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前 言
20世纪70年代末，中国拉开了改革开放的大幕。那时，也许并不是每个人都能清楚地知道，这场改革对于中国这个五千年文明古国真正意味着什么。20世纪80年代，不少在中国从事扶贫、妇幼保健和计划生育工作的人士都知道：1987年，福特基金会北京办事处成立，这个办公室的开办，意味着一系列创新项目的启动和探索。几十年过去，弹指一挥间。2008年，中国改革开放30年成为一个热门话题，同时，福特基金会北京办事处在华工作20周年，回顾历史和评价变化自然地被提到人们的日程。其中，性与生殖健康是一个值得回顾的领域。
伴随着改革与开放，中国的性与生殖健康领域在30年间也发生了重大变化，它同时又是福特基金会在中国的重点工作领域之一。众所周知， 1994年，联合国人口与发展大会(ICPD)接受了世界卫生组织(WHO)提出的生殖健康定义：“人类生殖系统及其功能和运作所涉及的一切事宜上身体、精神和社会等方面的完好状态,而不仅仅指无病或不虚弱。” 20年来，福特基金会在华支持过诸多意义重大的项目，参与广泛，影响深远。尤其在中国性与生殖健康领域的项目支持，极大推动了中国性与生殖健康服务的改善，以及人民群众性与生殖健康水平的提高。
为了反映中国性与生殖健康领域的变化，福特基金会邀请了一批专家以“纪录片”的形式客观、真实地回顾30年的历史，全面总结经验和教训，深刻分析挑战与预机遇，展望未来，从而成就了本书的诞生。
本书内容涉及人口与计划生育、妇女赋权、性与生殖健康服务、青少年性与生殖健康、性与社会性别、生殖道感染/性病/艾滋病、性与生殖健康领域NGO的成长、医疗体制改革等诸多学术领域。撰稿作者来自中国性与生殖健康变化最具代表性的北京、上海、云南三地，同时它们也是福特基金会在华项目最有特色的三个地方。
本书共分为八部分：
中国的人口与计划生育工作是在生殖健康领域中努力最多、变化最大，同时也是一个颇受争议的话题。中国政府和福特基金会合作，从东部到西部开展了诸多卓有成效的项目。1994年ICPD以来，中国谨慎地引入了国际人口和计划生育领域“以人为本”的理念，开始探索改革，2000年后则不失时机地把试点地区的成功经验拓展到全国，实现了从单纯人口控制向关注生殖健康的转变。
女性占中国人口数量的一半左右，连同儿童中的女童共占了总人口的2∕3，妇女赋权是生殖健康的最本质要求之一。同时，国际上在谈到生殖健康时也必然强调社会性别。从妇女赋权的视角反思和再认识中国性与生殖健康发展的历程，探索和实践中国性与生殖健康领域的妇女赋权，根据资源-选择-成果框架，分析如何让妇女赋权从理念转化为行动，由倡导提升为实践，无疑才具有现实意义。
性与生殖健康服务是落实国际人发大会行动纲领的重要方面。系统回顾三十年来中国在计划生育、妇幼保健、艾滋病防治等领域服务发生的重大变化，深入挖掘共性，并聚焦服务开展极具特色的云南，引进国际新理念，结合自身实际进行创新、推广，形成云南经验，对全国乃至国际本领域的发展都有重要影响。
无论是国内还是国际，青少年性与生殖健康都是一个重要而核心的问题。以认知-信念-行动理论审视青少年性与生殖健康的发展轨迹，并在干预实践中探讨，有助于健康教育/促进的知－信－行理论进入一个新的层面，促进青少年健康的性与生殖发育及行为的成熟，增加青少年获得公平的、负责任的性关系的机会。
在ICPD上，艾滋病防治被列为生殖健康服务的重要内容之一。几十年来，艾滋病在中国正以迅猛的速度和超强的威力将其魔掌伸向各个角落，严重危害人类健康。生殖道感染概念的提出打破了“沉默文化”，引起医学、社会学等多学科重视，针对生殖道感染/性病/艾滋病流行所做出的回应和实践，对在中国实现生殖健康和生殖权利有重要的意义。从“沉默”到“承诺”，尽显改革开放三十年来生殖道感染/性病/艾滋病防治领域的重大变化。
与改革开放和社会结构的变迁同步，中国人的性实践、性观念和性关系经历了一场性革命，政治、社会、项目和个人所组成的情境因素带来性与社会性别多元化，权利和快乐兴起。针对中国的性与社会性别的研究及实践工作也开始起步并逐步地显性化，向生殖健康、艾滋病防治、教育等工作领域渗透。
性与生殖健康显然需要政府主导，全社会参与，其中，该领域NGO（非政府组织，Non government Organization的缩写）扮演了重要角色。从ICPD以前以官办NGO为主导到ICPD之后草根NGO的兴起，三十年来，中国性与生殖健康领域的NGO更趋活跃，数量迅速增加、领域不断扩大、作用日益增强，促进了中国性与生殖健康领域的变革。
中国的医疗卫生体制改革举世瞩目，近13亿人口的健康保障体制、公共政策的开发、健康服务受体的变革，必然对全体公民的性与生殖健康产生重要影响。中国医疗卫生体制改革历经三十年艰难的尝试和改进，虽然取得一定成效，但仍需深化发展。本书在最后章节对此进行了深入探讨。一是喻示性与生殖健康服务要满足中国十几亿人口的需要尚任重而道远，二是展望未来又充满希望。
