In the five years since the 1994 International Conference on Population and Development (ICPD), the controversial agenda advanced at that landmark meeting in Cairo has become part of the fabric of international population and development efforts. The centrality of the reproductive health agenda was strongly confirmed in 1999 in a document adopted unanimously (although with some reservations) by the United Nations (UN) General Assembly. The report, the culmination of an official evaluation of the Cairo Programme of Action, outlined some of the progress that has been made in the five years since the 1994 conference and proposed further steps that should be taken around the world to promote development, gender equality, women's empowerment and reproductive health.
The writing of the document, entitled "Key Actions for the Further Implementation of the ICPD," was contentious at times. Moreover, the process took substantially longer to complete than had been anticipated. Nevertheless, the final report confirmed that the reproductive health agenda now is the mainstream of development efforts. UN officials pronounced themselves heartened by the outcome. At the conclusion of the General Assembly session, Ambassador Anwarul Karim Chowdhury of Bangladesh, who had chaired the committee that drafted the final report, described the process as a "grand success" and added: "We now have a document that gives guidance on where to focus in the difficult task to which we are committed. This process will reinvigorate the momentum that was generated in Cairo."1 Nafis Sadik, director of the United Nations Population Fund (UNFPA), commented, "The momentum is there, the will is there....I hope we can get some strong support from all members of the international community on the things that have happened at his wonderful meeting."2
The final report was the consummation of more than a year of preparatory conferences and weeks of difficult negotiating that began in March 1999 but did not conclude until July 2, just hours before the report was to be presented to the General Assembly. Thousands of government officials, UN officials and representatives of nongovernmental organizations (NGOs) from around the world had been involved, and discussions had covered a broad range of topics—everything from individual sexual behavior to macroeconomic policy. Moreover, the negotiating process required crafting a consensus that was acceptable to sometimes opposing constituencies.
How the Process Worked
In July 1997, the UN Economic and Social Council asked the General Assembly to examine the feasibility of evaluating the implementation of the Cairo Programme of Action.* In December of that year, the General Assembly voted to convene a special session from June 30 to July 2, 1999, "at the highest possible level of participation," to conduct the review. A key provision of the General Assembly resolution was that the evaluation would be undertaken "on the basis of and with full respect for the Programme of Action, and that there will be no renegotiation of the existing agreements contained therein"3 [emphasis added]. This provision eventually would loom large in the review discussions.
Preparations began more than a year before the scheduled special session: The UNFPA organized three roundtables in 1998, one on adolescent sexual and reproductive health, one on reproductive rights and human rights issues, and one on partnership with civil society.† In addition, three technical meetings were convened in 1998 (to discuss such issues as international migration and development, population and aging, and reproductive health services in crisis situations), along with five regional reviews on population and development.
The first formal international meetings related to the evaluation took place in the Hague in February 1999. A gathering of elected representatives and other government officials (the International Forum of Parliamentarians on ICPD Review) was followed by two concurrent conferences, one involving NGOs (the NGO Forum) and the other consisting of young people aged 15-30 (the Youth Forum). These meetings led directly into the Hague Forum, an intergovernmental conference charged to review and appraise the implementation of the Programme of Action.
The reports of all of these meetings were used by UNFPA to develop a draft report that was submitted to the UN Commission on Population and Development for discussion. That commission served as a preparatory committee for the July special session, and at a series of meetings held in New York in March, May and June, country representatives negotiated the details of the report eventually adopted by the General Assembly.
The Hague Meetings
The purpose of the Hague Forum and its associated meetings was to draft reports on the successes that had been achieved in attempts to implement the Programme of Action, and to map out the progress that still needed to be made. However, unlike the final report that was to be presented to the General Assembly in July, the reports of the various Hague meetings were not negotiated documents. Thus, rather than being statements of consensus among nations, they served instead as inventories of lessons learned and actions needed.
