Implementation of the Dakar/Ngor Declaration (DND) and the ICPD-PAICPD+5 logo




After the introductory text, this page is divided into three sections:


       Achievements & best practices




       Recommendations for the way forward


Visit the Reproductive health & rights proceedings section to read the proceedings related to this thematic area.




The goal of the ICPD-PA is that the recommendations relating to reproductive health (RH) and reproductive rights (RRs) should be viewed in the broader context of the need to provide basic health services and fulfil overall socio-economic development needs of all the people. In this regard, the ICPD-PA calls on all member States of the United Nations family to make available universal access to a full range of high quality RH services30 through their primary health care (PHC) system31 no later than the year 2015. Equally, according to the ICPD-PA, RRs rest on the recognition of the 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 RH. It also includes their right to make decisions concerning reproduction free from discrimination, coercion and violence.



Achievements and best practices

The ECA member States present considerable diversity in their RH/RRs status and services. Indications are that virtually all of them have made considerable effort to expand and improve access to RH services through a variety of channels including the public primary health care (PHC) system, private practitioners, NGO clinics, pharmacies and drug stores, work places, and social marketing and CBD programmes. Availability, quality, utilisation of RH/sexual health (SH) services vary dramatically by type of service among them (see Tables 1, 2, 3 and 4). The primary achievement since Cairo has been the sensitisation of policy makers to ICPD tenets of RRs (including those of adolescents) and of integrated comprehensive RH services. Although RH concepts are now much better understood than before by those in leadership positions in the ministries concerned, few States are yet to experience a significant gain in the quality of available integrated RH services.


Towards the development and implementation of their RH programme strategy, Burkina Faso, Burundi, Côte d'Ivoire, Guinea, Niger, Sao Tome and Principe, Senegal, Tanzania and Togo have integrated family planning and safe motherhood in their PHC system. Other related actions include the use of team approach in both intra and inter-sectoral collaboration; prevention of STDs and HIV/AIDS; integration of RH in the NDP (Algeria, Botswana, Cape-Verde and Lesotho); training of service providers (including integration of family health issues) on how to offer integrated services (Ethiopia, Lesotho, Kenya, Malawi); and introduction of RH in the "minimum package of activities" to improve health services in rural areas (Mali, Rwanda).


Policies and programmes that have been adopted as well as laws that have been enacted that are favorable to adolescent RH include the establishment of centers for counselling on FP/RH and service delivery to young people (Burkina Faso, Cape Verde, Central Republic of Africa, Guinea, Lesotho, Malawi); formulation of Action Plan on adolescent RH (Burkina Faso); increasing accessibility to health facilities for commodities and services (Botswana, Cape Verde, Ghana); formulation and implementation of RH Strategy and/or Youth Development Policy (Burkina Faso, Central African Republic, Guinea, Sao-Tome and Principe, Tanzania, Togo and Uganda) ; amendment of the penal code and abolishment of the 1920 French law on abortion (Ethiopia, Guinea) ; and removal of spousal consent for supply of contraceptives/sterilization (Ghana, Kenya).


Recent measures/strategies adopted in the area of maternal mortality include mainly the formulation and/or implementation of safe motherhood strategy to reduce maternal mortality, expanding of coverage and improving quality of primary health care through IEC, better referral services, provision of emergency obstetric care, training of lower cadre of health staff and Traditional Birth Attendants (TBAs) in life saving skills and building more health facilities in remote areas. Those in the area of infant mortality include the continuation of the national immunization campaign to eradicate major diseases of childhood (Algeria, Burkina Faso, Burundi, Congo, Eritrea, Gambia, Ghana, Lesotho, Mali, Senegal, Malawi); promotion of breast feeding (Burkina Faso, Burundi, Malawi, Mali, Morocco); adoption of the WHO/UNICEF approach for an integrated management of childhood illness (Eritrea, Gambia, Kenya, Mali, Morocco, Togo); formulation and implementation of a nutrition policy (Algeria, Burkina Faso, Cape Verde, Central African Republic, Gambia, Malawi, Senegal); free treatment for malnutrition and diarrheal diseases (Ghana); and free health care for pregnant mothers and children under the age of 6 (South Africa).


There is heightened awareness of the need to provide RH services to special groups. In this regard, there are adolescent reproductive health (ARH) projects which offer RH services including peer counselling and IEC in combination with recreation in almost all member States. In some States (e.g. Eritrea, Kenya, Uganda and Botswana) there are youth centres that target out-of-school adolescents. Women's professional NGOs have set up crisis centres and legal clinics for counselling and research (e.g. Uganda and countries of SADC) to deal with issues of gender violence particularly sexual violence including rape, defilement, wife beating and forms of dangerous traditional practices.