本书邀请的作者均为各领域的知名专家，有来自国家计生委、北京大学、中国人民大学和清华大学的教授，也有来自上海市计划生育研究所、中国社会科学院和云南健康与发展研究会的研究员等。他们不仅有丰富的学术积累，而且在百忙之中以严谨的学术态度拨冗赐稿。同时，本书还聘请了一批独立审稿专家审阅中文稿，有顾宝昌、赵鹏飞、郭岩、张玫玫、罗淳、方菁、曾光、李银河、彭晓辉、刘伯红、陶传进、王小林、王丰、胡善联，其中有世界卫生组织的学者型官员、中国人民大学的教授、全国妇联妇女研究所、中国社科院和中国妇女理论研究所的研究员等。他们不仅在相关领域有长期的积累和独特的见解，更是中国性与生殖健康三十年历史的经历者和见证者，对这一领域的变化如数家珍，并高屋建瓴地提出了中肯意见，对确保本书质量做出了重要贡献，在此深表谢意。
展望全球，性与生殖健康尚属一个新领域，其在中国的发展任重而道远，故疏漏之处难免。望广大读者和同仁不吝指正，使中国的性与生殖健康这一关乎13亿人幸福的事业蓬勃发展。
PREFACE
For anyone who knows well about China, the reform and open-door policy in China thirty years back brought about dramatic social changes. They, however, may not associate it with the significant changes in sexual and reproductive health in China. The opening policy set the Chinese people free from the restrictive and oppressive mentality towards sexual and reproductive health issues. At the same time, it enabled greater involvement of a wide spectrum of stakeholders - the government, maternal-and-child health care, family planning, population study and women development – in addressing reproductive health issues through long-term collaboration with the international community. To be worth mentioning, the remarkable progress we have achieved so far should never be separated from the growing support from the Ford Foundation Beijing Office over the past two decades.
As is known to us all, governmental delegates from nearly 200 countries and representatives from more than one thousand non-governmental organizations (NGO) attended the International Congress of Population and Development (ICPD) in Cairo in 1994. They had hot debates and careful discussions surrounding key global issues related to population and development for the next twenty years. In order to address shared concerns while appreciating differences and promote greater international cooperation, the participants went through careful consideration, negotiation and modification. Finally, they formulated the Cairo Action Plan and accepted the WHO definition of Reproductive Health.
