SPECIAL REPORT:
Implementing the ICPD
Programme of Action

Since the Cairo and Beijing conferences, countries have undertaken a broad range of actions to implement the ICPD approach. Reports from UNFPA field offices cite numerous revisions of population and development policies and related institutional changes; legal and constitution reforms to better protect women’s rights and promote gender equality; and efforts to strengthen and reorganize health services to reduce maternal mortality and address a comprehensive set of reproductive health concerns.

While many developing countries have made important progress in implementing the ICPD Programme of Action, in many others a shortage of funds and trained personnel is impeding efforts to improve family planning and reproductive health programmes.



Population Policies

Many countries where national population policies were in place before the Cairo conference have modified them to embrace the ICPD approach; this group includes countries as diverse as Indonesia, Jamaica, Kenya, Lesotho, the Marshall Islands, St. Lucia and Zambia.

A number of governments that had no formal population policy in 1994 have since formulated comprehensive policies reflecting the Cairo agreements, or are in the process of doing so; they include Botswana, Cambodia, Lao People’s Democratic Republic, Malaysia, Mongolia, Nicaragua, Namibia, South Africa, Syria, Uganda and Zimbabwe.

Brazil has established a National Commission on Population and Development, the first in Latin America. Population commissions or units have also been created within key ministries in Algeria, Belize, Paraguay and Tajikistan, among others. Ghana has revitalized its Population Council. Jordan has expanded its National Population Commission to include representatives from non-governmental organizations and academic institutions.

In some countries reproductive health and family planning issues that were once considered too sensitive to discuss publicly are now part of the political discourse. During the 1996 election campaign in the Dominican Republic, for example, the two major political parties included population policy in their platforms for the first time; both cited the ICPD Programme of Action.

Reproductive Health and Family Planning

After the ICPD, many countries organized workshops and seminars for planners and health workers on the new reproductive health approach and how to put it into operation. A number of countries have made institutional changes to strengthen and reorient their policies and programmes in health care and family planning. Mexico, for instance, created a new General Directorate of Reproductive Health out of the former Directorates of Maternal and Child Care and Family Planning. The Philippines’ Department of Health has set up a Task Force on Women’s Reproductive Health. El Salvador has a Department of Reproductive Health within the Ministry of Public Health. In Panama, the Ministry of Health created a National Commission on Sexual and Reproductive Health.

Even more widespread are various measures to expand access to reproductive health services, improve their quality and widen their focus. Family planning is increasingly being integrated with other reproductive health concerns. This process has increased public awareness of the vast unmet needs of women, especially those in the poorest and most marginalized groups.

To improve the quality of reproductive health and family planning services, many developing countries have begun to train health care providers in interpersonal communications and counselling, to strengthen the health infrastructure, and to develop medical protocols. India has started to train medical officers at primary health centres in various states. Iran has expanded its Women Health Volunteers Programme, using some 18,000 volunteers to provide reproductive health and family planning information and services in urban slums; it has also established 15 new Rural Midwives’ Training Centres in nine provinces.

Kenya’s new Health Framework aims to integrate family planning with other reproductive health services, including STD/HIV/AIDS control, early detection of reproductive organ cancers and counselling on sexuality. This is intended to avoid duplication, make services more convenient and accessible, especially in underserved communities, and increase cost-effectiveness. Thailand and the Philippines are also moving to integrate reproductive health services and make them more accessible.

Ghana’s Ministry of Health has developed a National Reproductive Policy and Standards, based on ICPD definitions, to improve reproductive health service delivery, especially in marginal communities. Mali has similarly revised service norms in accordance with the ICPD Programme of Action.

The Cairo commitments are also reflected in Chile’s new Health Programme for Women, which takes a holistic, life-span approach to sexual and reproductive health issues.

Many countries are, like India, moving away from narrowly defined demographic targets in favour of a broader approach aimed at meeting individual needs for reproductive health information and services.

