International Women's Health Coalition - The International Conference on Population and Development: What the Programme of Action Really Says

The International Conference on Population and Development: What the Programme of Action Really Says

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Summary: In 1994 in Cairo, 179 nations committed to a 20-year comprehensive plan of action that linked the reproductive health and human rights of women to the global struggle to reduce poverty and achieve sustainable development. This backgrounder summarizes the key goals, core agenda, and additional provisions of that agreement, known as the ICPD Programme of Action. Additionally, it provides background on U.S. involvement in women's health and rights worldwide (7 pages).

Background: U.S. involvement in women's health worldwide
Organized efforts to address key global health challenges of relevance to women—from childhood illnesses to basic family planning—began some 40 years ago. With encouragement from business, experts, and others, the United States played a leading role in launching international health efforts, which enjoyed broad political support in the country during the Nixon, Ford, and Carter Administrations. As a result, tremendous progress has been made in international health:

Global life expectancy has doubled
Children's health has been enhanced
Maternal mortality has been reduced
Preventable diseases have been eliminated
Women's health and rights have been lifted

Yet profound challenges remain. More than 500,000 women die each year in pregnancy or childbirth. African women are 175 times more likely to die in childbirth than women in developed countries. Women account for 57 percent of HIV/AIDS infections in sub-Saharan Africa and 55 percent in North Africa and the Middle East. Because of profound gender inequalities, HIV prevalence is 4-7 times higher among adolescent girls as compared to boys in some African countries.

These inequalities persist because of a general lack of political will and politicization of women's reproductive health. During the 1980s, the Reagan administration backtracked on women's health issues. It forced the international nongovernmental organizations it funded to subscribe to a Global Gag Rule (under which health providers were required to withhold information from patients about their medical options), withheld funds for the United Nations Population Fund (UNFPA), and curtailed overall funding on family planning.

Despite the U.S. administration's stance, the world moved ahead in the 1980s, developing new initiatives related to family planning and reproductive health care, maternal and child health, education, and other basic human needs. In particular, as understanding of women's economic and social contributions to families and communities grew, the centrality of women was increasingly recognized as key to development strategies.

In the 1990s, the Clinton administration retook a leadership role to advance global health efforts substantively and financially. Joining with citizen's organizations from around the world, the U.S. government helped forge consensus on a new approach to global health challenges at the International Conference on Population and Development (ICPD), held in Cairo, Egypt in September, 1994. Human rights and health, equality and environmental protection, economic and social justice were all recognized as a means of ensuring a better quality of life and sustainable future for people around the world. The comprehensive approach embraced at Cairo recognized that economic, social, and environmental progress are critical and interrelated elements of an overall effort to improve the quality of people's lives and achieve sustainable development.

This "rights-based" approach agreed at the ICPD holds that if people's needs for family planning and reproductive health care are met, along with other basic health and education needs, then population stabilization will be achieved naturally, not as a matter of coercion or control.

What is the ICPD Programme of Action?
The ICPD Programme of Action contains 16 chapters of consensus recommendations and commitments agreed to by 179 governments at the International Conference on Population and Development, held in Cairo in 1994. These recommendations and commitments, strengthened and updated at the ICPD five-year review (New York, 1999), range from basic principles that guide population and development efforts to concrete steps each nation should take to make such efforts successful by the year 2015.

Key goals embodied in the Programme of Action

The 1990 illiteracy rate for women and girls should be halved by 2005; and by 2010, the net primary enrolment ratio for children of both sexes should be at least 90 percent.
By 2005, 60 percent of primary health care and family planning facilities should offer the widest achievable range of safe and effective family planning methods, essential obstetric care, prevention and management of reproductive tract infections, including sexually transmitted infections (STIs), and barrier methods to prevent infection; 80 percent of facilities should offer such services by 2010, and all should do so by 2015.
At least 40 percent of all births should be assisted by skilled attendants where the maternal mortality rate is very high, and 80 percent globally, by 2005; these figures should be 50 and 85 percent by 2010; and 60 and 90 percent by 2015.
The gap between the proportion of individuals using contraceptives and the proportion expressing a desire to space or limit their families should be reduced by half by 2005, by 75 percent by 2010, and by 100 percent by 2015.
To reduce vulnerability to HIV/AIDS infection, at least 90 percent of young men and women, aged 15-24, should have access by 2005 to preventive methods-such as female and male condoms, voluntary testing, counseling, and follow-up-and at least 95 percent by 2010. HIV infection rates in persons 15-24 years of age should be reduced by 25 percent in the most affected countries by 2005 and by 25 percent globally by 2010.
By 2015 all countries should aim to achieve an infant mortality rate below 35 per 1000 live births and an under-5 mortality rate below 45 per 1000.
Countries should strive to reduce maternal mortality by 100 percent by 2015.

