Mr. Stephen Lewis, UN Envoy on HIV/AIDS in Africa, on Women, AIDS and Apathy
	UNFPA Goodwill Ambassador Mikko Kuustonen on the MDGs
	Ms. Mona Sahlin, Swedish Minister for Democracy and Gender Equality, on the ICPD goals
	"Doing the Sums on Africa" by Jeffrey Sachs
	Face to Face and the Millennium Development Goals
	MDGs: Targets and Progress Indicators
	Interactions between Reproductive Healthcare and the MDGs
	Investing in Sexual and Reproductive Healthcare

The following speech was given by Stephen Lewis, UN Envoy on HIV/AIDS in Africa, to the "Microbicides 2004" conference in London on March 30, 2004.

"There is, I will admit, a touch of amiable irrationality in racing across the ocean for a half hour speech. I want to assure you that I don't do it as a matter of course. But in this instance, it seemed to me that your kind invitation to address the Conference could not possibly be forfeited. I'm here because I think the work in which you're collectively engaged ... the discovery and availability of microbicides ... is one of the great causes of this era, and I want to be a part of it. It is in this room that morality and science will join together.

I've been in the Envoy job for nearly three years. If there is one constant throughout that time, a large part of which has been spent traversing the African continent, it is the thus- far irreversible vulnerability of women. It goes without saying that the virus has targeted women with a raging and twisted Darwinian ferocity. It goes equally without saying that gender inequality is what sustains and nurtures the virus, ultimately causing women to be infected in ever greater disproportionate numbers.

And the numbers tell a story. It was the report issued by UNAIDS on the eve of the International AIDS Conference in Barcelona in 2002, that identified the startling percentages of infected women. And it was during a panel, at the same conference, when Carol Bellamy of UNICEF used a phrase — for the first time in my hearing — that was to become a repetitive mantra: "AIDS has a woman's face".

But the problem is that the phenomenon of women's acute vulnerability did not happen overnight. It grew relentlessly over the twenty years of the pandemic. What should shock us all, what should stop us in our tracks, is how long it took to focus the world on what was happening. Why wasn't the trend identified so much earlier? Why, when it emerged in cold statistical print did not the emergency alarm bells ring out in the narrative text which accompanied the numbers? Why has it taken to 2004 — more than twenty years down the epidemiological road — to put in place a Global Coalition on Women and AIDS? Why was it only in 2003 that a UN Task Force on the plight of women in Southern Africa was appointed to do substantive work? Why have we allowed a continuing pattern of sexual carnage among young women so grave as to lose an entire generation of women and girls?

Ponder this set of figures if you will: in 2003, Botswana did a new sentinel site study to establish HIV prevalence, male and female, amongst all age groups. In urban areas, for young women and girls, ages 15 to 19, the prevalence rate was 15.4. For young men and boys of the same age, it was 1.2. For young women between 20 and 24, the rate was 29.7. For young men of that age it was 8.4. For young women between the ages of 25 and 29, the rate was 54.1 (it boggles the mind); for young men of the same age, it was 29.7.

Have I not addressed the fundamental question? The reason we have observed — and still observe without taking decisive action — this wanton attack on women is because it's women. You know it and I know it. The African countries themselves, the major external powers, the influential bilateral donors, even my beloved United Nations ... no one shouted from the rhetorical rooftops, no one called an international conference and said what in God's name is going on, even though it felt in the 1990s that all we ever had time for were international conferences? It amounts to the ultimate vindication of the feminist analysis. When the rights of women are involved, the world goes into reverse.

For more than twenty years, the numbers of infected women grew exponentially, so that now virtually half the infections in the world are amongst women, and in Africa it stands at 58, rising to 67 between the ages of 15 and 24. This is a cataclysm, plain and simple. We are depopulating parts of the continent of its women.

And while finally, after the doomsday clock has passed midnight, we're starting to be engaged and agitated, very little is changing. Please believe me: on the ground, where women live and die, very little is changing. Everything takes so excruciatingly long when we're responding to the needs and rights of women.

Between three and four years ago, I visited the well-known pre-natal health clinic in Kigali, Rwanda. I met with three women who had decided to take a course of nevirapine; they were excited and hopeful, but they asked a poignant question which haunts me to this day: they said "We'll do anything to save our babies, but what about us?" Back then, more than four years after antiretrovirals were in widespread use in the west, we simply watched the mothers die.

Well, thanks to the Columbia School of Public Health, funded by several Foundations and USAID, and working with the Elizabeth Glazer Foundation, UNICEF and governments, the strategy ofPMTCT PLUS (Prevention of Mother to Child Transmission Plus) has been carefully put into place in several countries, where the "Plus" represents treatment of the mothers and partners; indeed, of the entire family. But it's a slow process, and though Columbia will roll it out as quickly as possible, it is necessarily incremental. In principle, the majority of such women will one day fall under the rubric of public antiretroviral treatment, through Ministries of Health, when it's finally introduced in most countries. But there's no clear guarantee of when that day will dawn, or that women will get the treatment to which they're entitled. It's entirely possible that the men will be at the front of the bus.

Everything proceeds at glacial speed for women, if it proceeds at all, in the face of this global health emergency.