In some countries, the ICPD approach underpins new laws and administrative mechanisms relating to sexual and reproductive health and rights. In Argentina, pending legislation would create a national programme to provide reproductive health information, counselling, and government-approved contraceptives to low-income women. Bolivia’s new Maternity and Child Insurance gives women free access to prenatal care, delivery and post-natal care, including family planning, and pap smear tests; use of maternal and child health services reportedly increased 20 per cent in the programme’s first month.

Reduction of maternal mortality, a central ICPD goal, is the focus of reproductive health efforts and special campaigns in several countries, including Bolivia, the Dominican Republic, Guatemala, Haiti, Indonesia, Lao People’s Democratic Republic and Paraguay. The Cairo conference recognized unsafe abortion as a leading cause of maternal mortality; South Africa and Guyana have subsequently passed laws establishing a regulatory framework for safe abortion. Draft legislation on abortion is under review in Cambodia. Other countries, like Bolivia, now include management of complications of unsafe abortion in their reproductive health programmes.

Improving the quality of family planning services is a principal goal in most countries. Brazil now includes a full range of contraceptive methods in federal budgetary allocations, broadening the choices available to clients. In the Bahamas, the first officially sanctioned family planning project provides family planning counselling to adolescents.

The expansion of family planning services has been a special priority in the underserved countries of Eastern Europe and the former Soviet Union. Ukraine recently established its first family planning programme. Kazakstan now has family planning clinics in all its cities; in three years, abortions have been reduced by 20 per cent and contraceptive use has increased by 28 per cent. Family planning activities are also reported to have been strengthened in Tajikistan and Poland.

Adolescents

Since 1994, many governments have taken initiatives to meet adolescents’ reproductive and sexual health needs, often in collaboration with NGOs. In some countries—Papua New Guinea, for example—the government is addressing adolescent sexuality for the first time, motivated in part by rising rates of sexually transmitted diseases including HIV/AIDS among young people. Sri Lanka’s Ministry of Health has instituted an Adolescent Health Steering Committee.



A number of governments, particularly in Latin America, are promoting education about reproductive health and family planning in an effort to reduce teenage pregnancies. Institutional support for such programmes has recently increased in Cuba and Colombia, for instance. Cuba is also using the mass media to inform young people about responsible sexual conduct and condom use. In Ecuador, the Ministry of Public Health has designed a plan to provide pregnant adolescents with information, counselling and quality health services.

In El Salvador, the National Secretariat of the Family is striving to prevent adolescent pregnancy, sexually transmitted diseases and HIV/AIDS by promoting healthy and responsible behaviour and providing counselling and services. Venezuela’s Ministry on the Family has launched an unprecedented National Plan for the Prevention of Early Pregnancies, involving both the government and NGOs. In the Dominican Republic, three regional adolescent health centres provide counselling and services in sexual and reproductive health, family planning and responsible paternity; this is the first time the government has addressed adolescent health issues.

Non-governmental Organizations

As the Cairo conference recognized, non-governmental organizations have an essential role to play in both reproductive health advocacy and service delivery. Governments and NGOs have increased their collaboration in various ways since the ICPD; an example of this progress is the establishment in Bangladesh of an NGO Advisory Group to work with the government in implementing the ICPD Programme of Action. Similarly, in Honduras, a network of 17 NGOs was formed to promote ICPD recommendations.

NGOs providing services typically have higher quality-of-care standards than the public sector. They have traditionally shown greater flexibility in reaching marginalized sectors of the population and addressing sensitive or controversial issues. Consequently, governments have asked NGOs to assist in providing services, especially to the rural and urban poor, adolescents and battered women; to test new approaches that can be used by larger public programmes; and to assist in training of government staff.

In Maldives, a national NGO established the country’s first family planning clinic in 1995. NGOs in Iran have become more active since the ICPD in delivering reproductive and family planning services. In the Philippines, two women’s NGOs have started model clinics that use gender-sensitive approaches to family planning, infertility, adolescent health and violence against women. In India, an NGO provides regular screening and diagnostic testing for breast and cervical cancer. In Cambodia, local women’s NGOs have opened the country’s first shelters for battered women.

In Barbados and Grenada, NGOs have taken initiatives to help young people acquire necessary skills in order to support themselves, while at the same time helping them through counselling. In South Africa, the Planned Parenthood Association works with socially dislocated young people, who are particularly vulnerable to sexual health risks. In many other countries, NGOs are training adolescent peer groups in counselling techniques.



