Implementing the ICPD Programme of Action: What a Difference a Decade Makes

Abstract

The Programme of Action adopted at the International Conference on Population and Development in Cairo in 1994 was conceived as a 20-year programme. Now, at its mid-point in 2004, we have reached a time for assessment and re-commitment to its goals. This paper is a reflection on some of the political and other changes that have taken place during the first ten years of the Programme of Action and their implications for its implemention in the coming decade. Many countries have gone ahead and integrated sexual and reproductive health services into primary health care, whether or not the concept has been supported at the international level, and are doing what they can to accommodate the needs of those requiring information and services. The shape of the “playing field” has changed in the past ten years and the goal posts have moved. Yet many countries are adjusting and adapting. The big question, which has yet to be answered, is whether the international community will help or hinder the efforts at country level to achieve the goal of access for all to sexual and reproductive health by 2015.

Résumé

Le Programme d'action adopté à la Conférence internationale sur la population et le développement au Caire en 1994 a été conçu sur 20 ans. En 2004, à mi chemin, il est temps d'évaluer ses objectifs et de renouveler notre engagement. Cet article réfléchit sur certains des changements politiques et autres qui ont eu lieu pendant les dix premières années du Programme d'action et à leurs conséquences pour sa mise en œuvre pendant la prochaine décennie. Beaucoup de pays ont intégré les services de santé génésique dans les soins de santé primaires, que le concept ait été ou non soutenu au niveau international, et font de leur mieux pour répondre aux besoins d'information et de services. Le « terrain de jeu » a changé ces dix dernières années et les buts se sont déplacés. Pourtant, de nombreux pays s'adaptent. La grande question, qui n'a pas encore de réponse, est de savoir si la communauté internationale aidera ou entravera les efforts nationaux pour atteindre l'objectif d'un accès de tous aux services de santé génésique d'ici à 2015.

Resumen

El Programa de Acción adoptado en la Conferencia Internacional sobre la Población y el Desarrollo, celebrada en El Cairo en 1994, fue concebido como un programa de 20 años. Ahora, en su punto medio en 2004, ha llegado la hora de evaluar y reanudar el compromiso a sus metas. Este trabajo es una reflexión sobre algunos de los cambios polı́ticos y de otra ı́ndole que han ocurrido durante los primeros diez años del Programa de Acción y sus implicaciones para su ejecución en la próxima década. Muchos paı́ses han comenzado a integrar los servicios de salud sexual y reproductiva a la atención primaria de la salud, independientemente de que el concepto haya sido apoyado a nivel internacional, y están haciendo lo que pueden por cubrir las necesidades de aquellas personas que necesitan información y servicios. Tanto el terreno como las reglas del juego han cambiado en los últimos diez años. Sin embargo, muchos paı́ses se están ajustando y adaptando. La pregunta fundamental, que aún falta por contestar, es si la comunidad internacional ayudará u obstruirá los esfuerzos de cada paı́s para lograr el objetivo de acceso para todos a la salud sexual y reproductiva para el año 2015.

Key Words:

• International Conference on Population and Development
• sexual and reproductive health
• reproductive rights
• Millennium Development Goals
• HIV/AIDS
• primary health care

The ICPD Programme of Action in 1994¹ was indeed a watershed. Gone was the concept of “just” family planning. Instead “reproductive health” was introduced as “a state of complete physical, mental and social well-being and not merely the absence of disease”. In addition, reproductive health now implied that “people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so”. The Programme of Action states specifically that its definition of reproductive health includes sexual health, the purpose of which “is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases”.² In addition to family planning counselling, information, education and services, the Programme of Action states that, within the context of primary health care, reproductive health should include:

“… education and services for prenatal care, safe delivery and post-natal care, especially breast-feeding and infant and women's health care; prevention and appropriate treatment of infertility; abortion as specified in paragraph 8.25, including prevention of abortion and the management of the consequences of abortion; treatment of reproductive tract infections; sexually transmitted diseases and other reproductive health conditions; and information, education and counselling as appropriate, on human sexuality, reproductive health and responsible parenthood.” ³