Recent strategies/measures taken towards appropriate treatment of infertility and/sub-fertility in most cases include the provision of RH services ; setting-up of infertility clinics; and attachment to FP clinics (Ghana) and to Universities (Algeria and Central African Republic). Health education campaigns have also been developed and/or implemented to prevent STDs or harmful traditional practices (Central African Republic, Ethiopia, Kenya, Niger, and Togo).


Strategies/measures taken to enhance the role of men in sexual and reproductive health include sensitization and awareness campaigns for involvement of males in FP services and their positive behavior change in RH issues; targeting men for RH facilities services (Botswana, Cape Verde, Central African Republic, Ethiopia, Ghana, Kenya, Lesotho, Namibia, Senegal, Uganda); and man to man motivation sessions (Algeria, Malawi, Mali); integration of men's health in the "Minimum Package of Activities" (Benin). Strategies/measures adopted to provide RH services for refugees or displaced persons include the provision of services to refugees at their respective camps, usually with the assistance of UN agencies (Algeria, Côte d'Ivoire, Guinea, Kenya, Mali, Rwanda, Senegal, Tanzania, Uganda and Zambia).


In no other area of RH are the activities of government, private sector, NGOs, community-based organisations, households and individuals as pronounced as in the prevention and management of HIV/AIDS, a momentum which was created by the Joint UN Special Programme on AIDS (UNAIDS) as early as 1986/87. Increasingly, National AIDS Control Programmes, with support from UNAIDS and others, have promoted multi-sectoral approaches to AIDS control. Government and NGOs have organised workshops and undertaken sensitisation activities to promote sexual behaviours that reduce risks for contracting STDs and HIV. There are clubs and programmes comprising youth, men and women of people living with AIDS as well as annual public rallies, walks and marches to publicise the HIV/AIDS preventive and curative interventions. In some States, laboratory and health facilities are increasingly well equipped for the prevention and treatment of STDs.


There are several examples of best practices. There is the establishment of Uganda AIDS Commission within the President's Office indicating government direct involvement and commitment as well as of safe motherhood and emergency obstetric care (again in Uganda) which has led to drastic reductions in maternal mortality rates. There is also the initiation of a community-based education and sensitisation initiative (in Uganda) that focuses on influential groups in the community and has led to a 36 per cent reduction in the number of girls and women that have undergone FGM.


The establishment of a CBD programme in Zimbabwe with about 700 people distributing non-prescriptive contraceptives nation-wide has led to an increase in the recommended stock levels of STD drugs from 68 per cent in 1993 to 88 per cent in 1995. The decision to channel procurement and distribution of all medical supplies through the Medical Stores Department (as in Tanzania) and to place responsibility for procurement and distribution of contraceptives with AIBEF (as in Côte d'Ivoire) have resulted in cheaper contraceptives than when procured through the government pharmacies.


A number of States have also decided against embracing all dimensions of RH but to take on only those activities for which they have some expertise and to encourage the private sector and NGOs to take on the other dimensions. In Tanzania, the AMREF and UMATI are given responsibility for developing most of the youth RH programmes and of the CBD approaches. As mentioned earlier, the contraceptive supply system in Côte d'Ivoire is entrusted to the AIBEF. The health sector in Lesotho has depended over the years on the facilities provided by the Christian missions.


Guidelines have been published by women's professional associations (e.g. Botswana, Uganda, Tanzania, Kenya) aimed at assisting the women to understand the laws that affect them and their families. Equally, seminars and workshops have been organized with political and community leaders to resolve conflicts between customary laws and traditional practices. Direct financial support have been provided by some member State Governments to the NGOs in addition to the substantive assistance provided in the form of premises, logistic support, tax and other duty exemptions, training and sponsorship to attend meetings and even detachment of government staff. The AIBEF of Côte d'Ivoire receives substantial funds from the government every year and recently obtained government backing for multilateral funding to expand its services. In Zambia, government subventions are usually budgeted.


In some States, the intervention areas have been zoned so that each actor of the sector is assigned a specific part of the state. All actors are then expected to abide by the policy guidelines and standards of service delivery while adapting their interventions to the local realities of their zones of intervention (e.g. in Cameroon where the programs run by the GTZ, the UNFPA, the European Union and the French Cooperation are located in specific provinces or districts within provinces; Tanzania and Lesotho have also worked along identical patterns). This practice has eliminated overlapping of interventions and occasionally the various actors hold meetings to share their experiences and to examine new strategies.