Reproductive Health, a new English term at that time, is translated into Chinese as ‘sheng zhi jian kang’ or ‘sheng yu jian kang.’ As early as in the end of the 1980s, Dr. Jose Barzelatto, the former Director of the WHO Special Programme of Research, Development and Research Training in Human Reproduction, first came out with the concept of Reproductive Health. He argued that Reproductive Health should at least include four elements – family planning, maternal health care, infant and child health care and control of STIs. The first official definition of Reproductive Health came from Dr. M.F. Fathalla, the successor of Dr. Jose Barzelatto. In WHO’s 1988 Biennial Report of Special Programme of Research, Development and Research Training in Human Reproduction, Dr. Fathalla clearly pointed out that “the state of reproductive health should be such that : 1) people have the ability to reproduce as well as to regulate their fertility; 2) women may safely experience pregnancy and child-birth; 3) pregnancy outcomes are successful in terms of maternal and infant survival and well being; 4) couples can have sexual relations free of the fear of unwanted pregnancy and of contracting disease. ” This concept of Reproductive health was later adopted by the Ford Foundation to guide its reproductive health strategic planning for the 1990s. In the 1991 report titled Global Status of Reproductive Health, Dr. Fathalla gave another definition of reproductive health – “WHO defines Reproductive Health as a state or condition in which people have the ability to reproduce, regulate their fertility and enjoy harmonious sexual relations. It implies that women can go through pregnancy and child-birth safely. It also indicates that people are able to adopt contraception without risks to their health and they are safe in having sex. Apart from that, Reproductive Health includes that infants survive and grow up healthy. ” In 1994, WHO developed an official definition of Reproductive Health which was accepted later by the ICPD - “Reproductive Health is a state of physical, mental, and social well-being in all matters relating to the reproductive system at all stages of life and not merely the absence of disease or infirmity. People are able to have a satisfying and safe sex and they have the capability to reproduce and the freedom to decide if, when, and how often to do so. Men and women are entitled to the rights to be informed and to have access to safe, effective, affordable, and acceptable methods of family planning of their choice, and the right to appropriate health-care services that enable women to safely go through pregnancy and childbirth.”
The definition of Reproductive Health indicates that reproductive health is a broader concept than the traditional sense of family planning. It also includes sexual health, the purpose of which is not merely counseling and care related to reproduction. In addition, it addresses prevention and control of STI/HIV, infertility problems, safe abortion, prevention of tumors related to reproductive system, and protection and fulfillment of reproductive rights etc. It is far more than what we traditionally perceive health should include.
The debut of the concept of Reproductive Health has marked an upgraded understanding about population, health and development. People have been paying more attention to achieving sustainable development through comprehensive human development and coordinated relations between population and economy, society resources and environment, a shift away from merely limiting population growth.
The emerging concept of reproductive health indicates that the human society has a higher-level understanding of, and gives high priority to, the issues of human rights and development. As early as in 1948, WHO defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” People developed better understanding of health – it is not only an important asset for, but also one of the important goals of, social development, and it is an integral part of quality of life and the right to health is fundamental. In that sense, the new concept of reproductive health accepted by the ICPD Cairo Action Plan would exert profound impact upon different countries in terms of provision of health services and social development.
For the past twenty years or so, Ford Foundation has been actively supporting a wide range of projects in China. They were significant enough and many of them generated far-reaching impact. For instance, sexual and reproductive health projects Ford Foundation supported in China improved, to a great extent, sexual and reproductive health services in China, and enhanced sexual and reproductive health quality of the Chinese people as a result.
In order to highlight profound changes about sexual and reproductive health in China, Ford Foundation involved a bunch of well-known scholars and senior experts into a project aimed at documenting the true and objective history of sexual and reproductive health in China. They would draw experiences and lessons, and examine challenges and opportunities, and pinpoint its most possible future. That’s why we have the book today.
