less urbanized countries, populations, on the other hand, have declined as a
despite the fact that many are now urbanizing very proportion of the total urban population, even in
quickly (by 2 per cent or more annually). sub-Saharan Africa, where 70 per cent of the
population in urban areas in 1990 were in housing
“Proactive planning for urban population designated as slums. Slum growth is, in a signifi-
growth” is an issue that was addressed by well cant way, an outcome of governance decisions to
over half (57.8 per cent) of countries, with limit access to the city for the poor, by limiting
higher levels prevailing in fast-growing and less- service provision to informal settlements or by
urban-ized countries. This information contrasts forced evictions and resettlement of the urban poor
with other data showing a steady increase in to peripheral or underserviced areas.
the number of developing countries that are
attempt-ing to reduce urban growth. It also The vulnerability of people, especially women, in
contrasts with addressing the “integration of many urban areas today reflects the absence of
rural-urban migrants”, which only 23 per cent of proactive, innovative planning for the provision of
countries reported. Commitment to this issue is safe housing, adequate health services, reliable
critical, since failure to integrate migrants into transport to the economic centre and protection
the city has been cited as one of the major from violence, as well as community systems of
factors underlying the rapid growth of slums. social protection. States, including through local
municipalities, should fulfil the need for public
4. The challenge of slums housing; provide for affordable housing and the
Amid widespread urban growth, many development of infrastructure that prioritizes the
Governments are presented with significant urban upgrading of slums and the regeneration of urban
management concerns, including gaps in service areas; and commit to improving the quality of
provision, traffic congestion, poor land manage- human settlements so that all people have
ment and sprawl, and environmental degradation. access to


basic services, housing, water and sanitation, average the urban poor received better


and transportation, with particular attention to antenatal and delivery care than rural residents,
security and safety, especially to prevent the dis-advantage of the urban poor was more
gender-based violence. notable in countries where maternal health care
was somewhat better.424 In short, where health
Yet despite the numerous stresses within sectors are least effective, rural and urban care
urban slums, including evidence of heightened suffers to a similar degree, but where resources
violence and risk within informal urban settle- have strengthened care, the urban middle and
ments,423 urban centres continue to attract upper class have gained disproportionately.
rural populations, especially young adults, in
devel-oping countries, as they seek greater For the urban poor, health services are routinely
economic opportunities and social freedom. overcrowded and often staffed by over-stretched
This is why, despite anti-urban policies and health workers. With the rise of unregu-lated
widespread attention to lowering urban growth private providers in urban areas, poor urban
rates around the world, urbanization persists. residents may have to pay for services that are
delivered free of charge at public health posts in
The importance of urban rural links: rural areas. For those living in slums, health-
seeking can require long travel to facilities lo-cated
strengthening the health system
on the outskirts of slums, and transport and cost
At the lowest income levels, health indicators for can both act as barriers to care. The urban poor
poor urban residents are often equivalent to or often receive poorer-quality services in both public
worse than those for their rural counterparts, and and private-sector facilities compared to wealthier
far below those for the urban well-to-do. A review urban residents. The urban poor also face
of rural and urban maternal health care across 23 unhealthy and often risky living conditions that can
African countries in the 1990s found that while on contribute to poor health outcomes.

Human rights elaborations since the International Conference

on Population and Development
BOX 20: Water and sanitation

Intergovernmental human rights outcomes: In resolution 64/292 on the human right to water
and sanitation (2010), the General Assembly recognized “the right to safe and clean drinking
water and sanitation as a human right that is essential for the full enjoyment of life and all
human rights”. Subsequently, the Human Rights Council, in resolution 15/9 on human rights
and access to safe drinking water and sanitation (2010), affirmed that the right to water and
sanitation was derived from the right to an adequate standard of living.

Other soft law: In general comment No. 15 on the right to water (2002) the Committee on Eco-
nomic, Social and Cultural Rights explained that the right to water is implicit in articles 11 and 12
of the International Covenant on Economic, Social and Cultural Rights, which protect the right to
an adequate standard of living, and the right to health. The draft guidelines for the realization of
the right to drinking water and sanitation (2005) are “intended to assist government
policymakers, international agencies and members of civil society working in the water and
sanitation sector to implement the right to drinking water and sanitation”.