The goals and content of the ICPD Programme of Action are sweeping in scope. That said, the Programme's "core agenda" revolves around four constituent parts: basic family planning, expanded reproductive health, information and education on sexually transmitted infections, and data/research. This "core agenda" was reviewed exhaustively-enough to develop detailed resource estimates through the year 2015 in advance of the ICPD.

The Core Agenda

1. Family planning. As part of a comprehensive approach, the ICPD Programme of Action signaled the world's renewed commitment to launch high quality, voluntary family planning programs with the aim of making them available to all who want them as early as possible. Currently, there are an estimated 350 million couples who lack access to the full range of family planning information and services. The components of the ICPD family planning package include:

contraceptive commodities and service delivery
capacity-building for information, education and communication regarding family planning
infrastructure and upgrading of facilities
policy development and program evaluation
information management systems
basic service statistics
efforts to improve quality of care

Estimate of global resources required: $11.5 billion in 2005; $12.6 billion in 2010; $13.8 billion in 2015

2. Reproductive Health. In perhaps the most significant new development, the ICPD agreed that family planning should be placed in the context of a much broader approach to reproductive health for women and men of all ages. Quality reproductive health care goes beyond narrow family planning to encompass improving women's general health, promoting healthy pregnancies, reducing infant and maternal morbidity and mortality, and alleviating suffering and disease. The ICPD reproductive health package includes:

routine services related to safe motherhood, including prenatal care, normal and safe delivery, post-natal care, and breastfeeding
safe abortion services (where not against the law) and treatment for complications of unsafe abortion under any circumstances
information, education, and communication about reproductive health, including sexually transmitted diseases (STDs), human sexuality, responsible parenthood, and harmful practices
counseling
diagnosis and treatment for sexually transmitted diseases and other reproductive tract infections as feasible
infertility prevention and treatment where feasible
counseling and referrals for STDs, including HIV/AIDS, and for pregnancy or delivery complications

Estimate of global resources required*: $5.4 billion in 2005; $5.7 billion in 2010; $6.1 billion in 2015

*This 1994 estimate does not reflect the resources currently needed for HIV prevention services given the extent of the pandemic.

3. Sexually Transmitted Infection Education and Prevention Campaigns. While the medical aspects of STIs are addressed in the reproductive health package outlined above, the ICPD also embraced implementation of major STI prevention programs through various information, education, and communication efforts. The ICPD STI prevention program includes:

mass media and in-school education programs
promotion of voluntary abstinence and responsible sexual behavior
expanded distribution of condoms

Estimate of global resources required: $1.4 billion in 2005; $1.5 billion in 2010; $1.5 billion in 2015

4. Basic Research and Data. Only with an in-depth understanding of population and development can international agencies and national governments respond with appropriate plans and motivate political will for action. Despite great improvement in data collection and analysis, even the basic demographic indicators provided by many countries are unreliable, incomplete, or difficult to obtain. This so-called "data barrier" is an obstacle for planners in many developing countries. The ICPD Programme of Action urges nations and the international community to support training programs in statistics, demography, and population and development studies. It also identifies specific areas in need of further research:

reproductive health and the socio-cultural context for sexual and reproductive behavior
development of new family planning methods, including more methods for men, and barrier and other methods (such as microbicides) for women, to help prevent the spread of STIs, including HIV/AIDS
gender roles and relationships and belief systems to inform programs to end violence and other abuses against women, and to eradicate harmful practices such as female genital mutilation (FGM)
gender-disaggregated data to provide a more accurate picture of women's economic contributions to society, including their unpaid labor in the family and in the informal sector.

Estimate of global resources required: $200 million in 2005; $700 million in 2010 and $300 million in 2015

Additional aspects of the ICPD Programme of Action
Beyond the core package, the ICPD articulated a broader group of investments that would need to be pursued to stabilize global population and promote development. This broader package includes:

1. Education
The ICPD Programme of Action calls for universal primary education and closing the gender gap in secondary education (lack of secondary education for girls and women correlates with high fertility). Participants agreed on the wisdom of an ambitious agenda for education around the globe-not only to advance development, but also to reduce rapid population growth. The basic right to education was established in 1948 as part of the Universal Declaration of Human Rights. But education remains a distant dream for millions, especially girls. There are 121 million children out of school around the world; 65 million of them are girls, and 83 percent of those girls live in sub-Saharan Africa (UNICEF, 2003). Roughly two-thirds of the world's 862 million illiterates are women (UNESCO, 2003). Global public spending on education was $1.54 trillion in 2000, but 85 percent of that was spent in developed countries (World Bank, 2003).

Educating girls and women is closely associated with better health, lower infant mortality, lower fertility, higher economic growth, and environmental stewardship. In developing countries, each additional year of schooling is associated with a 5 to 10 percent decline in child deaths. Experts suggest that education is second only to family planning in lowering family size. And on the economic front, each 1 percent increase in female secondary schooling is estimated to result in a 0.3 percent increase in national economic growth (UNFPA, 1998 and 2000).