However, it became clear very soon at the Hague Forum and its related meetings in February 1999 which issues would become the main points of contention. Among the more than 800 individuals (representing around 700 NGOs) who attended the NGO Forum, many pointed to a shortfall in resources as the most critical problem. Governments have generally failed to meet the levels of funding that they pledged at Cairo: Overall development assistance that was expected to top $160 billion by now is stalled at about $50 billion, and while donors had pledged to contribute nearly $6 billion for population activities by the year 2000, only about $2 billion is currently being provided.
Another important theme of the meetings in the review process was the significance of youth: Given that young people aged 15-24 now make up about one-fifth of the world's population, the concerns of youth were considered particularly relevant to the process. Thus, 132 individuals aged 15-30 (most of them 25 and younger) from 111 nations were brought together to discuss implementation of the Programme of Action in their countries and recommend future actions, all from the perspective of the young.
The Youth Forum deliberations produced two novel proposals—that governments promise to devote a fixed percentage of all spending on reproductive health to programs and services for youth, and that a UN organization for youth be established, to ensure that young adults are "treated as equal partners at all levels of the policy and decision-making process."4 In all, the youth delegates offered nearly 40 specific recommendations to the Hague Forum in such areas as education, individual development, sexual and reproductive health, and violence.
More than 2,000 individuals from about 250 country delegations and international and national organizations attended the Hague Forum. During the Forum, the participants were addressed by such notable figures as Nana Konadu Agyeman Rawlings, the first lady of Ghana; Baron Vaea, the prime minister of Tonga; Elizabeth Aguirre de Calderon Sol, the first lady of El Salvador; and Hillary Rodham Clinton, the first lady of the United States. In the Forum's keynote address, Clinton reaffirmed the U.S. government's commitment—or at least the Clinton Administration's desire—to meet its ICPD respon- sibilities. She also reminded participants that "as important as it is that we continue to fulfill our commitments to family planning and reproductive health services, we know that in reaching the goals of Cairo we are called upon to do so much more. We are called upon to make investments in the human and economic development of people, particularly girls and women."5
The discussions at the Hague Forum were structured around five topic areas deemed particularly important for the proper implementation of the Programme of Action—creating an enabling environment (i.e., promoting governmental accountability and transparency, political commitment to the aims of Cairo and more balanced development, among others); enhancing gender equality and equity and empowering women; promoting reproductive health; strengthening partnerships with civil society; and mobilizing resources. Participants' views on these issues, in particular the constraints encountered over the last five years and actions that might be taken to overcome these barriers, were summarized in a final report that was to be an important source for the draft Secretary General's report to the UN special session.
Running through discussions in all of these areas, however, were tensions over several difficult topics that would emerge later in the New York negotiating sessions. Besides resource constraints, the most predictable of these was abortion: In early discussions on reproductive and sexual health, the Holy See (the UN delegation from the Vatican)‡ objected to mentions of emergency contraception, for example, arguing that it is an abortifacient, not a contraceptive. Likewise, the term "safe motherhood" was described as a code word for abortion legalization.
Other issues surfaced at the Hague as well. One was the tension involved in protecting adolescents' access to needed health care yet respecting parents' rights to raise their children according to their own beliefs. Another involved the range of reproductive health services that should be extended to refugees. All of these would become problem areas once negotiations began less than two months later.
The Report Is Negotiated
The first opportunity to debate the actual text of the review came in March, when the Commission on Population and Development met as the preparatory committee (or Prep Com, in UN terminology) for the special session. During deliberations scheduled to last from March 24 to March 31, the Prep Com was expected to negotiate the final text of the report to the General Assembly.
Slow initial progress soon led to pessimism that the document would be completed by the end of March. Much of the most difficult negotiating—on contentious subjects such as services for teenagers, abortion and sex education, among others—was left until the last few days. Thus, even though discussions were extended for an additional day, by April 1 many sections of the report still had barely been discussed, or were bracketed.§ This necessitated further talks: an informal negotiating session in early May, and formal talks in the week before the General Assembly special session.