ICPD BEYOND 2014 153

Ultimately, the “urban health advantage” that facilitate connections and reduce inequality
masks disparities between poorer and across the spatial divide. A major challenge for
wealthier urban areas.425 the coming decades is the creation and evalua-
tion of such innovative health system structures,
In most countries health workers are al-ready responding to urban growth in a way that also
disproportionately concentrated in urban areas,426 encourages investments in rural care.
although not necessarily serving the urban poor. 427
To avoid neglect of rural areas, innovations are States should promote development that will
needed to ensure that urban investments also foster and facilitate linkages between urban
benefit rural areas, for instance through health and rural areas, in recognition of their
worker rotations, new uses of mobile technologies economic, social and environmental interde-
and other rural-urban health system linkages. 428 pendence, including the development and
These innovations also need to move outside the equitable distribution of satellite and nodal
traditional boundaries of the health system, to centres of excellence in health, education,
develop transport, resource and financial linkages business, transportation and communica-tions,
between rural and urban areas to promote mobility, opportunity and


Sustainable urbanization
Preparing for urban expansion: access to
residential land for the urban poor 430

Ecuadorian cities are no exception to urban expansion, and while currently there is undevel-
oped land available for residential development, there are serious shortages of serviced
urban land for low-income housing in the formal sector. This has led to a great deal of land
subdi-vision and sale in the informal sector, either through land invasions or through
informal land subdivisions that do not conform to zoning and subdivision regulations.
Compared with other countries, a very high percentage of urban households in Ecuador live
in unauthorized housing communities without legal title documents.

In order to guarantee that residential land for the urban poor will remain affordable,
municipal-ities must ensure that accessible urban land remains in ample supply in the
coming years, so that land prices will not be subject to speculative increases.

To this end, seven intermediate-sized municipalities in Ecuador that are currently

experiencing rapid urban growth have started delimiting new expansion areas based on
preliminary popu-lation and built-up area projections, planning the arterial road networks in
the new expansion areas, refining legal tools for acquiring the rights of way for the arterial
road networks and estimating the budgets needed for implementation. If carried out early
enough, this strategy will involve a relatively low amount of investment and has a
potentially high rate of return in economic, social, demographic and environmental terms.


economic growth for those residing in urban the urban poor in contexts of rapid urban growth;


centres, small and medium towns and rural as more people come to urban areas, space
areas alike. constraints and inequality in the distribution of land
tend to produce rapidly increasing costs of living,
Given the urban growth expected in the coming with the elite capturing the most accessible and
decades, coupled with the enormous reliance on desirable land.429
urban areas for poverty reduction, economic
growth and environmental sustainabil-ity, The most significant policy challenge in the
multisectoral leadership in urban planning is a context of urbanization is not to change its
growing need, nationally and globally. trajectory, but to identify ways to extend the full
set of potential benefits of urban life to all current
Securing available and affordable land and and future urban residents, and to do so in ways
housing is crucial to ensure housing security for that can also link urban-rural development.

Capitalizing on urbanization431

First step: accept urbanization as a part of the development process

Political opposition to urban growth has little impact on slowing it but infringes on individual rights, and
can make both urban and rural poverty worse. When migrants make a choice to move to the city,
they are making a rational choice to improve their lives and reduce their vulnerability.
Once policymakers accept the inevitability of urban growth, they are in a position to improve their
cities and the lives of their present and future residents.

Second step: plan for growing cities in the context of rural urban links
The major issues that affect cities throughout the world — housing, transportation, environment,
water, sanitation and energy, among others — all require a coordinated regional approach that
cuts through fragmented boundaries and includes both peri-urban and rural areas. Rural
development and urban development are not contradictory but instead reinforce each other,
particularly given that many people have dual residence.

Third step: promote the sustainable use of space

Work openly and transparently with communities and the private sector to develop a participatory
vision of where and how the city should grow.
Promote urban growth within a systematic concern for environmental values.
Minimize the size and impact of the urban blight through policies to limit sprawl.
Set aside land for public space.
Favour energy-saving and well-integrated mass transportation.
Favour density, compactness and effective links between agglomerations.

