A Decade After Cairo
Women's Health in a Free Market Economy
Von Sarah Sexton, Sumati Nair & Preeti Kirbat / Women's Global Network for Reproductive Rights WGNRR
The 1994 UN International Conference on Population and Development in Cairo was heralded as a "quantum leap" forward and a "paradigm shift in the discourse about population and development” A decade later, however, the Cairo Programme of Action is still far from being implemented, and the reality of Women’s reproductive health and rights remains dire.
The Cairo Programme of Action, endorsed by 179 countries and intended to establish international and national population policy for the following two decades, was the first and most comprehensive international policy document to promote the concepts of reproductive rights and reproductive health. This was largely as a result of the concerted organising and lobbying of women's groups.
The Programme's recommendation - that population programmes provide reproductive health services rather than just family planning - assumes that women's fertility will not drop until children survive beyond infancy and young childhood, until men also take responsibility for contraception, and until women have the right to control their fertility and enough political power to secure that right.
One decade later, however, maternal mortality worldwide remains high. Some 600,000 women die each year, 95 per cent of them in sub-Saharan Africa and Asia, and 18 million are left disabled or chronically ill because of largely preventable complications during pregnancy or childbirth. Such figures indicate that many women do not have access to essential and emergency obstetric care from skilled health services. Meanwhile, in several sub-Saharan African countries, infant mortality rates have increased. Some 70 per cent of young child deaths can be attributed to diarrhoea, pneumonia, measles, malaria and malnutrition, the incidence of which is on the rise. An estimated 330 million people are infected each year with sexually transmitted diseases of which HIV/AIDS accounts for six million; women and children are disproportionately affected.
These negative health trends can be attributed in large part to the implementation of neo-liberal economic and health policies over the past two decades, first by means of structural adjustment programmes (SAPs) and more recently by international "free" trade agreements and national-level policies. A retrospective look at these trends suggests some lessons for the next decade of women's health organising and activism and avenues for more fruitful alliances with other social movements. It also suggests that the Programme of Action, together with the political organising that accompanied it, undermined itself by not challenging neo-liberalism sufficiently.
The Cairo Programme of Action
The United Nations’ International Conference on Population and Development (ICPD), held in Cairo, Egypt, in 1994 was the third population conference organised by the United Nations Fund for Population Activities (UNFPA). To influence the ICPD process, some women's groups sought to look for "common ground" with population organisations, governments and donor agencies. In the early 1990s, several women outlined the resulting "feminist population policy", drawing on a reproductive and human rights agenda that aimed to ensure women had safe and legal access to abortion. The policy had several features. First, it presented "population stabilisation" as a desirable ultimate goal, but one that did not warrant the use of compulsion. Second, it justified national population programmes providing access to contraception in terms of individual human rights and women's health. Third, it presented women's empowerment as a prerequisite for the enduring low fertility that population stabilisation requires.
The Programme of Action adopted at the 1994 Cairo International Conference on Population and Development reflects this background.
- The Cairo Programme put women at its centre. "Advancing gender equality and equity and the empowerment of women, and the elimination of all kinds of violence against women, and ensuring women's ability to control their own fertility, are cornerstones of population and development-related programmes."
- The Cairo Programme expressly rejected the use of incentives and targets in family planning services. "Demographic goals, while legitimately the subject of government development strategies, should not be imposed on family planning providers in the form of targets or quotas for the recruitment of clients", and family planning should not employ any form of coercion or use incentives and disincentives.
- The Cairo Programme stressed the need for comprehensive reproductive health services, not just provision of family planning methods. The purpose of population programmes is to promote reproductive health by ensuring that women have "the capability to reproduce and the freedom to decide if, when and how often to do so". Reproductive health care services should be made accessible through the primary health care system to all individuals of appropriate ages as soon as possible and no later than the year 2015. They were to be integrated and coordinated with each other and other health services rather than provided in isolation. They encompassed not only family planning but also safe and legal abortion, care during pregnancy (prenatal and postnatal care, safe delivery, nutrition, and child health), prevention and treatment of sexually transmitted diseases, basic gynaecological care (screening for breast and cervical cancer), sexuality and gender education, and referral systems for other health problems.
A useful Lobby and Advocating Tool
Although the Programme of Action is "soft law" that is not binding on governments, its rhetoric has consequences. It has proved to be a useful lobbying and advocacy tool for women's reproductive rights and health activists in countries ranging from Brazil to the Philippines, from Argentina to South Africa. They have applied its guidelines and human rights framework to evaluating existing reproductive and sexual health services in their countries more rigorously. They have used it to lobby for better quality and access, particularly in contexts where influential institutions, such as those of church or state, limit women's self-determination.
International development organisations, meanwhile, have been "reframing family planning programs as reproductive health programs, and population control programs as gender equity programs". Institutions such as USAID, UNFPA and the World Bank now use language that does not explicitly imply population control and that advocates women's reproductive health and rights and an integrated approach to health services. Supporters of women's rights working within population and aid institutions, moreover, have been able to push a reproductive rights agenda within their agencies.