And that's what I want to drive home. We deplore the patterns of sexual violence against women, violence which transmits the virus, but all you have to do is read the remarkable monographs by Human Rights Watch to know that for all the earnest blather, the same malevolent patterns continue. We lament the use of rape as an instrument of war, passing the virus, one hideous assault upon another, but in Eastern Congo and Western Sudan, possibly the worst episodes of sexual cruelty and mutilation are taking place on a daily basis as anywhere in the world, and the world is raising barely a finger. We have the women victims of Rwanda, now suffering full-blown AIDS, to show the ending of that story. We talk adnauseam of amending property rights and introducing laws on inheritance rights, but I've yet to see marked progress. We speak of empowering women, and paying women for unacknowledged and uncompensated work, and ushering in a cornucopia of income generating activities ... and in tiny pockets it's happening, especially where an indigenous local women's leadership is strong enough to take hold ... but for the most part, in Churchill's phrase, it's all "Jaw, Jaw, Jaw".

For much of my adult life, I have felt that the struggle for gender equality is the toughest struggle of all, and never have I felt it more keenly than in the battle against HIV/AIDS. The women of Africa and beyond: they run the household, they grow the food, they assume virtually the entire burden of care, they look after the orphans, they do it all with an almost unimaginable stoicism, and as recompense for a life of almost supernatural hardship and devotion, they die agonizing deaths.

Undoubtedly — and I must acknowledge this — with the sudden growing awareness internationally of what the virus hath wrought, we will all make increasing efforts to rally to the side of women. It's entirely possible that we will make more progress over the next five years than we have made in the past twenty. But I cannot emphasize strongly enough that the inertia and sexism which plague our response are incredibly, almost indelibly engrained, and in this desperate race against time we will continue to lose vast numbers of women. That is not to suggest for a moment that we shouldn't make every conceivable effort to turn the tide; it is only to acknowledge the terrible reality of what we're up against.

People say to me, Stephen what about the men? We have to work with the men. Of course we do. But please recognize that it's going to take generations to change predatory male sexual behaviour, and the women of Africa don't have generations. They're dying today, now, day in and day out. Something dramatic has to happen which turns the talk of generations into mere moments in the passage of time.

And that, ladies and gentlemen, is where all of you come in. I'm not pretending that microbicides are a magic bullet. Microbicides aren't a vaccine. Nor do I dispute the powerful point made by Geeta Rao Gupta at the opening of the conference, that we can neither forget nor diminish the structural cultural changes so urgently required. But when so many interventions have failed, when the landscape for women is so bleak, the prospect of a microbicide in five to ten years is positively intoxicating.

The idea that women will have a way of re-asserting control over their own sexuality, the idea that they will be able to defend their bodily health, the idea that women will have a course of prevention to follow which results in saving their lives, the idea that women may have a microbicide which prevents infection but allows for conception, the idea that women can use microbicides without bowing to male dictates — indeed the idea that men will not even know the microbicide is in use ... these are ideas whose time has come.

For me, while microbicides are not a salvation, they come as close to salvation as anything else I've heard about. I pray that everyone at this conference understands that the women of Africa and many other parts of the world are counting on you. It is impossible to overstate how vital is the discovery of a microbicide. If we were making progress on several other fronts, microbicides would pale. But we're not making progress, or we are making progress in such painfully minute installments, that it feels as though we're moving from paralysis to immobility. The resources of the international community should flow, torrentially, into the hands of the scientists and researchers and advocates and activists assembled here who fight the good fight, because in those hands lies life.

I admit: I have a proclivity for hyperbole. It's a molecular disability, with one exception. This subject is the exception. I don't know how to convey to you what's happening out there. I move from country to country, from rural hinterland to rural hinterland, from project to project, and everywhere I go the lives of women are compromised. And it's not changing. How do you get governments and international financial institutions and bilateral development donors to understand? It's not changing. Three merciless years, and women face today exactly what they faced in yesteryear and yesteryear before that.

I travel and absorb incidents and moments that sear themselves into the mind. Some of the following anecdotes I've used before, but I cannot shake them. I meet a grandmother of 73 in Alexandra Township in Johannesburg. She lost all five of her children between 2001 and 2003. She's looking after four orphans, all of them HIV positive. Her life is in ruins. She stands for the legion of grandmothers on the continent who bury their children in a perverse reversal of the rhythm of life, and then, heroically, look after the grandchildren. How has it come to this? I travel with Graca Machel to ground zero of the pandemic in Uganda, to visit a child headed household. ... a young girl of 14, looking after two sisters of 12 and 10, and two brothers of 11 and 8. Graca and I sit on the floor of the hut; I have the two boys on my left and Gra?a has the three girls on her right. She shoos everyone out of the hut except for one translator. And then she turns to the two older girls and in a gentle voice asks: "Have you started to menstruate yet?" And shyly, oh so shyly, in whispered fragments, the little girls say yes. And then Graca asks a series of questions: Do you know what it means? Do you talk to your teacher about it? Do you talk to the other kids at school. Do you talk to the villagers? Does anyone ever give you any pads? And as I sat there listening, I realized that these girls were receiving the first act of mothering around an experience that must surely be one of the most important moments of a young girl's life. And I thought to myself: this is what's happening across the continent: the mothers and fathers are gone. The mothers especially are gone. The transfer of knowledge, love and care from one generation to the next is going. How has it come to this?