Despite some progress in the informal discussions in May, the talks concluded with about one-third of the document still unapproved. The participants reconvened formally on June 24, with just four working days remaining until the General Assembly special session opened. On June 30, the report was still incomplete, and negotiations had to proceed concurrent with the special session. It was not until the evening of July 1, just before the General Assembly special session was scheduled to end, that negotiators reached agreement on the last contentious paragraphs.
As polemical arguments over relatively minor differences in wording dragged the talks out, some observers feared that the final document would say little new. Yet the final report signaled some important advances: All but a few nations had accepted the essentials of the Cairo agenda; expanding access to reproductive health services is no longer a controversial issue; and the challenges of implementing the ambitious goals of the Programme of Action are now in the forefront.
Besides reaffirming Cairo's core principles, the five-year review moved beyond the Programme of Action by offering concrete proposals that will help people and governments further implement the goals of Cairo. For example, the document presents a number of specific benchmarks for improving contraceptive practice, lessening illiteracy among women and girls, reducing maternal mortality and helping young people avoid HIV and AIDS.
Thus, in Paragraph 58, the report states that "where there is a gap between contraceptive use and the proportion of individuals expressing a desire to space or limit their families, countries should attempt to close this gap by at least 50% by 2005, 75% by 2010 and 100% by 2050." The paragraph adds that "in attempting to reach this benchmark, 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."6
The review also advises countries to use, as a measure of progress toward the reduction of maternal mortality, the proportion of births that are assisted by skilled attendants. In places where maternal deaths are very high, the report comments, this proportion should be at least 40% by 2005, 50% by 2010 and 60% by 2015. Further, "all countries should continue their efforts so that globally, by 2005, 80% of all births should be assisted by skilled attendants, by 2010, 85%, and by 2015, 90%."7 These kinds of specific benchmarks were largely missing from the Cairo Programme of Action, but were deemed essential for a document intended to examine implementation of the ICPD.
Gaining the resources to support the goals of the Programme of Action also was a major focus of the review. The document calls for "increased political will from all Governments and reaffirmation of the commitment for mobilization of international assistance, as was agreed at Cairo,"and demands that countries "make every effort to mobilize the agreed estimated financial resources."8 Reiterating the Cairo report, the review asks donor countries to "implement the costed elements of the Programme of Action, that is: ...$5.7 billion in 2000, $6.1 billion in 2005, $6.8 billion in 2010 and $7.2 billion in 2015," and "to take the necessary action to reverse the current decline in overall official development assistance and ... strive to fulfill the agreed target of 0.7% of gross national product for overall development assistance as soon as possible."9
Adolescents and their needs figured prominently in the discussions that produced the report. Some paragraphs reaffirmed Cairo, such in a section stating that adolescents and young adults should receive "education about population and health issues, including sexual and reproductive health issues."10 Others called on nations to enhance young people's well-being, promote responsible sexual behavior, and protect them from pregnancy, HIV infection, and sexual abuse and violence—with the proviso that such education is undertaken with "the active involvement and participation of parents, youth, community leaders and [other] organizations."11
Elsewhere in the document, sections emphasized adolescents' right to information that will "enable them to make responsible and informed choices and decisions regarding their sexual and reproductive health needs...."12 Moreover, the review sets benchmarks urging that by 2005, governments and donors "ensure that at least 90%, and by 2010 at least 95%, of young men and women aged 15-24 have access to the information, education and services necessary to develop the life skills required to reduce their vulnerability to HIV infection."13 The passage also urges governments to focus on reducing overall HIV infection rates by 25% globally by 2010. On the other hand, many specific requests from the Youth Forum, such as to allocate a set percentage of resources to youth concerns and to establish a youth-oriented UN presence, were not endorsed in the final report.