Almost all member States but particularly Botswana, Democratic Republic of Congo, Gambia and Ghana have reported sensitizing all concerned target groups about their RRs through IEC campaigns, seminars, workshops, posters, radio-drama or publications. FLE has also been introduced into school curriculum in some cases in order to ensure that men and women are aware of and can exercise their RRs (Botswana, Ghana, Gambia, Democratic Republic of Congo, Kenya, Lesotho, Morocco).




Faced with a seemingly endless series of competing crises, Ministries of Health and NGOs involved in health care are finding prioritization both politically and technically difficult. Even within RH itself, conflicting opinions are expressed on whether, for example, HIV/AIDS should be addressed at the preventive or the treatment level. Clearly, available resources do not permit "doing everything well", but more important, the technical bases and the political will to prioritize are still lacking. In spite of the fact that many of the critical RH challenges require an IEC solution, there is still a shortfall in funding and a relative shortage of personnel who are adequately trained to produce the quality and quantity of counseling, teaching, mass media, and the other materials required.


The inherent comprehensive service delivery approach to RH has caused several operational problems. The activities of these components are usually implemented as vertical programmes with separate management structures including logistics and information systems. Even in service delivery sites with only one provider, separate registers as well as reporting and acquisition forms are kept and separate sites are set within the same health facility to provide specific services of RH components. Equally, although all the approved FP methods are provided in public sector hospitals, they are not regular due to stock shortages. Safe motherhood services, especially emergency obstetric care, are offered only in very few areas on a pilot project basis. Even these are mostly limited to antenatal care, normal delivery and postnatal care due largely to inadequate number of trained health care providers, lack of equipment and non-functioning referral mechanisms.


Only donor-supported RH and RRs components (e.g. in-service training) are being addressed; the management and service delivery practices are not integrated. Despite the apparent increased knowledge, attitudes and skills on RH issues, the compartmentalization between these aspects has persisted. For instance, either different service providers are trained for different component intervention or the same provider is trained in all the components on separate occasions to learn separate logistic mechanisms and IEC practices. The content of education received by service providers as well as the regulations governing licensing and maintenance of standards have lagged considerably behind social and health developments of most States. There is also lack of knowledge about constitutional provisions and health workers depend on hear-say rather than informed behaviour; this obstructs individual freedom of choice of RH services and quality of care.


Laws concerning abortion remain quite restrictive and effectively prohibit the development of safe and effective services for women in most States. Abortion is legal only when the life or health of a girl or woman is endangered and in many States, this must be affirmed by the presence of two senior medical doctors. Abortion is permitted following rape or incest in only a few States. The exception is the Republic of South Africa where abortion on demand has been legalised. In the public sector, very few district or regional government hospitals provide abortion-related services and many health workers do not use manual vacuum aspiration equipment because it is either not available or they are not trained or they are not legally permitted to do so.


Although there is increased availability and accessibility to FP, it remains mostly female-centred and supply-side short-term oriented. Pills and injections are most often used by women and contraception is practised mostly for birth spacing. Surgical sterilisation for both males and females are inadequately utilised. The female condom is available in some States through social marketing programmes and in few commercial outlets. Social marketing programmes (in some States) also offer pills, vaginal foam tablets and injectables.


In spite of being a priority, safe motherhood and emergency obstetric services are available in very few pilot projects. Safe motherhood services, provided at PHC level are limited to ante natal care, normal delivery and postnatal care. Health centre staff including midwives are not allowed to use forceps, vacuum extractors or to administer oxytocics or intravenous fluids. Even though the key to accessibility and cost-effectiveness in safe motherhood is the referral mechanism, its non-functioning, lack of fully trained personnel and non-availability of medical equipment are the norm in most States. (The three key elements of a safe motherhood and emergency obstetric care mechanism are communication and transport from the patient's home to the required health facility; appropriately equipped service delivery sites; and competent health provider(s).) The major implementation constraint for adequate referral systems is insufficient finances.


Most member States are decentralizing their administrations including the RH sector. This has created fear among staff resulting in key project staff of either being laid off or transferred to different services. The new comers into the projects and programmes need some time and training to acquaint themselves with the reorientation process. There are problems as well with the laws and regulations that govern health care workers.