I stand outside a clinic in Lusaka, Zambia, where mothers have come for testing, and the possible use ofnevirapine during birth. The mothers approach me: "Mr. Lewis, you have drugs in your country to keep your people alive, why can't we have the drugs to keep ourselves alive". I cannot tell you how often women have asked me that question. Their sense of collective dismay and vulnerability, their panic-stricken tremors at the prospect of leaving their children as orphans is palpable. I don't know how to answer the question. How do you explain that we're dealing with one of the ugliest chasms between the developing and developed world on the face of the planet. How did it come to this? How is it that we can't seem to get the world to understand that if you want to reduce the deluge of orphans, with which deluge no country can cope, you keep the mothers alive. Treatment is one way. Microbicides are the preferred way.

Just ten days ago, with my colleague Anurita Bains, who is here at the conference, I traveled to Swaziland. On a Thursday afternoon, we trekked into the hinterland to visit a small community of women living with AIDS, looking after hordes of orphan children. They led us along a narrow footpath, for what seemed an eternity, into the surrounding brush, until we'd reached the home of a woman who lay dying. I've spent a lot of time in huts where women lie dying; I don't know why this particular encounter had such a profound effect on me, but I haven't been able to get the image out of my head. I guess I've never seen anyone quite so ill before, the face a mask of death; a young woman in her twenties — they're always in their twenties — valiantly raising her head a few inches to acknowledge the visitors. You touch her hand; utter soothing words; she's unaware. Sometimes I think I make such gestures more for my own benefit than for the person who's so desperately ill. And around her were children, watching her die. That's what children in Africa do: they don't become orphans after their parents die; they become orphans while their parents are dying; and then they watch the death itself; and then they attend the funeral.

How has it come to this?

For myself, I'm filled with rage. I can barely contain it. I know it reduces my effectiveness, but there's nothing I can do about it. The madness of what is happening, the fact that it is so completely unnecessary, the fact that we could subdue this pandemic if the world put its mind to it... all of that renders me almost incoherent with the roiling blood of anger. We must find a way to bring this nightmare to an end. Africans and the world will obviously work with every instrument at our collective command to reduce the heart-breaking decimation of individuals, families and communities. But the women, certainly the women of Africa need huge quotients of additional help, and that help lies, in significant extent, in the discovery of a microbicide.

I don't have to tell anyone here — God knows, I'm way out of my depth — about the science and the trials and the timetable and the resources. I've read the materials, and as much as a layperson can grasp such things, I have grasped them. I ask only that you see microbicides, not merely as one of the great scientific pursuits of the age, but as a significant emancipation for women whose cultural and social and economic inheritance have put them so gravely at risk.

Never in human history have so many died for so little reason. You have a chance to alter the course of that history. Can there be any task more noble?"

-END-

Click here for more information about the Microbicides Conference.

Click here for more information about the Stephen Lewis Foundation.

ECUMENICAL CHRISTMAS IN TURKU
FINLAND 2003
A Humanitarian Message by
UNFPA Goodwill Ambassador Mikko Kuustonen

Dear Friends!
In the end we are all one of a kind. Torn to pieces or radiating with joy, escaping the everyday or longing for it, made weather-beaten by poverty or numbed by abundance. In the end we are one of a kind. Seekers of peace.

Like so many of us, I am exhausted with empty words. I want to believe more in complete silence. The kind of silence where we quietly stop by the essential – without the violence of being right.

Still, I wish to share with you a touch of hope and burden. We are, after all, sharing the expensive time of our common world.

During the last fifteen years, the picture of my world has been formed of fragments of Africa, Asia, Latin America and the northern paradises.

One does not need to travel to learn that we do great injustice to one another. The combined fortune of the three richest people in the world is larger than the collective gross national product of six hundred million poorest people in the world. Even each European cow is supported daily with two euros, when at the same time over a billion people have to make do with less than an euro a day – most of these people are women. The same women, who we know will be the key of sustainable development, if they are given a chance to make choices. For us, living in the promised land of child welfare clinics, it is hard to understand that each minute a woman dies of pregnancy-related complications – today, three aeroplanes full of mothers. It is not rare in an African village that a mother says goodbye to her family when leaving to give birth.

At the same time, fourteen people are infected with HIV every minute. Of the 43 million HIV positive people in the world, 30 million live in Africa south of the Sahara, in circumstances where an extended family and community are often the only safety net.
This inheritance of joint responsibility is crucial. However, structures are having a hard time at the limits of subsistence, while millions of orphans caused by AIDS have to be provided for and the able-bodied population is falling.

Recently I met Mr. Chirwa in Malawi; he was a strong, aged man who was widely respected in his village, not only because of him being 80 years old. In a country where the mean life is half that age, Mr. Chirwa knew he had lived. He also had a good reason to fight for a better tomorrow: he had lost his seven children to AIDS, and 34 orphan grandchildren were left in his courtyard. Mr Chirwa said that he could never replace the lost parents but believed that school would bring the children a chance.