The book discusses different topics, including population and family planning, women empowerment and gender equality, sexual and reproductive health services, sexual and reproductive health among young people, sexual health and rights, reproductive tract infection (RTI)/sexually transmitted infections (STIs)/HIV, the involvement of NGOs in the sphere of sexual and reproductive health, and reforms of the medical system etc.
The book consists of eight chapters as follows:
Population and Family Planning
China’s population and family planning has been always the most controversial area of reproductive health, but the one with the greatest changes. With the support of Ford Foundation, the Chinese Government and agencies initiated numerous effective pilot projects from the eastern to the western parts of China. The people oriented concept well embraced by the international community for population and reproductive health has been introduced into China since the ICPD in Cairo in 1994. The new concept provided new insights that made a difference to the ways of thinking and doing in terms of family planning work. In a timely manner, the successful experiences obtained from the program areas have been replicated all over the country since 2000, which marks a fundamental shift of focus from population control to reproductive health.
Women’s Empowerment and Gender Equality
Women’s empowerment and gender equality is the prerequisite for reproductive health. Without gender mainstreaming, our efforts on reproductive health and rights would be in vain. The development of sexual and reproductive health has been reviewed and for new understanding through the perspective of women’s empowerment with the support of lots of historical facts. Underpinned by the resources-options-results framework, the author summarizes women’s empowerment in terms of sexual and reproductive health in China, discusses how we can translate women’s empowerment from theory into action, and promote its practice through advocacy. Undoubtedly this is an important chapter due to its practicability.
Sexual and Reproductive Health Services
In order to make sure that the Cairo Action Plan on the ground, it is important to improve the quality of sexual and reproductive health services. The chapter gives a systematic overview of the China’s great changes in the fields of family planning, maternal and child health care and prevention of RTIs over the past thirty years. After taking a look at the commonalities among the changes, the author sheds spotlight on Yunnan, a province unique for its changes in reproductive health services. The chapter describes the historical process of how new concepts from overseas were introduced, accepted and made appropriate to the local Chinese contexts. It is of great value because it illustrates through plenty of evidence, the course of China’s sexual and reproductive health development.
Sexual and Reproductive Health Among Young People
Sexual and reproductive health among young people, although a bit sensitive, has been always one of the basic issues for discussion, both in China and overseas. The author examines the trajectory of the development of sexual and reproductive health among the young Chinese people using a lens of ‘perception-belief-practice’ model. Built upon the author’s valuable experiences in the inquiries into young people’s sexual and reproductive health in urban and rural settings and supported by lots of concrete facts and evidences, the chapter sums up experiences and lessons and discusses confusions and afterthoughts confronting China. Unquestionably, the ideas from this chapter will be of help in terms of providing better health education and health promotion activities to young people in the future. In addition, they can help young people to build equitable and responsible sexual relationships.
RTIs/STIs/HIV
HIV/AIDS is one of the key issues for reproductive health services to address. From the perspective of Reproductive Health, HIV/AIDS is a communicable disease that does great harms to people’s health and can be life threatening. The emerging concept of RTIs broke the ‘culture of silence’ and gave rise to a multidisciplinary approach that involves not only bio-medicine but also social sciences. The response to RTIs, STIs and HIV/AIDS contributes significantly to better reproductive health and improved accessibility to reproductive rights. The author successfully portrays the major changes from ‘silence’ to ‘commitment’ that took place in the fields of RTI, STI and HIV/AIDS over the past few decades following China’s opening and reform policy.
Sexual Health and Sexual Rights
In an era of an opening Chinese society with more social structural changes, the Chinese people have been experiencing a silent revolution with respect to their sexual practice, norms and relationship. As an experienced avant-garde sexologist, the author led the sexuality research in China and conducted lots of studies about sexuality, both theoretical and empirical. Pillared by her valuable academic experiences over the past decades, the author describes how the political, social, programmatic and individual contextual factors have shaped the diversity of gender and sexuality, and depicts how rights and sexual pleasure are given more priority. She also points out by using plenty of data, an increasing tendency of seeing, more studies and practice work in relation to gender and sexuality, and more of it into the spheres of reproductive health, HIV/AIDS prevention, education, and so on.