Cairo Endorses Neo-Liberal Policies
Despite these significant changes, the general consensus among women's rights activists is that, a decade later, the Cairo Programme of Action is still far from being implemented. This has variously been attributed to lack of political will on the part of governments or lack of donor funding. But other forces are also at work. Health services in many countries are in decline. The underlying conditions determining women's health and their control over childbearing are deteriorating. Fundamentalisms opposing women's rights are on the rise. And neo-Malthusian thinking is as ingrained as ever in many development institutions, donor agencies and government departments. In many respects, the Programme of Action and its institutionalised concept of reproductive rights endorsed the neo-liberal forces that have such a negative impact upon the determinants of health.
What is needed instead of a population framework, Women's Global Network for Reproductive Rights (WGNRR) and DAWN among others have long contended, is a framework firmly linking reproductive and sexual health issues to both human rights and macroeconomic policies. Access to contraceptive information, safe and legal abortion, services to prevent and treat sexually transmitted diseases and reproductive cancers, prenatal care and mental health services needs to be combined with "access to housing, education, employment, property rights and legal equality in all spheres" as well as "freedom from physical abuse, harassment, genital mutilation and all forms of gender-based violence". In the run-up to the Cairo ICPD, Loes Keysers from WGNRR stressed that "reproductive health and justice ... has to do with contraceptive services, with eradication of hunger, with education, with health, with income, with clean water, etc. All of which can be achieved only in a completely overhauled system."
Backlashs and Fundamentalism
Many women's rights activists lobbying a decade ago for reproductive and sexual rights did not, however, pay sufficient attention to the structural and macroeconomic conditions for those rights. One reason was that, in the early 1990s, both feminists and the population establishment were diverting "disproportionate energy towards combating ... fundamentalist and traditionalist attacks" on women's rights.
In what can be seen as a backlash against the Cairo framework and its human rights approach, for instance, the United Nations, in consultation with the IMF, World Bank and OECD (but not "civil society"), ignored the Programme of Action's goal of reproductive health services being accessible to all women who need them by the year 2015 when it drew up its eight Millennium Development Goals in September 2001. Even sections of the women's health movement that had supported feminist population policies expressed disillusionment. As the journal, Reproductive Health Matters, commented, "Thus does 25 years of international work for women's health vanish into thin air not with a bang but a whisper."
But thinking of women's empowerment, education or employment as a means rather than an end, as the Programme of Action does, has disturbing practical consequences. The history of contraceptive development and provision illustrates the point. Because the research and design of contraceptives has long been guided by the aim of reducing population growth rather than enhancing self-determination, "the lion's share of money for contraceptive research is spent on long-acting, provider-controlled surgical, hormonal and immunological methods which promise a bio-medical approach to fertility control."
In sum, groups seeking to implement reproductive and sexual rights have to confront macroeconomic, fundamentalist and neo-Malthusian agendas that perpetuate gender, race and class inequalities and impede the vast majority from achieving those rights. In the past decade, it has become much clearer that the struggle for reproductive health and rights is nothing less than the "democratic transformation of societies to abolish gender, class, racial, and ethnic injustice".
Defence of women's reproductive and sexual rights has been most successful not just where NGOs and governments are supportive but also where popular movements are strong, as in Brazil, the Philippines, India, South Africa and Peru.
To be effective, such movements need to build networks and alliances with each other. After all, peace, health, environment, women's, indigenous, anti-racist and economic justice movements are confronting many of the same forces and interests that are ranged against them. Moreover, activists working on issues of reproductive rights, immigrant support, genetically-engineered agriculture, anti-racism and disability rights (to name a few) are all affected by neo-Malthusian ideology and practice.
Organisations such as WGNRR now collaborate not just with women's groups but also with a range of social movements striving for health and social justice. Working with the People's Health Movement, for instance, WGNRR highlights general health issues as well as the reproductive and sexual rights aspects of health. By rejecting the population framework, it seeks to avoid losing its critical edge, dulling its tools of analysis, divorcing itself from the women it is supposed to represent and placing too much faith in official rhetoric. It opts instead, together with many others, for a broader politics of social and economic transformation.
Feminist activists from different parts of the South and North have made their presence felt at international gatherings such as the World Social Forums in recent years. In doing so, they pave the way for reproductive and sexual rights to be incorporated within the larger agendas of other social movements and of society in general. Numerous encouraging initiatives at local and national levels give hope for new ways of making alliances and working for change. The vision of women's health groups, anti-racist movements, disability rights groups, grassroots activists and others can be not just of social justice but of "an alliance which can forge a new way ahead".
This is an abbrieviated version of ”Corner House Briefing 31” of the same title, published in June 2004 and written by Sumati Nair and Preeti Kirbat of WGNRR with Sarah Sexton of The Corner House, Dorset, UK. It results from a joint project between the two organisations exploring issues related to ”Women, Population Control, Public Health and Globalisation”. The full version of this briefing and other briefings in the series are available at www.thecornerhouse.org.uk