The Conference defined reproductive rights as the right of all couples and individuals “to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health”. It also recognised “their right to make decisions concerning reproduction free from discrimination, coercion and violence, as expressed in human rights documents”.⁴

Several paragraphs of the draft Programme of Action were challenged in Cairo in 1994, not least of which was paragraph 8.25 on unsafe induced abortion. While the final wording of this paragraph was considered by many, including some feminist groups, as not going far enough, it was indeed an achievement insofar as it reached a level of consensus that the majority of the countries could accept. Furthermore the ICPD Programme of Action framed abortion as a public health issue, rather than a moral, cultural or political one, which meant that countries were able to work on the medical treatment of abortion complications, something which most of them could agree to.

The last of the controversial paragraphs to have been resolved in Cairo dealt with adolescents.⁵ While it too was felt by many as not having gone far enough, it did begin the discussion on the rights of adolescents to information—as opposed to the rights and responsibilities of parents to withhold it—and this was reinforced the following year in the Platform for Action of the Fourth World Conference on Women in Beijing.⁶

Putting sexual and reproductive health in the “health context”

The ICPD Programme of Action introduced new concepts and included some highly controversial issues, one of which was the placing of reproductive health which, except for aspects such as treatment of obstetric and gynaecological morbidity, sexually transmitted infections (STIs) and reproductive cancers, is more concerned with preventive rather than curative health, within the context of public health, a perspective that was by no means fully accepted in Cairo. Even so, reproductive health was placed firmly within primary health care, and since Cairo, governments have not experienced serious difficulty in integrating reproductive health into their primary health care services in practice. Before Cairo this had been the subject of intense disagreement between the supporters of primary health care, on the one hand, and those who promoted separate family planning services on the other.

It is interesting to note that the objectives set out in the section on primary health care and the health care sector of the Programme of Action's chapter on health, mortality and morbidity do not mention reproductive health specifically, although in the section on actions to be taken, governments are urged “to make basic health care services more sustainable financially by integrating reproductive health, including maternal and child health and family planning services, and by making use of community-based services, social marketing and cost recovery schemes, with a view to increasing the range and quality of services available”.⁷

Whilst the ICPD Programme of Action dealt with the need for reform of the health sector, it did not mention the integration of reproductive health care in this context, nor did the Key Actions of the ICPD+5 Review, adopted by the General Assembly in 1999,⁸ although it did emphasise that “the reduction of maternal mortality and morbidity should be prominent and used as an indicator for the success of such reforms”.⁹ A possible reason for this omission may have been the limited involvement of health ministers in either meeting, as opposed to that of population and family planning experts and advocates.

In retrospect, this was unfortunate insofar as the need to place sexual and reproductive health firmly within reforms of the health sector was not reinforced. Indeed, it has not been until the last few years that governments, NGOs and others have realised the serious implications of this omission, e.g. that sexual and reproductive health have often not been adequately addressed in the development of sector wide approaches (SWAps). This is particularly unfortunate as many developing countries rely heavily on donor funding for providing their reproductive health services. Similarly, the recent Poverty Reduction Strategy Papers (PRSPs) frequently do not cover sexual and reproductive health care, while Poverty Reduction Credits (PRCs), which have been introduced even more recently by the World Bank, may not include prioritisation on health at all, let alone sexual and reproductive health.

HIV/AIDS, sexual and reproductive health

The ICPD Programme of Action addresses the prevention of HIV/AIDS mainly within the context of STIs, although it also recognises the importance of a multi-sectoral approach in working to control the epidemic. It points out that worldwide incidence of STIs has worsened considerably with the emergence of HIV and refers to the vulnerability of women arising from their poor social and economic status and issues around stigma and discrimination. In its recommendations, the Programme of Action includes the need for information, education and communication (IEC) to raise awareness and promote behaviour change and responsible sexual behaviour; adequate training for health care providers in the control and treatment of STIs and prevention of HIV infection; and the wider availability of condoms. Governments and the international community are also called on by the Programme of Action to take measures to reduce the spread and rate of transmission of the disease. In retrospect, this part of the Programme of Action probably reflects the lack of urgency about HIV/AIDS that existed at the time among those working in sexual and reproductive health.