We know that things may get better. With a couple of per cent of our world’s wealth clean water, food, basic health care and education could be provided for all. There are ways to do this: the global economy must be regulated in a way that also the developing countries benefit from the cash flows of trade. This might mean, for example, lowering the export duties of poor countries and developing the fair trade. Heavy debt burdens must also be forgiven, as long as it is possible to commit to striving for sustainable development and democracy

What about development co-operation? - It must also develop towards interactive partnership. People must be helped to help themselves. To succeed in this we need mutual learning and respect. Looking into the mirror is important also as far as our children’s safety and the environment are concerned. Our own ecological footprint is intolerably deep – we wear our planet down 50-fold, on average, compared to people in the developing countries.

Finland cannot boast its development co-operation allocation. A slow change towards the better can be seen but the people would like to see a more determined effort. The message is clear, both on the streets and at the grass roots work of civic organisations.

The United Nations have set Millennium Development Goals, which offer for the governments a jointly agreed plan of action along with a schedule. For us citizens, these theses help us understand the functioning principles of development co-operation. The central content of the declaration is to halve the number of people living in extreme poverty by the year 2015. We already know that in many communities this thought will remain a dream. But we also know that the intolerable poverty of many people will become tolerable. A special challenge is given to population programs by the Millennium Development Goals; after all, there are more young people in our country these days than ever.

I will not forget the mothers of a Thai village, who started silk production with microcredit. They gathered daily and changed the future of their entire community. They were especially proud of a chalkboard put up in the middle of the village in decorative frames: the microcredit of each family was written on it, with repayments.

I see the same dignity and belief in change at the Bolivian Altiplano highlands, in a group of Indian women. Commitment and fighting for children’s future made even the loan repayment a holy ceremony.

We have a lot to learn here in the jungle of efficiency and fast time.

In the middle of wealth, our own poverty is often expressed as sickness – when there is too much of everything, nothing matters. Deprivation can be found all over the world, but our own pitfall may be that here, in the developing country of happiness, we lose the depth and meaning of our life. I feel that while watching the courtyard of an African family I find clearly the essential – from birth to death. And often exactly that what I had already buried in the congested moments of my own life.

The following speech was given by Ms.Mona Sahlin, Swedish minister for democracy and equality, at the UN General Assembly on October 14, 2004.

Let me first underline that Sweden aligns itself with the statement made
by the Netherlands on behalf of the European Union.

The conference in Cairo was a groundbreaking event, placing the individual
at the core of population policies and development. Issues that used to be
taboo are today on the international agenda, in particular sexual and
reproductive health and rights, adolescent sexuality, gender based
violence and harmful traditional practices such as female genital
mutilation.

Unfortunately, the international community is not providing the sufficient
political support and funding to achieve the ICPD goals. What we therefore
need is a reinforced commitment and increased resources. Implementation of
the Cairo agenda is indispensable for achieving the Millennium Development
Goals. The Swedish Government recently decided that we will achieve our
own goal to allocate 1 percent of our Gross National Income for Official
Development Assistance by 2006, which will mean more resources for sexual
and reproductive health and rights and hiv/aids.

Last week, the Government of Sweden together with UNFPA hosted a technical
seminar that discussed the social and economic benefits of investing in
sexual and reproductive health. This technical meeting will be followed up
by a high-level meeting in Stockholm early next year, in which leaders
from all over the world will issue a call for commitment for investments
in sexual and reproductive health and rights.

My Government fully supports the work of UNFPA. While the organization has
lost important financial support from other donors, like the United States
of America, Sweden has continued to increase its core contribution to the
fund. In 2005 we will continue to raise our support with 11 million
additional US dollars. We do this because we recognize the funds central
role in implementing the Cairo agenda. Sweden also supports the invaluable
work of IPPF and other civil society organizations. We would not have come
this far, and we will not succeed in reaching our goals, without them.

Mr. President,

In my speech today, I would like to, shortly and openly, highlight seven
areas of concern that must be given greater attention the next ten years.

Firstly, all people should be able to have a satisfying and safe sex life.
Discussions about sexuality and sexual relations are sensitive and it
means that we place the most private in the public eye. We, especially the
states, must take our responsibility to speak openly about these issues.

Secondly, young people need to have means to protect themselves from
unwanted pregnancies and sexually transmitted infections, including
HIV/AIDS. They need sex education as well as condoms and other
contraceptives. Too many actors today promote abstinence only. The reality
shows us that the promotion of abstinence does not work. For many girls
and women, this message is insufficient, in view of the too often
prevailing perception of womens subordination to men. Where rape and other
forms of sexual violence are widespread, abstention is not an alternative,
at least not for women. Abstinence-only-programs exclude necessary
information needed when the person in question at some point chooses to
have sex. These programs may therefore lead to unwanted pregnancies and
transmission of sexual transmitted infections. Furthermore, it is pivotal
that we use the knowledge and experience of young people in our work.