The ECA region contains about 30 per cent of the world's refugees and more than 50 per cent of the world's internally displaced people (See Roberta Cohen and Francis Deng, "Masses in Flight" in Global crisis of internal displacement (Brookings Institute, 1998), chap. 2; See also The State of World's Refugees: a humanitarian agenda (UNHCR, 1991), page 2). In a Memorandum of Understanding signed between the High Commissioner of UNHCR and the Executive Director of UNFPA in 1995, the two agencies agreed to work together in helping member States address the RH needs of both groups of people. However, the practical side of the accord has to depend on the awareness of and support by member States. More importantly, member States are to address the root causes of internal displacement and processes that create refugees. Africa hosts a large size of disabled persons as a result of diseases, accidents and more importantly, wars, and civil conflicts. Most disabled persons are destitute and depend on minimal familial or community support, if any. Their specific needs are hardly ever considered during the design of projects. They are constantly discriminated against in terms of access to social services and employment and very few NGOs have been formed to attend to their specific problems.



Recommendations for the way forward

The goal of the ICPD-PA is that the recommendations relating to reproductive health (RH) and reproductive rights (RRs) should be viewed in the broader context of the need to provide basic health services and fulfil over all socio-economic development needs of all the people. In this regard, the ICPD-PA calls on all member States of the United Nations family to make available universal access to a full range of high quality RH services through their primary health care (PHC) system. (RH implies that people are able to have a satisfying and safe sex life, are able to reproduce and have the freedom to decide if, when and how often to do so (ICPD-PA paras 7.2 and 7.3). To have this right, they must have knowledge, skilful services, requisite supplies and financial resources as well as individual empowerment to use all of these. Comprehensive RH services include FP information and services, pre and post natal medical care, prevention and management of complications of unsafe abortion including safe abortion services where they are not against the law, treatment of reproductive tract infections and sexually transmitted diseases including HIV/AIDS, active discouragement of harmful practices, and other conditions of the reproductive system including breast and other cancers, prevention and treatment of infertility, and information and counselling on human sexuality, responsible parenthood and RH. PHC refers to the kind of care that is provided at the first point of contact with the health care system; its drive has been to provide a network of basic health services that are available and accessible to everyone. The earlier PHC focus on disease is now evolving into a focus on the individual within a social, cultural context with as much emphasis on the context as on the individual.) no later than the year 2015. Equally, according to the ICPD-PA, RRs rest on the recognition of the 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 RH. It also includes their right to make decisions concerning reproduction free from discrimination, coercion and violence. Accordingly, the meeting recommended that:

  • Further advocacy campaigns aimed at governments and the private sector should be undertaken in order to obtain more resources for RH. Cost recovery was also mentioned as a partial solution. However, the limited purchasing power of the majority of the population in most countries was noted; it was recommended that service fees should not constitute an obstacle to obtaining services for the poorer population.

  • All possible modalities to extend accessibility to RH services should be employed. Depending on national circumstances, this may include deployment of mobile service units, use of community-based agents and the construction of new health units, where possible, particularly in under-served areas. Existing facilities should be improved and/or enhanced.

  • An incremental approach to developing integrated RH/FP/SH services should be adopted which implies starting with those elements most responsive to national health priorities such as the HIV/AIDS prevention in order to eventually integrate all components of RH in the primary health care system.

  • Quality reproductive health services should be made accessible, including through the private sector. This would reduce the "patient load" burden on the public sector.

  • Parliamentarians, women's groups, other professional societies and NGOs should publicize and promote reproductive rights.

  • In the integration of RH services, HIV prevention and related services such as treatment of sexually transmitted infections should be prioritized. However, each country would need to make its own decisions about the distribution of relatively scarce financial/human resources among such RH components as HIV prevention, STI treatment, FP, safe motherhood interventions, etc.

  • Priority should be given to programmes aimed at reaching children and adolescents with the information and services necessary to avoid infection. Approaches to reach the young both in and outside schools should be emphasized.

  • In addition to funding for HIV prevention, donors should continue to invest in the search for effective vaccines and cures.

  • Accessibility to counseling and safe abortion, where legal, should be improved and treatment for abortion complications provided.




Visit the Reproductive health & rights proceedings section to read the proceedings related to this thematic area or visit one of the other areas identified in the assessment of the African experience:




 Theme 2 Family, youth and adolescents

Family, youth & adolescents

 Theme 3 Gender empowerment

Gender empowerment

 Theme 4 NGO amd private sector roles

NGO & private sector roles

 Theme 5 Policy amd development strategies

Policy & development strategies

 Theme 6 Advocacy and IEC Strategies

Advocacy & IEC Strategies