In other words, educated women are more likely to be a productive part of the labor force, to invest their earnings in their family, and to seek health care for themselves and their children. They are better at producing food and using resources in a sustainable manner. They are more likely to delay marriage, use family planning, raise healthy children, and live longer.

2. Primary Health Care
An estimated 900 million people in developing countries do not have access to modern health services (Family Care International Fact Sheet on Reproductive Health). The ICPD emphasized the importance of basic health needs, beyond those articulated in the core agenda. Here, too, several key components can be readily identified, priced, and pursued.

Strengthening the primary health-care delivery system involves:

making primary health care universally available
enhancing the ability of developing countries to produce generic drugs for the domestic market or otherwise ensure availability of vaccines, antibiotics, and other commodities
providing emergency obstetrics
addressing special needs in rural areas

Promoting child survival involves:

providing prenatal care and counseling
offering adequate delivery assistance
ensuring neonatal care, including breastfeeding and information on proper breastfeeding practices
providing micronutrients and tetanus toxoid
reducing the number of low birthweight babies and those with other nutritional deficiencies (such as anemia)
reducing major childhood diseases-particularly infectious and parasitic diseases
preventing malnutrition
ensuring universal access to safe water and sanitation

3. Promoting Women's Social and Legal Rights
The ICPD recognized the importance of promoting equity and equality in economic, social, and political life. It urged that special attention be given to the legal and civil rights of women of all ages-including laws related to marriage based on consent, land ownership, and inheritance.

Reducing violence against women is also part of the agenda for strengthening women's social and legal rights. Of special concern is the continued practice of FGM and sex slavery, forced prostitution, and trafficking in women and young girls. One in three women will be raped, beaten, coerced into sex, or otherwise abused in her lifetime (UNIFEM, 2003).

4. Creating Economic Opportunity for Women
Women's economic integration is a powerful impetus for economic, social, and environmental progress at the local and national level. The ICPD agreed that involving women fully in policy and decision-making processes - including all aspects of economic, political, and cultural life - is an important end in itself and is essential for achieving development. It also called for all women, as well as men, to receive the education required to meet their basic human needs - including skill development and preparation for employment.

In urban and other non-agricultural settings, women face a host of barriers, such as unequal pay for equal work, lack of access to credit, and other discriminatory practices. Traditional accounting usually understates women's economic contribution by ignoring informal-sector work and home farm labor. Especially in rural areas, women's efforts to grow and prepare family food, and to collect water and fuel for cooking and fodder for domestic animals are largely unquantified and unrewarded. If unpaid household and agricultural labor is included, women are estimated to work 30 percent more than men (UNFPA, 2000).

Women in the informal sector have benefited from the advent of microcredit programs, which provide seed loans for investing in income-generating enterprises.

5. Environment
The ICPD agreed that integrated strategies for ensuring economic and environmental progress are essential for individual, national, and global futures. Economic and environmental conditions link the world's people as never before. And in turn these conditions affect demographic trends in powerful ways. Poverty, pollution, and population are linked in effect, as in solution.

6. Men's Responsibility for their own Behavior
The ICPD agreed that efforts should be undertaken to encourage and enable men to take responsibility for their sexual and reproductive behavior and play a more active role in family planning and child-rearing. The support, cooperation, and involvement of men can help end gender discrimination and violence against women and improve reproductive health. The empowerment of women relies on joint decision-making with men in families, communities, and government. Men can advance gender equality and improve their family's welfare by:

protecting their partner's health and supporting her choices
taking care of their own reproductive health
taking a stand against gender violence
practicing responsible fatherhood
promoting women's education and participation in society

7. Provision of Family Planning in Emergency Situations
According to UN estimates, three quarters of the world's refugees and displaced persons in trouble spots around the world are women, the elderly, or children. About 25 percent of those displaced by war, famine, persecution or natural disaster are women of reproductive age; of these, one in five is likely to be pregnant. Displaced pregnant women are often at risk of malnourishment, violence and infectious diseases, and they face hazardous conditions when giving birth. Women and girls who have been forced to leave their homes in crisis situations face a heightened risk of rape and sexual violence. Estimates of the numbers of women from Bosnia and Herzegovina raped during the Bosnian conflict range from 10,000 to 60,000, for example (WHO, 2002).

The ICPD Programme of Action recognized the need to ensure reproductive rights and provide reproductive health care in emergency situations, particularly for women and adolescents. These efforts include:

family planning, including contraception
antenatal care, safe delivery, and post-natal care
management of sexual violence and rape, including emergency contraception
treatment and prevention of STDs, including HIV/AIDS
management of complications from unsafe abortion (according to WHO, post-abortion complications account for some 25-50 percent of maternal deaths in refugee situations).

Prepared by Ellen Marshall for the International Women's Health Coalition. The full text of the ICPD Programme of Action is available online through UNFPA's website. Click for more information about IWHC's role in the ICPD negotiations.

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