Thirdly, HIV/AIDS represents a huge threat to development. We know that
80% of all new infections of HIV/AIDS are spread through unsafe sex, that
is, sex without a condom. It is thus life-threatening and certainly
contrary to pro-life that for instance actors within the Vatican are
spreading false rumors that condoms are dangerous. Further, if condoms are
going to be used they also need to be widely available.

To be successful, we have to integrate the HIV/AIDS and the sexual and
reproductive health and rights agendas. Many of the poorest women do not
have access to sexual and reproductive health services; due to lack of
services and inaccessibility caused by social, cultural, gender-based,
geographic and economic barriers. The problem is particularly acute for
adolescent girls who are more susceptible to HIV and STDs and carry
greater risks in pregnancy. Many women and girls are infected, due to
sexual harassment and violence, coerced sex and outright rape. But studies
also show that married women are more likely to be infected than
unmarried. In general, more attention must be paid to the role of boys and
men and their sexuality.

Focusing on the fight against HIV/AIDS we often forget the individuals
behind. An HIV-positive woman has the right to decide if she wants to have
sex and if she wants to give birth or not - if it is safe for her
partners. To make responsible choices, she needs access to information,
education, health care and services, safe and legal abortions as well as
antiretroviral drugs. People living with HIV/AIDS far too often suffer
from discrimination. Several countries prohibit people infected with
HIV/AIDS from entering the country. Why? I cant really understand that
since we all know that HIV/AIDS is not transmitted through the air!

Fourthly, gender equality, which includes mens responsibility, is crucial
in our common struggle. Women are still being discriminated against just
because they are women. Thus, women do not have the same access as men to
the health care and educational systems nor to the labor market. Women's
empowerment is a key factor for securing women's sexual and reproductive
health and rights. We must acknowledge that states have a particular
responsibility in this regard with forceful instruments such as
legislation, law enforcement, education and budget allocations. Further,
men must take their responsibility in the fight against hideous crimes,
such as trafficking, prostitution and crimes committed in the name of
honor and other harmful traditional practices.
As long as there is an imbalance of power between women and men we do not
have fully democratic societies.

Fifthly, we must improve maternal health. The goal of decreasing maternal
mortality and morbidity is far away. We must invest more in contraceptive
services, increase the number of skilled birth attendants and emergency
obstetric care. Further, every day more than 400 women die as a result of
illegal, unsafe abortions, which constitutes 13 percent of all maternal
deaths around the world. The Swedish Government will continue to argue
that every woman should have the right to choose a legal and safe
abortion. Every woman must have the power to decide over her own body. The
Swedish Government is also currently studying under what conditions
foreign women may be entitled to an abortion in Sweden.

Mr. President,

Sixthly, once again; all people should be able to have a satisfying and
safe sex life. All people include women, lesbians, gay men, bisexuals and
transgender persons. Therefore Im very sad that womens sexual actions as
well as for example lesbians and gay mens sexual action are often punished
in different ways. This is also often sanctioned or condoned by the state.
Over 90 countries have laws that prohibit sexual relations between two
persons of the same sex and in some of these countries the death penalty
is imposed. In order to stop discrimination and violence against lesbians,
gay men, bisexuals and transgender persons Sweden has taken a number of
measures, including new legislation.

Seventhly, persons with disabilities should of course enjoy the same
sexual and reproductive health and rights as everyone else. The Vienna
Declaration for Human Rights reaffirms that all human rights and
fundamental freedoms are universal and thus unreservedly include persons
with disabilities. The ICPD encourages governments to recognize the needs
of persons with disabilities concerning reproductive health and HIV/AIDS.
The Swedish Government works actively not just to meet the needs of
persons with disabilities but also to promote and protect their rights.

Mr. President,

Sexual and reproductive health and rights must remain high on the
international agenda. These issues have to be addressed in the 10-year
review of the Beijing Platform for Action and the mid-term review of the
Millennium declaration. Population and reproductive health must therefore
also be addressed in the Secretary General's report on progress towards
the Millennium Development Goals.

Finally, it is first and foremost the states that have the responsibility
to implement the ICPD. However, civil society organizations have important
roles to play both in implementation on the ground and advocacy. We can
all learn from each other and our task will be easier if we co-operate. My
Government was a strong actor ten years ago and I can assure you that
Sweden will continue to give our full support to the ICPD.

Thank you.

Developing Africa's economy
Doing the sums on Africa
May 20th 2004
From The Economist print edition

Small amounts spent on promoting Africa's economy can save billions and make the
West more secure AFRICA'S importance for global security has risen dramatically in recent years. Africa has served as a staging-post for terrorist attacks both within the continent and in the Middle East. West Africa's development prospects have brightened with the discoveries of offshore oil and gas reserves that could supply perhaps 25% of America's hydrocarbon imports within a decade, yet the orderly and transparent development of these reserves is threatened by violence and instability. Al-Qaeda has reportedly tapped into the illicit diamond trade in west Africa and has promoted insurgencies across the Sahel (the border region between desert and savannah).

Governments in countries such as Ethiopia, Kenya, Tanzania and Uganda are co-operating closely with America to fight these threats. But poverty, hunger and disease leave the region vulnerable to security and humanitarian disasters.

