Lori S. Ashford
President, Clarity Global Health LLC
(September 2004) The early 1990s marked a dramatic departure from conventional ideas about how governments should try to influence the size and well-being of the societies they govern, and brought an unparalleled consensus among national governments about population policy. This new perspective shifted the emphasis of population policies away from slowing population growth to improving the lives of individuals, particularly women. The policies spawned by this consensus continue to evolve.
A turning point in international discussions on population was the 1994 International Conference on Population and Development (ICPD), held in Cairo. Whereas earlier world conferences on population had focused on controlling population growth in developing countries, mainly through family planning, the Cairo conference enlarged the scope of policy discussions.
Governments now agreed that population policies should address social development beyond family planning, especially the advancement of women, and that family planning should be provided as part of a broader package of reproductive health care. Underlying this new emphasis was a belief that enhancing individual health and rights would ultimately lower fertility and slow population growth.
The Cairo conference was also far larger and more inclusive than earlier world population conferences. It brought together 11,000 representatives from governments, nongovernmental organizations (NGOs), international agencies, and citizen activists. The diversity of views contributed to the unprecedented international consensus achieved in 1994.
By placing the causes and effects of rapid population growth in the context of human development and social progress, governments and individuals of all political, religious, and cultural backgrounds could support the recommendations. Although there were ideological and religious differences over issues such as definitions of reproductive health, adolescent sexuality, and abortion, all but a few nations fully endorsed the final program.
Cairo’s Programme of Action (PoA) is ambitious: It contains more than 200 recommendations within five 20-year goals in the areas of health, development, and social welfare (see Box 1 below). A central feature of the PoA is the recommendation to provide comprehensive reproductive health care, which includes family planning; safe pregnancy and delivery services; abortion where legal; prevention and treatment of sexually transmitted infections (including HIV/AIDS); information and counseling on sexuality; and elimination of harmful practices against women (such as genital cutting and forced marriage).
The Cairo PoA also defined reproductive health for the first time in an international policy document. The definition states that “reproductive health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system.”
The PoA also says that reproductive health care should enhance individual rights, including the “right to decide freely and responsibly” the number and spacing of one’s children, and the right to a “satisfying and safe sex life.” This definition goes beyond traditional notions of health care as preventing illness and death, and it promotes a more holistic vision of a healthy individual.
Many countries have attempted to implement the recommendations of the Cairo conference, although progress has been uneven. In many low-income countries, addressing such a wide range of health and social concerns requires greater resources and organizational capacity than are currently available.
Also, funding from donor agencies to support these changes has fallen below expectations. Under the Cairo guidelines, the donor/ developing country breakdown would have translated to $5.7 billion and $11.3 billion, respectively, in 2000. In fact, the UN estimates that donor funding levels in 2000 were less than half the required amount.
And the shortfalls in spending apply only to the estimated costs included in the Cairo PoA for providing family planning and basic elements of safe motherhood and for preventing sexually transmitted infections. The estimates did not include the cost of meeting additional goals supported in principle in the Cairo document, including improving overall health care systems; providing emergency care for childbirth complications; closing the gap between girls’ and boys’ education; eliminating harmful practices against women; improving women’s job opportunities; or the costs associated with the treatment of STIs, including HIV/AIDS.
Sharp ideological differences divided participants at the Cairo conference and continue to be divisive today. Women’s health advocates lobbied hard for incorporating the concepts of reproductive health and rights in the conference document, and have called on governments to reaffirm these rights in international meetings since Cairo. Though most governments are supportive, the Vatican, some Catholic countries, and the United States under the Bush administration (in a departure from the previous administration) have taken issue with how these rights are defined.
A central sticking point is whether abortion can be interpreted as a component of reproductive health and as a universal right. The Cairo conference forged a consensus with carefully crafted language stating that “in no case should abortion be promoted as a method of family planning,” and that “in circumstances in which abortion is not against the law, such abortion should be safe.” This consensus, however, has not held firm over time.
Debates also continue about the importance of controlling population growth and whether the entire Cairo agenda is feasible. Because large numbers of young people are in or approaching their childbearing ages, world population will continue to grow well into the 21st century. Recent survey data from Bangladesh and Egypt show that average family size hardly declined at all in these countries in the second half of the 1990s.
These findings were surprising given that the drop from 5 or 6 children to 3.5 children on average occurred fairly rapidly between the 1970s and 1990s. It is possible that the two-child average is still a long way off, or will never be reached, in some societies.
And while advancing women’s health and rights may well contribute to the transition to smaller families, the goal may also require long-term efforts in the poorest societies. After all, women in the poorest societies suffer the greatest health problems and have the most limited opportunities.
World Population Projections, 2000–2050
*TFR (total fertility rate) is the average number of children a woman would have under prevailing age-specific birth rates.
Source: UN Population Division, World Population Prospects: The 2002 Revision (2003).
These efforts are of no small consequence for world population: Population projections show that a small difference in average family size worldwide, such as an average of 2.5 children versus 2.0 children, translates into a difference of 1.7 billion people in the world’s population total in 2050 (see Figure 1).
A number of other factors influence current discussions on population. The HIV/AIDS epidemic dwarfs other health and development concerns in some countries in Africa and requires major government comments and infusions of funds to save lives and salvage communities. In Asia and other regions where birth rates have fallen, governments face the problem of aging populations and a critical lack of social and economic support for the elderly.
In spite of continuing debates and other obstacles, a large number of countries have redefined policy and program objectives and adopted approaches that aim to meet individual needs rather than national demographic goals. Language about sexuality and reproductive health that was considered new and groundbreaking in 1994 is now part of the health lexicon in most countries.
The world’s two most populous countries, India and China, also embarked on new initiatives in the second half of the 1990s that reoriented their national family planning programs toward meeting reproductive health needs.
Given the enormous challenges faced in less developed countries and the limited resources devoted to population and reproductive health activities, even small progress toward the international community’s goals is noteworthy. In fact, the five-year review of the ICPD documented a great deal of commitment and progress, perhaps in part because of the widespread appeal of the concepts in the Cairo agreement and the activism of NGOs.
The review process reinforced two important principles: that women’s health and rights are central to population and development policies; and that nongovernmental actors play a critical role in local, national, and international deliberations on population issues. Some examples of this progress include:
Two common initiatives have been the integration of health services (to meet a broader array of health needs in a single health visit); and improvements in service quality, particularly efforts to improve health care providers’ technical and counseling skills.
In the 21st century, continued population growth presents many of the same challenges to development as the rapid growth of the last century. But governments’ responses to growth (in particular, their public stances) are dramatically different from a decade ago: Policies aimed at population control are no longer acceptable in most countries.
An important lesson from the Cairo process is that national population goals cannot be pursued without some form of public scrutiny, either at home or abroad. If individuals’ perspectives and needs are disregarded, policies will likely meet with evasion or open resistance. Now that NGOs and citizen activists have taken on a prominent monitoring role in international agreements, they are likely to continue to pressure governments to respect individual rights.
Given (a) the growing body of evidence showing the links between women’s status and population and development trends, and (b) the growing influence of women’s groups, it is hard to imagine that women’s health and rights issues will disappear from population policy debates. Issues related to sexuality and childbearing are value-laden and complex, ensuring that policy debates will continue.
This primer is adapted from two Population Bulletins by Lori S. Ashford, “New Population Policies: Advancing Women’s Health and Rights” (March 2001), and “New Perspectives on Population: Lessons from Cairo” (March 1995). Both reports are on PRB’s website.
Lori S. Ashford is technical director for policy information at PRB.