Politics and Future of International Family Planning Programs: Where are we and Where Should we be? Should the Donor Community I

The International Conference on Population and Development, held in Cairo in 1994, was a watershed event that recognized that the world's most pressing challenges—poverty, ill health and environmental destruction—could be considerably eased by addressing the needs and rights of every girl and woman. In addition, the Cairo Conference confirmed each individual's right to health, education and, of course, to control her or his sexuality and reproduction.

The question Karen wants us to discuss today is fairly straightforward: should the donor community be investing more in international reproductive health and family planning programs? Before we do that we have to answer some preliminary questions: What have we achieved since Cairo and what are the opportunities for moving forward?

Undeniably, past investments have paid off: we have made substantive progress on a number of issues since 1994, including a significant reduction in global fertility rates and an improvement in access to modern contraceptive methods. We probably will all agree, however, that more investments are needed because we have fallen short of the goals agreed to in Cairo.  Much remains to be done if we are to make sexual and reproductive health care for all a reality by 2015.

Let me start by discussing the good news. In the past thirteen years many countries have begun to pay more attention to sexual and reproductive health issues. In Latin America, for instance, governments adopted new policies and worked to improve access to sexual and reproductive health services. They also started providing free contraceptives in their health facilities, a practice that was virtually non-existent and unthought-of before Cairo. As a result, overall contraceptive use increased dramatically in the 90s, with 62 percent of women aged 15 to 49 now using modern contraceptives in the region (figure 1).

Another positive piece of news is that commitment to the Cairo Program of Action has been reaffirmed in several follow-up conferences. The most recent victory took place at the 2005 World Summit. Governments from all over the world committed to “achieving universal access to reproductive health by 2015 [and to integrate] this goal in strategies to attain the internationally agreed development goals, including those contained in the Millennium Declaration, aimed at reducing maternal mortality, improving maternal health, reducing child mortality, promoting gender equality, combating HIV/AIDS and eradicating poverty.” This is a major accomplishment, one that is worth celebrating, especially if we consider the enormous amount of pressure put forth by different conservative groups, including the US government, to roll back the agreements reached at Cairo.
But so much for the good news… Now let’s talk about the downside. As you know, a number of obstacles have stopped the Cairo agenda from moving forward as effectively and quickly as we expected in 1994. I will discuss briefly three main reasons that have prevented Cairo from achieving full success: 1) a relentless conservative assault on sexual and reproductive health in the US, 2) the frailty of health systems in many countries and, last but not least, 3) the persistency of social and health inequities.

The first obstacle is increased conservatism in the US government policies vis a vis the sexual and reproductive health agenda. The Bush administration, as you all know very well, has re-established the Global Gag Rule, has defunded UNFPA and has narrowly focused its international aid program on abstinence and faithfulness. As a result, important service providers, particularly those that refuse an ideologically-based approach to health, have seen their funding sources drastically reduced. Additionally, important population subgroups, such as sexually active unmarried young people, have been receiving totally inadequate messages and little services.

The youth programs supported by the US administration convey a deleterious and unrealistic message that leaves young people unprepared for practicing safe sex when they become sexually active, and fails to take into account the fact that sexual behaviors, attitudes, and norms vary around the world. This situation is especially worrying since the US is a key player in the international development field, contributing more than half of the total donor assistance for sexual and reproductive health worldwide.

The second obstacle relates to the weakness of public health systems.  Fragile and fragmented health systems, that lack adequate financial and human resources, are unable to ensure availability and access to the key health interventions, including sexual and reproductive health services, that are needed to improve the quality of life of millions of people, especially the marginalized and voiceless. Political will is needed to inject the resources necessary to enable public health systems to function as safety nets capable of providing care to those who need it most.

Finally, the third obstacle to achieving the goals set in Cairo refers to the persistency of social and health inequalities. In general we have not done a good job in improving the sexual and reproductive health conditions of the most vulnerable sectors of society. Inequities both between and within countries continue to be appalling. In every country for which we have data, women in the highest quintile have much higher access to contraceptives when compared with the lowest quintile (figure 2). In parts of sub-Saharan Africa women have a 1 in 6 chance of dying in childbirth, while in parts of North America and Europe lifetime risk is as low as 1 in 8,700 . (These disparities are outrageous and unacceptable as they deny poor women two of their most basic human rights: the right to life and the right to health).