By the time of ICPD+5, however, the threat presented by AIDS to so many countries had a significant impact on the UN General Assembly in deliberating on key future actions. Indeed, its recommendations included the importance of commitment at the highest political level; of scaling-up education, research and treatment projects aimed at preventing mother-to-child transmission of HIV; and of the need for the development of vaccines and microbicides. The Key Actions also set specific targets for reducing infections in young people aged 15 to 24. What was lacking, particularly in the ICPD Programme of Action, but to a lesser extent in the Key Actions, was the realisation that attention to HIV/AIDS was beginning to overwhelm health services in sub-Saharan Africa because of the devastating rates of transmission and lack of treatment for AIDS-related diseases.

In reality, however, it was not until the adoption of the Declaration of Commitment on HIV/AIDS by the United Nations General Assembly Special Session on HIV/AIDS in 2001 that the momentum really built up to tackle HIV/AIDS as a “global crisis”.¹⁰ While recognising the need to act as a matter of urgency, the UNGASS Declaration did not emphasise the importance of sexual and reproductive health and health care in resolving the HIV pandemic.

Millennium Development Goals

The advent of the new century brought with it the Millennium Development Goals (MDGs).¹¹ In relation to health, while goals were included for maternal health and HIV/AIDS, malaria and other diseases, the proposed overarching goal of reproductive health was dropped. With the implementation of the MDGs as the current benchmark for achieving progress globally in relation to development, the international “goal posts” were effectively moved.

Despite the exclusion of sexual and reproductive health as a specific goal, it has become increasingly clear that most of the goals that were adopted will not be reached by 2015 without the implementation of the ICPD Programme of Action. For example, the implementation of the ICPD goal that “All countries should strive to make accessible through the primary health care system, reproductive health to all individuals of appropriate ages as soon as possible and no later than the year 2015”¹² is intertwined with the MDG achievement of maternal health.

Adolescents

The Programme of Action refers to adolescents by calling for their sexual and reproductive health needs to be met, such as the avoidance of unwanted pregnancies, unsafe abortion and STIs, including HIV.¹³ By 1999 governments and other decision-makers had recognised the importance of taking on board and focusing on this age group, who in most developing countries comprise a substantial proportion of the population. While progress has been made in the past ten years, significant obstacles have been raised by the more conservative elements of society in several countries, blocking access to information and services.

When policies are developed, moreover, adolescents are often perceived as a homogeneous group, despite the fact that the needs of 13-year-olds are different from those of 19-year-olds, and the needs of street children different from those of secondary school pupils. The only real difference that is taken into account seems to be whether they are in or out of school. Of equal concern, if the sexual and reproductive health and other needs of young people are to be taken seriously, is the fact that in some countries the Minister for Youth is also the Minister for Sport, or perhaps Culture. Surely, the health, education, employment and other aspects of adolescent development warrant a Ministry dedicated more specifically to adolescents, or inclusion within the office of the head of government.

Gender equality

The Programme of Action also included a chapter on gender equality, equity and the empowerment of women, which is significant insofar as it was adopted the year before the Fourth World Conference on Women in Beijing.¹⁴ Both the Cairo Programme of Action and the Key Actions recognise that gender-based violence must be addressed, as well as the empowerment of women and the introduction of a gender perspective into policy and programme development. But progress in all areas in terms of gender mainstreaming has, at best, been slow and much remains to be done. Indeed, it is likely that the figures on violence against women around the world are seriously under-reported.

And reproductive rights

The concept of reproductive rights was addressed in the ICPD Programme of Action. Indeed, in the year before ICPD, the Vienna Declaration and Programme of Action adopted by the International Conference on Human Rights¹⁵ had referred only to the right of access to family planning. During the decade since ICPD, however, a great deal of work has been carried out in developing the right to “the highest attainable standard of physical and mental health”, which has become known as the “right to health”. This has had an important impact on the work of the three most relevant treaty monitoring committees, namely the Committees on Economic, Social and Cultural Rights; Discrimination against Women (CEDAW); and the Rights of the Child. They have all issued general comments or recommendations on the right to health, including sexual and reproductive health.