In every aspect of Africa's complex plight an ounce of prevention will be worth a ton of treatment. In recent years America gave a negligible $4m a year to Ethiopia to boost agricultural productivity, but then responded with around $500m in emergency food aid in 2003 when the crops failed. In the 1990s America gave less than $50m a year for Africa to prevent AIDS, so now will spend $3 billion per year to treat the disease after it has spread to more than 50m Africans—20m dead and 30m currently infected.

America's security outlays in Africa have shot up by $100m in the new East Africa Counterterrorism Initiative, and could soon dwarf economic development assistance. America recently committed almost 2,000 troops in the Combined Joint Task Force Horn of Africa, based in Djibouti, and is providing security and intelligence training in the Sahel. But direct military efforts will not achieve long-term security when Africa's underlying crises of hunger, disease, poverty and bulging youth populations remain unaddressed. Indeed, under today's conditions, a growing American troop presence in Africa could easily provoke a backlash.

American strategic planners generally recognise the value of economic development assistance in the aftermath of wars, as in the case of $20 billion that America will spend in Iraq and the $2.3 billion committed to Afghanistan. Yet when it comes to development assistance to prevent conflict there is almost no money to be found. America's foreign policy is strikingly out of kilter, allocating $450 billion per year for the military and a meagre $15 billion (at most) for development assistance.

Strip out sums for emergencies such as food aid and anti-retroviral medicines, military assistance, debt service, as well as sums paid to American consultants rather than to African countries, and total American development assistance for Africa will be less than $1 billion this year for more than 700m Africans. What about America's new Millennium Challenge Account, budgeted this year at $1 billion, but to be scaled up to $5 billion per year by 2006? This sum is distributed throughout the developing world, and in any case will be much too small to address Africa's financing needs for roads, power, clean water, sanitation, children's health, schools, fertilisers and irrigation, and other specific investments that could unlock the continent's economic growth.

A much smarter plan for Africa would save a fortune in the future by ending Africa's trap of poverty, disease, hunger and violence and bolstering Africa against the virus of terror. America and its allies need to appreciate that there are several well-governed African countries in which investments on a meaningful scale would fuel regional economic development rather than corruption and misrule. Specific and well-targeted investments over the coming decade would provide the foundation for self-sustained growth. And donor countries need to realise that they are sitting on under-utilised systems that could deliver that aid effectively.

Find your partners

The first step is to identify plausible African partners. In Afghanistan and Iraq America has not withheld development assistance pending “good governance”. It has ploughed ahead with development spending even in the midst of extreme violence and even though the respective American-backed governments in Baghdad and Kabul barely have a writ of authority that runs beyond (or even within) their respective capitals. In Africa, the options are vastly better. At an over-arching level, the new African Union, with its development flagship, the New Partnership for African Development (NEPAD), has launched an enormously valuable process of “peer review”. So far, 16 African governments have signed up.

Strong national leadership backed by regional peer review offers a powerful combination to improve the performance of governments. In west Africa, at least two strategically positioned countries stand out for their exceptionally good governance: Ghana and Senegal. Both are multi-party democracies. Both are led by impressive and popular elected leaders, Presidents John Agyekum Kufuor and Abdoulaye Wade. Both countries have an educated cadre that can lead a bold strategy. Both have acceded to peer review. Yet both are mired in poverty because of the lack of key infrastructure and because of unabated disease, especially malaria.

Other impressively governed yet impoverished countries in the region include Mali and Benin. Nigeria too could turn the corner on governance. President Olusegun Obasanjo inherited a corrupt governance mess when he came to power in 1999, but he has worked hard and against the odds to improve the situation. His new and widely admired finance minister, Ngozi Okonjo-Iweala, has recently tabled an impressive poverty-reduction strategy backed by much more rigorous systems of public administration and accountability.

In east Africa, there are also several outstanding partners. Effective leaders in Ethiopia and Uganda have taken two seemingly hopeless countries and set them on a path of development despite desperate initial conditions. Meles Zenawi, the prime minister of Ethiopia, has the most insightful, indeed ingenious, ideas about rural development of any leader in that country's modern history. President Yoweri Museveni of Uganda has fashioned the fastest-growing economy in east Africa, and the only country in all of Africa to have turned the corner on AIDS. All of this is despite Uganda being landlocked and victimised by an insurgency in the north backed by Sudan's Islamist forces. Both Messrs Meles and Museveni have been staunch and unstinting supporters of America's anti-terrorism efforts, and both have also acceded to African peer review.

To the east and south, Kenya and Tanzania have democratic and development-minded governments, but are under extreme stress from pervasive poverty and disease. Well-governed poor countries farther south include Botswana and Mozambique, among others. The situation in Kenya is especially poignant. A bold democratic opposition united to unseat the deeply entrenched and corrupt ruling party in the 2002 elections. But just as this government came to power, Kenya was hit by an American State Department travel advisory warning of potential terrorist threats. Tourism fell off and the government was immediately on the ropes.

On anybody's list—the World Bank, Freedom House, Transparency International—a growing and significant number of African countries has the quality of leadership and governance to achieve economic development and to fight terrorism. But these countries lack the means. Consider the dire infrastructure situation in six of these well-governed countries. They lack the roads, electricity, health care and teachers needed to break out of poverty. Without this basic infrastructure, these countries cannot reliably feed themselves, much less attract investors for long-term growth.