Human Rights

Some of the most important initiatives since the ICPD involve strengthening of national laws, policies and mechanisms promoting human rights, particularly the rights to reproductive and sexual health, gender equality and freedom from sexual violence. South Africa’s new constitution explicitly prohibits discrimination on grounds of gender, sex, pregnancy, marital status, or sexual orientation, among others. It also recognizes that everyone has the right to make reproductive decisions and to have access to reproductive health care. Chile is considering a constitutional reform to establish legal equality between women and men.

The government of Sri Lanka recently approved a Women’s Charter which acknowledges, among other things, women’s right to control their reproductive lives. In Colombia, the law creating a new social security system recognizes women’s rights to sexual and reproductive health. In Panama, a presidential decree forbids discrimination against or penalization of pregnant students and guarantees their right to continue their education.

Several countries have established institutions to safeguard the rights of women. They include Haiti’s Ministry of Women’s Affairs and Women’s Rights, a Commission on Gender and Social Equity in Jamaica, Colombia’s Directorate for Gender Equity, and the Women’s Rights Commission in Peru. Brazil has strengthened its National Council on Women’s Rights. New legislation in Nepal aims at improving the status of women. In Maldives, national laws are being reviewed to identify any that discriminate against women.

Both the ICPD and especially the Beijing women’s conference raised global awareness of the need to enact and enforce legislation protecting women against sexual and domestic violence. Laws against domestic violence have already been approved in Bolivia, Costa Rica, Ecuador and Panama, and similar measures have been submitted to legislatures in Guyana and Mexico. In Brazil, the Ministry of Justice launched a publicity campaign on violence against women. The Nicaraguan Women’s Institute is cooperating with the National Police and women’s NGOs to prevent violence against women and children and to support victims. Gambia has set up a multisectoral task force on violence against women.

Cambodian NGOs are promoting awareness of domestic violence, conducting training and counselling, and have opened the country’s first shelters for battered women. In the Philippines, the National Commission on the Role of Filipino Women has created a pilot hospital-based crisis intervention centre to assist survivors of domestic violence.

Women’s Participation

The ICPD emphasized the importance of empowering women to participate fully in the political and development processes. While the political gender gap is clearly evident in most developing countries, some notable advances have been made since the Cairo conference. In Uganda, for example, the new Constitution includes an affirmative action policy which mandates that each local council committee have a secretary for women, and that each of the 39 districts must elect at least one woman representative to the National Assembly; the vice-president is one of six women in the Cabinet. In 1995, for the first time in Jordan’s history, 12 women ran in local municipal council elections; one was elected mayor and nine as council members.

Role and Responsibility of Men

The ICPD Programme of Action stresses the importance of increasing the responsibility of men in sexual and reproductive behaviour and family life. This has led to a greater awareness of the need to involve men in reproductive health programmes, and some countries have initiated programmes specifically directed to men. In the Philippines, a new reproductive health centre for men is experimenting with innovative ways to involve men in reproductive health programmes. In Indonesia, the government plans to expand its counselling programme to include training materials on male participation in family planning and reproductive health. In Ghana, seminars and plays have been organized for both male and female audiences to generate discussions on partners’ joint responsibility in the use of family planning, parenting and family life.

Reproductive health and family planning have traditionally addressed women’s needs and largely neglected those of men. Several NGOs are now conducting research to assess men’s reproductive health needs, and to better understand their sexual, marital, parenting and family decision-making roles. Some studies have examined male participation in post-partum health care for mothers and babies. A study in Bolivia and Zimbabwe is examining men’s perspectives on family planning. One in India aims at identifying cultural and political constraints to male participation and support in reproductive health programmes.