Furthermore, a Rapporteur on the Right to Health has been appointed by the UN Commission on Human Rights, who is concerned with the right to sexual and reproductive health, as part of his remit.¹⁶ The Commission on Human Rights itself passed a resolution on the right to health in 2003, which refers to sexual and reproductive health.¹⁷ While opposition to reproductive rights still continues from conservative and religious elements, and particularly regarding the right to sexual health, it is very clear that reproductive rights are now part of a much broader concept of the right to health, as a result of their inclusion in the ICPD Programme of Action.

Looking ahead: 2005 to 2015

As we stand poised to begin the second decade of implementation of the ICPD Programme of Action, a number of influences have to be taken into account by those in charge of national strategies, plans and programmes. First and foremost, the implementation of the Programme of Action has to be seen within the context of the MDGs. This means that some recommendations must fall within the goal relating to improvement of maternal health, e.g. the reduction of maternal mortality and morbidity and ensuring the availability of and access to essential obstetric services, including antenatal and post-partum care. Others must fall within the goal relating to HIV/AIDS, malaria and other diseases, such as the prevention and treatment of sexually transmitted infections.

Less thought has been given to what can be done to ensure that other aspects of sexual and reproductive health, particularly access to contraception, are adequately addressed. Upon reflection, however, it seems clear that access to contraception easily fits under both the maternal health and HIV-related MDGs. Meanwhile the decision by the Millennium Project to appoint a Policy Adviser for Sexual and Reproductive Health is a positive indication that the implementation of the ICPD Programme of Action is officially recognised as essential to the achievement of the MDGs.

The magnitude of the HIV/AIDS epidemic poses a threat not only to the development of the affected countries but also to the survival of sexual and reproductive health programmes. At the same time, the importance of sexual and reproductive health in resolving the HIV epidemic must be recognised and appropriate measures taken. Since the development of the Global Fund for AIDS, Tuberculosis and Malaria, however, donors have increasingly seen HIV/AIDS as their main target for funding. While increasing funding is essential to fighting the impact of the pandemic on developing countries, it must not be allowed to have an adverse effect on funding of other health and development priorities, including sexual and reproductive health services. Ever since 1994, however, donor countries, in particular, have fallen far short of the commitments they made in Cairo to fund implementation of the ICPD Programme of Action. It must also be borne in mind that although the agendas of ICPD and HIV/AIDS overlap in places, each of them is also distinct and requires adequate resources.

It is critically important that funding is increased if couples and individuals are to be able to decide on the number and spacing of their children and to have the means to do so, if adolescents are to have access to the services they need, and if women are to be permitted to live instead of die if they seek abortion to terminate an unwanted pregnancy.

Countries such as Mexico, Ghana, South Africa and Thailand, to name only a few examples, have shown considerable success in integrating sexual and reproductive health care into primary health care. In doing so, they have shown that sexual and reproductive health must be seen within the context of health in general and not as a separate component. Sexual and reproductive health must be considered in this way so as to ensure that it continues to be regarded as part of “mainstream” health services. This will ensure that as the financial structure of health care develops, whether through SWAps, PRSPs, PRCs, direct budget funding or whatever other means, sexual and reproductive health services will be fully included from the outset. It is, of course, important that within the budget framework sexual and reproductive health should have its own budget line, wherever one does not already exist, so that it is a visible component of the general health services budget. Ultimately this will mean that the costs of implementing the sexual and reproductive health aspects of the Programme of Action at the primary, district and national levels will indeed be fully integrated.

With the rise in influence of health economists in the World Bank and World Health Organization in the past decade, health care has been in danger of being planned primarily within an economic framework, with economic arguments to justify or restrict particular aspects of health service expenditure. The limitations of this perspective, to the exclusion of others, are finally being acknowledged.