The Involvement of NGOs in Sexual and Reproductive Health
Obviously, to make a difference to sexual and reproductive health requires an approach of the wide community involvement led by the government. Non-Governmental Organizations (NGOs) or Non-Profit Organizations (NPOs) plays an important part in it. The author describes a change from ‘driven by NGOs founded by the government’ to ‘the involvement of more NGOs or Community-based Organizations (CBOs) after the ICPD.’ The past three decades saw a rapidly increasing number of NGOs in China, and their greater involvement in sexual and reproductive health issues. NGOs play a bigger role and address a much broader range of issues. Their active involvement facilitated the changes in sexual and reproductive health in China. Moreover, the rise of NGOs has become one of the indicators for social advances in China.
The Changes with the Medical System
China’s medical system reform has been drawing lots of public attention. Restructuring of the health security system for a base population of nearly 1.3 billion people, public policies development and medical and health institution reform will exert significant impact on Chinese people’s sexual and reproductive health. China’s medical and health institution reform, although having achieved certain desirable outcomes through thirty years of hard struggle and innovation, should go much deeper. The last chapter of the book has an in-depth discussion surrounding this topic. The author suggests that, we still have a long way to go before meeting the sexual and reproductive health needs of the all on the one hand, and should look forward, full of hope for the future on the other hand.
In order to ensure the quality of the book, Ford Foundation invited a group of high-level experts to review its draft. Of the independent review panels were scholarly officials from WHO, professors from the famous academic institutions such as Renmin University of China, Fudan University and Beijing Normal University, as well as senior research fellows from Chinese Academy of Social Sciences and Institute for Women’s Study of the National Women’s Federation They are: Gu Baochang, Zhao Pengfei, Guo Yan, Hu Shanglian, Zen Guang, Li Yinhe, Liu Bohong, Peng Xiaohui, Tao Chuanjin, Wang Xiaolin, Wang Feng, Zhang Meimei, Luo Chun and Fang Qing. The review panel all has rich experiences and insights in their respective fields. They experienced and witnessed by themselves, the historical advance of China’s sexual and reproductive health. They highly acknowledged all the changes happening in this field. Their pertinent comments made it a much better book. I would like to extend my sincere gratitude to them.
We are grateful to Ms. Eve Wen-jing Lee, Ford Foundation Program Officer as she has been involved in the planning and organizing of the book project since the beginning. Her keen suggestions as well as her rich experiences in sexual, reproductive health and rights contributed significantly and positively to the making of the book.
We would also acknowledge Ms. Shi Xuehua from Ford Foundation for her patience and coordination during the whole course of the book project. Without her support, we can barely have the book in shape so soon.
Wen Yuqun from Yunnan Institute for Health and Development, as the editor of the book, carefully reviewed and fine-tuned all the Chinese drafts. From her work we can see her extraordinary professionalism and meticulous attitude.
For a great deal of editing and compiling work in the making of the book, we should also express our heartfelt appreciation to colleagues from Yunnan Institute for Health and Development, such as Zhang Nan, Zhao Shuliang, Zhang Nanjie, Zhang Shanshan, Li Zhenghui, Gao Yingying and Chen Jinling.
Special thanks should also go to the Social Science Literature Publishing House, particularly the editors such as Mr. Tong Gengxing for their great support.
All over the world, sexual and reproductive health remains a fresh new territory with a lot to explore and research in the future. There could be some errors in this book we may not be aware of. However, we humbly expect that the book is not an end but a start point that invites more insightful comments from numerous readers and colleagues. Let’s join our efforts to improve sexual and reproductive health as a way to make a difference to the lives of myriads of Chinese people.