Even Uganda, with its impressive record of economic growth in the 1990s, has experienced an upturn of poverty. Without a multi-lane highway from Kampala, the capital, to the port of Mombasa in Kenya, and without a network of roads connecting villages to such a highway, the economy is trapped in a straitjacket.

Needs to know

The first step to help these countries is a detailed “needs assessment” of the kind that the UN and World Bank carried out last summer for Iraq at America's request. The assessment in Iraq was a joint product of the World Bank, the International Monetary Fund and about a dozen specialized UN agencies. These agencies identified Iraq's infrastructure-investment needs on a sector-bysector basis. The results showed that Iraq would need around $36 billion over four years for roads, power, water and other priorities. Another $20 billion was needed for targeted spending in “softer” areas like human rights and culture. The total assessment therefore came to $56 billion over four years. America has so far pledged around $20 billion of that. In the case of Afghanistan, a similar exercise in April identified $27.5 billion in investment needs over the next seven years, and the plan was backed by pledges of $8.2 billion during the coming three years.

This kind of needs assessment has never been done for Africa. In recent years, African countries have been told by the rich world simply to “live within their means”, however meagre those means might be. The IMF and World Bank have had to deliver this painful donor message. “Belt tightening” for people who cannot afford belts became the order of the day. The professional staffs of the Bretton Woods institutions know full well that their programmes lack adequate donor financing. But since these agencies are run by the same donor governments that are withholding adequate aid, deep frustrations are rarely expressed in public.

As special adviser to the UN secretary general, Kofi Annan, I asked my colleagues in the Millennium Project to undertake a needs assessment in order to assay what a more detailed study might show. Our much smaller team undertook a process very similar to the multi-agency study for Iraq, looking sector by sector at the gaps in infrastructure, social-service provision and human resources, and the costs of filling them in relatively well-governed countries. With only a small portion of what America is now spending on military and reconstruction outlays in Afghanistan and Iraq, it would be possible to enable hundreds of millions of people to break out of poverty. The average annual financing needs for the period 2005 to 2015 are roughly as follows.

Basic infrastructure—roads, investments in soil health, water harvesting for crops, drinking water and sanitation, modern cooking fuels, electricity—would cost around $45 per person per year between now and 2015 (using an average of the per-capita costs identified for Ghana, Tanzania and Uganda). Basic health care—for control of malaria, AIDS, TB, childhood diseases, safe childbirth, nutrition and family planning—would be another $30. Upgrading primary and secondary education would add another $15 per person per year. Other high-priority items would add roughly another $10, bringing the total needed investments to around $100 per person per year.

Some of these needs are, of course, covered by domestic budgets, while a small part comes from the out-of-pocket spending of the extremely poor. In total, domestic outlays might cover as much as $40 per person per year, if these poor countries push hard (but not punitively hard) on mobilising local resources. The remaining $60 gap would require international help. These countries already receive around $10 per person per year in aid that is directed at these priorities (additional aid is directed at other purposes). The unmet need is therefore around $50 per person per year. Applying these results to six countries—Ethiopia, Ghana, Kenya, Senegal, Tanzania and Uganda—with a combined population of 180m, this amounts to only $9 billion per year in addition to current aid flows, far less than what was targeted for Iraq alone with its 24m people.

Beacons of stability

Could this money be well absorbed? The answer is a decisive “yes”. In the six countries, the governments are stable. Bridges, pipelines and power pylons are not being blown up each day. All six countries have already prepared detailed, often ingenious, plans for scaling up their investments in the key infrastructure sectors. Ghana has its Ghana Poverty Reduction Strategy (GPRS), Ethiopia its Sustainable Development and Poverty Reduction Programme, and so forth. Indeed, these plans reveal a powerful and poignant truth.

Ever since the UN Millennium Assembly in September 2000, the low-income countries were told to “scale up” their ambitions in order to meet the poverty-reduction targets summarised in the Millennium Development Goals. They were told to make plans for Education for All (EFA), to Roll Back Malaria (RBM), to treat AIDS patients on the scale of 3-by-5 (3m patients in poor countries on anti-retroviral treatment by the end of 2005, covering half of all those who would need such treatment), and so forth. The well-governed countries took these initiatives seriously, making detailed plans and submitting them to the donors. But the donors got sidetracked by the September 11th attacks. Africa's plans are on the table, but the financing is not.

Ghana's GPRS, to name just one example, brilliantly identified the sources of rural poverty. It systematically laid out the case for a five-year investment programme, identifying regional needs and timetables for filling them. It produced, in short, a first-rate analytical effort. But the donors said that it was “unrealistic”—not in terms of Ghana's needs, potential, goals, or plans, but in terms of what the donors were prepared to fund. The GPRS went through four drafts as it was beaten down to “realism” by the donors. In consequence, the plan addresses only a fraction of the country's real needs.

With strategic and well-governed countries identified, with plans of action in place, and with relatively modest financing needs, the last remaining step is to set in motion a process in which the elements are combined. Such a process is surprisingly close at hand, if America can rouse itself even briefly from its election-year and Middle East preoccupations. The key lies in a multilateral approach to helping Africa, and America is the biggest missing element for greater multilateral assistance.