It is hard to ignore the impact of the United States government under George W Bush on sexual and reproductive health since 2001. Virtually his first act as President was to re-impose the Mexico City policy, commonly known as the “Gag Rule”, whereby foreign NGOs and other organisations cannot access USAID funding if they are involved in providing abortion information or services. This was tied in with the withdrawal of US funding for UNFPA and the International Planned Parenthood Federation. US efforts to undermine the ICPD consensus in international forums have met with active resistance and rejection on the part of many other countries, showing that even if Bush is re-elected he cannot dictate the international health agenda on his own. For example, the US Government was alone in opposing the ICPD Programme of Action at the preparatory conferences for ICPD+10 of the Economic and Social Commission for Asia and the Pacific in December 2002 and of the Economic Commission for Latin America and the Caribbean in March 2004. The US was also unable to derail the passage of the reproductive health strategy at the WHO Executive Board meeting in January 2004.¹⁸ Instead, the strategy was endorsed by more countries than almost any other resolution put to the Board in some years. The governments that support the implementation of the ICPD Programme of Action are ready to resist any further US attacks at the remaining regional preparatory meetings for ICPD+10 and at the World Health Assembly in May 2004, when the reproductive health strategy will again be put forward.

The new Director-General of WHO, Dr Lee, seeks to encourage countries to return to a primary health care approach, which is highly relevant for the Programme of Action, in that sexual and reproductive health care are central components of primary care. At the same time, the new WHO “3 by 5 initiative”, which seeks to ensure that three million people with AIDS have access to antiretroviral drugs by the year 2005, is placing emphasis on treatment rather than prevention. Unless a well thought-out balance between prevention and treatment is maintained, however, the fallout from this provocative campaign could have a detrimental effect on prevention strategies in many aspects of health care provision, including HIV prevention. The virtual disappearance of condom promotion in recent UNAIDS literature and campaigns, and the continuing failure of UNAIDS to actively promote—as central to HIV prevention–improvements in antenatal and delivery care, family planning and safe abortions, attention to the AIDS-related causes of maternal mortality and morbidity, and more recently even treatment of STIs, are all cogent examples.

It remains to be seen how the widening gap between middle-income countries and those that have been left behind by economic growth, many in Africa, will affect international development policies and programmes. However, some countries are funding an increasing proportion of their own sexual and reproductive health services. Access to antiretroviral drugs against AIDS is on the rise across the globe. Some countries have developed the capacity to manufacture a wide range of generic drugs for their own use and for export, and are training others to do so in south-to-south initiatives. Many countries are reaffirming the rights of their citizens and working to create more democratic and responsive institutions, prompted by increasingly aware and educated populations. International movements on environmental protection and against social exclusion, calls to cancel the international debt burden on impoverished countries and bring greater equity into world trade agreements—each of these represents a growth in grassroots awareness in a global community.

There is no question that the ICPD Programme of Action and the Key Actions are far-sighted, authoritative and valuable documents that should continue to be used to guide sexual and reproductive health and rights strategies and programmes in the coming decade. At the same time, all those who are engaged in this work must situate and re-situate themselves in the developing social, cultural and political climate. A programme that is bound to take 20, 30, even 50 years to accomplish requires long-term vision and planning to achieve its goals in a rapidly changing world.

Countries have begun to develop the capacity to move forward in the implementation of the ICPD Programme of Action. Many have gone ahead and integrated sexual and reproductive health services into primary health care, whether or not the concept has been supported at the international level, and are doing what they can to accommodate the needs of those requiring information and services. Yes, the shape of the “playing field” has changed in the past ten years and the goal posts have moved. Yet many countries are adjusting and adapting. The big question, which has yet to be answered, is whether the international community will help or hinder the efforts at country level to achieve the goal of access for all to sexual and reproductive health by 2015.

Acknowledgements

Thanks to Marge Berer, RHM editor, and John Havard, chairperson, Commonwealth Medical Trust, for help in formulating some of these thoughts.