Global and Regional Initiatives

Since the Cairo conference, there have been various international, regional and subregional initiatives to support national implementation efforts. In 1995, Indonesia hosted the first Interregional Meeting on Ways and Means to Implement the ICPD Programme of Action. Experts from 18 countries with economies in transition met in Romania to assess the status and needs of reproductive health services in their countries. Members of the Economic Cooperation Organization (Afghanistan, Azerbaijan, Iran, Kazakstan, Kyrgyzstan, Pakistan, Tajikistan, Turkey, Turkmenistan and Uzbekistan) assembled in Kazakstan to promote cooperation in implementing the Programme of Action. A post-ICPD meeting in Ghana reviewed population activities and strategies in sub-Saharan Africa. In the Caribbean, a 1995 inter-ministerial meeting drafted a subregional ICPD follow-up plan.

Partners in Population and Development, a technical cooperation initiative launched at the ICPD, has established a headquarters in Dhaka, Bangladesh, and begun to promote the exchange of information and expertise among developing countries; the partnership is comprised of Bangladesh, Colombia, Egypt, Indonesia, Kenya, Mexico, Morocco, Thailand, Tunisia and Zimbabwe.

There have also been various global initiatives involving non-governmental organizations. In 1995, for example, Caribbean NGOs held a Convention on Reproductive Health for Adolescents and Youth. UNFPA has organized two post-ICPD meetings of an international NGO Advisory Committee established to advise the Fund on proposed policies, programmes and strategies.

Parliamentary Initiatives

As a follow-up to ICPD, parliamentarians from both developed and developing countries have organized various activities to promote population issues. The Inter-American Parliamentarians’ Group in Population and Development convened in Belize in January 1995. A European Parliamentary Forum for Action was held in Belgium in May 1995; participants called on governments to mobilize resources to make reproductive health care universally available by 2015. The first Regional Conference of African Women Ministers and Parliamentarians was held in Burkina Faso in July 1995. Parliamentarians from 57 countries gathered in Japan in August 1995 to address key themes of the Cairo and Beijing conferences. In July 1996, a Forum of African and Middle Eastern Parliamentarians on Population and Development was held in Jordan. In a number of countries, including Ghana and Tanzania, national parliamentary groups have been established to focus on population and development-related concerns.

Inter-agency Collaboration

After the ICPD, the United Nations established an inter-agency task force, chaired by the UNFPA Executive Director, to strengthen country-level collaboration in implementing the Programme of Action. In 1995 it developed a set of guidelines for the United Nations Resident Coordinator System to facilitate cooperation among governments, NGOs, UN agencies and other development partners. The mandate of the task force was expanded in 1996 to include coordination of follow-up to other recent global conferences; it is now the Task Force on Basic Social Services for All.

UNFPA has been working closely with other UN agencies and international experts to develop a reliable, multidisciplinary set of indicators to measure progress towards the goals and targets of different conferences. These will be used to help design reproductive health programmes and monitor their progress. Topics addressed include family planning, maternal health, reproductive tract infections and sexually transmitted diseases, abortion and post-abortion care, and infertility. Besides conventional statistics on service outputs, utilization and contraceptive practice, the new indicators will also measure unmet demand, access, service coverage and quality of care. They will also indicate whether the enabling legislative and administrative policies for comprehensive reproductive health services are in place.

Resource Mobilization

The ICPD was the only international conference in this decade to agree on specific money amounts needed to implement its recommendations. The Programme of Action estimates the costs of a basic package of population and reproductive health programmes, including: universal, primary-level reproductive health services and STD/HIV prevention, and related policy development, research and data collection. This will require some $17 billion annually by the year 2000, and $21.7 billion by 2015. The conference anticipated that about two thirds of these global costs would have to come from domestic resources (varying according to national capacity), and about one third from the donor community. This estimate does not include resources needed for reproductive health services at referral hospitals, for general infrastructure (including transport and roads) or for broader social development programmes (for example credit systems, education, other health system improvements, trade and economic development promotion).

Success can only be achieved through concerted action by the international community. The measures agreed by all nations in Cairo, including the resources to be allocated, are both practical and necessary. However, while many governments have increased their allocations for population programmes since 1994, annual global expenditures are still well below half the $17 billion that ICPD estimated will be required in 2000. The evidence is that developing countries are prepared to commit the resources needed to meet the goals of the ICPD. The question remains whether richer nations are prepared to do the same.