The International Development Association (IDA) of the World Bank is the right focal point for revamping and expanding the aid flows. IDA provides the most successful form of development assistance in the world today, and it can be made even better. It does five important things. First, it provides the world's single largest flow of low-cost development assistance to poor countries, though not enough of it and not at low enough cost. IDA currently makes commitments of around $8 billion per year, of which 80% is low-interest long-term loans and the remainder outright grants. Second, it directs its outlays towards the priorities identified by the recipient countries.

Third, IDA harmonises donor resources. Typically, the 22 rich-country donors torment recipient governments by insisting on separate aid projects that allow each donor to “show the flag”. In the case of IDA, however, the donor governments agree, wisely, to pool their resources into a single basket that can back the specific strategy of the recipient country. Fourth, IDA commits its resources over a three-year time horizon rather than a one-year donor budget cycle typical of bilateral aid. Fifth, it aims to base its allocations on good performance, using indicators for governance and economic management.

Bigger is better

Still, IDA needs to be strengthened in four ways for it to play a breakthrough role in Africa. Most important by far, instead of $8 billion, IDA's annual programmes should be up to $25 billion, with around half of that going to Africa. Second, IDA needs to make grants rather than loans to the poorest recipients, which would include almost all of the countries in sub-Saharan Africa. The American government called for grants rather than loans to finance Iraq's recovery so as not to encumber future Iraqi generations, and the same principle applies even more emphatically for impoverished Africa. Third, IDA should work with the aid recipients on strategies that have a time horizon long enough to carry them from today to 2015 when they are supposed to meet the Millennium Development Goals. Fourth, IDA can and should focus even more on measurable, monitorable and proven interventions—roads, soil nutrients, anti-malaria bednets, to name a few—which in combination enable a country to break free of poverty.

In fact, the timing for introducing properly ambitious programmes could not be better. The next three-year round of IDA financing (IDA-14, covering fiscal years 2006-08) is currently under negotiation among donors. The African Union's peer-review mechanism is getting under way. Next year, Britain hosts the G8 Summit, and Tony Blair's government has made clear that a doubling of development assistance will be at the core of the agenda. Mr Blair's Africa Commission is due to report in spring 2005. And in September 2005, the world's leaders will gather at the UN to review progress in the five years since the Millennium Assembly. Will they still be enmeshed in bitter controversy over a highly contested war? Or will they say with confidence that well-governed developing countries will finally find a partnership with their rich counterparts to help the world escape from violence, terror, disease and extreme poverty?

Jeffrey Sachs is the director of the Earth Institute at Columbia University in New York and special adviser to UN secretary general, Kofi Annan, on the Millennium Development Goals

Women and Youth and the Millennium Development Goals

In 2000, 189 countries placed development at the heart of the global agenda by adopting the Millennium Development Goals (MDGs). The Goals set clear targets for reducing poverty, hunger, illiteracy, disease, discrimination against women and environmental degradation by 2015.

Critical to the achievement of the MDGs will be the work of environmental, population and development non-governmental organizations (NGOs) throughout the developing world. Equally important is safe and affordable access to family planning and sexual and reproductive healthcare for women and youth.

“The Millennium Development Goals …cannot be reached if questions of population and reproductive health are not squarely addressed …that means stronger efforts to promote women’s rights.” Kofi A. Annan

Today, Face to Face International is focused on helping governmental and non-governmental organizations (NGOs) build the coalitions, consensus and capacity necessary to achieve the Millennium Development Goals, including universal access to sexual and reproductive healthcare.

(Please refer to the following three acticles ...

The U.N. Millennium Development Goals and targets come from the Millennium Declaration signed by 189 countries, including 147 Heads of State, in September 2000.

The goals and targets are inter-related and should be seen as a whole. They represent a partnership between the developed countries and the developing countries determined, as the Declaration states, “to create an environment – at the national and global levels alike – which is conducive to development and the elimination of poverty.”

Targets and Progress Indicators

MDGs related links

The “Interactions” presentation (click below) represents the first stage in our look at the interactions between family planning, sexual and reproductive health care, women’s empowerment and the Millennium Development Goals (MDGs).

This analysis draws widely from our own experience and current development and population assistance sources, all of which are noted in the bibliography.

"Interactions between Family Planning, Sexual and Reproductive Healthcare, Women's Empowerment and the MDGs" is a work in progress by Joe Thomas of Face to Face. We welcome any comments or additions. Joe@facetoface.org

Interactions between Family Planning, Sexual and Reproductive Healthcare, Women's Empowerment and the MDGs

MDGs related links

“Investing in Sexual and Reproductive Healthcare” demonstrates the synergistic outcomes of investing in sexual and reproductive healthcare.

The facts and figures are taken from “Adding it up: The benefits of investing in sexual and reproductive healthcare”, prepared recently by the
Alan Guttmacher Institute

The document is a work in progress and we welcome any comments or additions. lenna@facetoface.org

Investing in Sexual and Reproductive Healthcare

MDGs related links