Fourth step: promote the social use of space

mproveI slum areas in situ, focusing on mixed-use construction and housing solutions that
can expand over time as households grow.
Improve functioning of land markets and reinvest taxes charged on capital gains from urban land
speculation in land banks for the future.
Develop supports for land, housing and services for the urban poor; their integration and prospects
for dignity and livelihoods are vital to the ongoing success of cities.

ICPD BEYOND 2014 155

Government priorities: Internal and Asia (29 per cent), where rapid urbanization
migration and urbanization is currently taking place, prioritized the latter.
Priority by per cent
Governments consistently prioritized “devel-opment
of governments
of urban planning policies, programmes and
Improving the quality of 51%
strategies and the creation of laws and insti-tutions”
urban life
associated with urbanization (48 per cent), as well
Develop urban planning 48% as “social protection” (32 per cent) and
programmes, policies, “environmental management” (23 per cent). Asian
laws and institutions Governments were more likely to be concerned
about environmental management linked to urban
Develop and promote small 32%
areas, with 34 per cent identifying it as a priority.
and medium urban centres
Social protection was the third most frequently
mentioned priority in the Americas, with 40 per cent
Social protection 32%
of Governments identifying it.
Environmental management 23 %
States should capitalize on the opportu-nities
that urbanization provides for sustain-able
National priorities pertaining to spatial distri-bution, development and undertake proactive
internal mobility and urbanization can be participatory planning to harness the benefits
understood across two critical dimensions aligned of higher population density in urban areas,
with the nature of urban growth and its intersec- recognizing the significant impact that greater
tion with both urban and rural development. The internal migratory flows have on the distribu-
first focuses on whether the Government places tion and concentration of populations in cities,
greater emphasis on improving urban centres, notably higher energy efficiency in transport
small and medium urban areas, or rural areas. and housing, as well as cheaper provision
Among these, Governments responding to the of health, communications and other basic
global survey were far more likely to give priority to services per capita.
“improving the quality of urban life” (51 per cent of
Governments mentioned this among their top five C. International migration
priorities), while fewer mentioned “develop and
promote small and medium-sized urban centres” The total estimated number of international
(32 per cent), or “rural development”432 (16 per migrants433 in the world increased from 154 million
cent). Almost 30 per cent of countries in 1990 to 232 million in 2013, and its continued
in Asia indicated that rural development was a rise is expected into the foreseeable future.
priority, but just 2 of 30 Governments in the Although this represents an increase in the number
Americas (where the urban transition is of migrants, the percentage of international
essentially complete) did so. migrants in the global population has changed only
slightly in the 23-year period, from 2.9 per cent in
The second dimension concerns whether 1990 to 3.2 per cent in 2013. The percentage of all
Governments prioritized recognition of “popula-tion international migrants living in developed countries
dynamics related to urbanization” — urban increased from 53 per cent in 1990 to 59 per cent
population growth, sprawl or concentration; inter- in 2013, when international migrants represented
nal migration out of rural areas or into urban areas 10.8 per cent of the total population in developed
(14 per cent of Governments) — or whether they countries, compared with 1.6 per cent of the total
prioritized “efforts to influence the spatial distri- population in developing countries.434
bution of the population or prevent urbanization”
(21 per cent of Governments). A relatively greater Contemporary patterns of international move-
proportion of Governments in Africa (27 per cent) ment are significantly more complex than those of


the past, not only because of the sheer numbers of Regional differentials in
international migrants, but also because the flows international migration
are now truly global. The growth and diversification In 2013, there was as much international
of migration patterns have meant that an migration between developing countries as
increasing number of countries are affected by there was from developing to developed coun-
migration, and that most countries are now tries. About one third of global migrants (82.3
concurrently countries of origin, destination and million people, or 36 per cent) both originated
transit. In 2010, of the 43 countries hosting at least from and were living in a developing country in
1 million immigrants, 24 were the places of origin of 2013. Another third of the total number of global
more than 1 million emigrants. Countries that migrants (81.9 million people, or 35 per cent)
experienced large gains in numbers of migrants were born in a developing country but resided in
between 1990 and 2010, such as Malaysia, Nigeria a developed country. Further, about one quarter
and Thailand, also experienced a large increase in of all international migrants in the world (53.7
the number of their citizens living abroad.435 million people, or 23 per cent) were born and
were living in a developed country. The percent-