But other types of inequalities, such as those observed in income, housing, and education, have a strong impact on sexual and reproductive health. And it is virtually impossible to bridge the gaps in sexual and reproductive health conditions when these other gaps remain unchecked. A woman has little chance of exercising her sexual and reproductive rights if she does not have access to a decent health care system, if she hasn’t had the chance to attend school, if she is unemployed, or if she is employed but receives a starving salary. Disparities in sexual and reproductive health are not random but follow an underlying pattern of social disadvantages that need to be addressed first if we are to move forward.

Gender inequalities, of course, also play an important role in this story. Unequal power relationships between women and men, as well as differences in terms of education and poverty levels prevent millions of women worldwide from having access to adequate sexual and reproductive health care, negatively impacting their overall health status. In many parts of the world, women are put at risk of contracting HIV because social norms encourage their husbands to behave promiscuously and at the same time discourage them from insisting on condom use. Gender stereotypes and limited opportunities for girls also have an impact in teenage pregnancy rates, which are persistently high in many countries, even when fertility rates among adult women are declining.

In addition, inequality and poverty are also heavily taxing our common dreams as a society. Urban violence is widespread in the cities across the world. Environmental degradation and global warming cast a dark cloud over our common future. Both have intrinsic links with the fact that there are millions of youth living in poverty, who have no future to aspire to and who have no reason to postpone childbearing. This situation further contributes to the reinforcement of the vicious cycle of poverty.

This picture of a glass half full has a lot to do with the international funding environment. As you all know, there was a decrease of international funding for family planning.  Family planning has dropped steadily down the list of international development priorities in recent years, despite the momentum generated by Cairo. Between 1995 and 2003, donor support for family planning commodities and services experienced an 18% reduction, falling from 560 to 460 million dollars. This funding decline severely limits the ability of the 200 million women living in developing countries to exercise their human right to determine the size of their families.

To reverse this negative trend, advocates must take advantage of three major new factors that some may see as problems but that may actually be opportunities. And I mean opportunities not only for new sources of funding, but also for new ways of delivering services and for integrating sexual and reproductive health and rights into a broader development agenda, which was in many ways the spirit of Cairo. I am referring to: first, the increased attention paid to HIV/AIDS; second, the renewed attention to eliminating poverty; and third, the decentralization of the development assistance architecture.

We all know that the decrease of international funding for family planning and sexual and reproductive health services has been coupled with an increase in funding for HIV/AIDS.  This phenomenon should not be viewed as a threat but as an opportunity for moving forward. As a matter of fact, HIV/AIDS prevention and sexual and reproductive health care are complementary. Just bear in mind that the majority of new cases of HIV infection are contracted through sex, birth, or breastfeeding. Also, HIV/AIDS as well as other problems related to sexual and reproductive health are affected by a set of common causes, including gender inequality, poverty, stigma and discrimination. For these reasons, it is both logical and practical to have an integrated response that articulates the struggle against HIV/AIDS with sexual and reproductive health programs.

Second, there is an increased awareness that poverty is much more than lack of income. Sexual and reproductive health is fundamental for achieving the Millennium Development Goals and for fighting poverty.  This change of tides came to its peak last year when the United Nations Secretary General recommended the adoption of a “new target under Goal 5: to achieve universal access to reproductive health by 2015.” This is particularly important since the omission of sexual and reproductive health from the current framework for development negatively affected the Cairo agenda, both in terms of financial and political commitment.

Finally, there are also important opportunities for change at the country level. The sexual and reproductive health community, which has been so effective at the international level, now needs to focus more attention to the policies and political negotiations taking place in each country.  Bilateral and multilateral aid agencies are directing more funds through national governments, and decisions on sexual and reproductive health budgets are increasingly made by recipient governments instead of donor institutions. All this makes advocacy at the country level more important. Funding for international programs is still needed because international networks and alliances offer much needed support for local NGOs and advocates struggling to hold their national governments accountable for meeting sexual and reproductive health needs.

We have eight more years to make sure that the promises made at Cairo become a reality. Eight more years to build bridges with the HIV/AIDS movement and make sure that HIV/AIDS and sexual and reproductive health services go hand in hand. Eight more years to mobilize supporters at the national level to create the political will needed to put sexual and reproductive health higher in the public agenda in each country. Eight more years to combat poverty and inequality, while promoting sexual and reproductive health and strengthening health systems. All this requires substantial investments which can only come from the international donor community.

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