Despite resistance from some participants, progress was even made on abortion-related language. One paragraph in the maternal mortality section highlighted the need to treat women who had had illegal abortions. In negotiations stretching from March to July, many arguments had occurred over how the text should read.
In the end, much of the section simply quotes the texts of Paragraphs 8.25 and 7.24 from the Programme of Action verbatim.** However, the document then urges that "in circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible."14 By recommending an action that governments can take, the sentence follows through on the Programme of Action's recommendation to reduce the consequences of unsafe abortion.††
In the years following Cairo, the concept of partnerships—particularly those between government agencies and NGOs—has grown more significant. The theme of partnership echoed throughout the five-year review. Many discussions emphasized the continued importance of NGOs in implementing the Programme of Action. The final document calls on governments to furnish resources to civil society organizations and to involve NGOs and grassroots community organizations in national-level policy discussions. Moreover, it urges governments and NGOs to broker partnerships with other parts of the society, such as the private sector, religious organizations, the media, community groups and young people.
What Were the Flashpoints?
Although the General Assembly's explicit instruction that the Cairo document not be "renegotiated" was important to prevent the ICPD agenda from being watered down, it also led to some repetition of the aims and goals of the Programme of Action. Often during the discussions, when one country representative proposed language highlighting a need or suggesting an action, a succeeding speaker (opposed to the suggestion) reminded participants that the specific issue was not discussed in the same way in the Programme of Action, and "we are not here to renegotiate Cairo." A frequent compromise was to suggest that the problematic passage simply quote directly or cite a relevant passage from the Programme of Action.
Thus, during negotiations on a section having to do with improving reproductive health services, the Holy See opposed language calling for "effective referral mechanisms across services and levels of care," asking for the addition of an explicit conscience clause that would allow providers to refuse to refer. Some countries objected, pointing out that the right of conscience is not in the Cairo document. The United States finally brokered agreement by suggesting the addition of a phrase from Paragraph 7.16 of the Programme of Action ("taking care that services are offered in conformity with human rights and with ethical and professional standards").
Yet even quoting the Programme of Action did little to reduce the contentiousness of abortion. Participants argued often over the paragraph relating to abortion in the maternal mortality section (Paragraph 63 in the final document), but inevitably the passage was set aside for further talks. It was the last section of the document to be settled, and some parties that entered reservations on the document (such as Argentina, the Holy See, Malta, Nicaragua and Sudan) specified the abortion section as one with which they disagreed.
Abortion also figured in repeated clashes over any mention of emergency contraception in the review. In a passage advising UN agencies and donors to provide sufficient resources to meet the demand for family planning methods, the United States, the European Union and some other Western developed nations argued in favor of the phrase "including female-controlled methods such as female condoms and emergency contraception, and underutilized methods such as vasectomy and male condoms."
This proposal was strongly resisted by the Holy See and several other countries, including Argentina, Libya, Nicaragua, Sudan and Syria. Representatives from these delegations argued that emergency contraception is tantamount to abortion, even though a representative of the World Health Organization explained that because the treatment works prior to implantation, the medical community does not regard emergency contraception as an abortifacient. In the end, the passage was left to read "including new options and underutilized methods."
Parents' rights to supervise their children were also an important source of friction during the negotiations. The Holy See and some delegations with which it was allied regularly sought to add "balancing language" from the Programme of Action that recognized "the rights, duties and responsibilities of parents" to provide their children with appropriate guidance in sexual and reproductive matters. However, after agreeing early in the negotiations to place explicit references to the relevant Cairo paragraphs in the section's introduction, many nations preferred not to repeat the parental rights language in each section pertaining to teenagers.
In the end, agreement was reached on compromise text covering several paragraphs related to young people's sexual and reproductive health needs. In this case, the language that finally proved acceptable to all parties stated that governments need to meet the needs of young people "with the active support, guidance and participation, as appropriate, of parents, families, communities, NGOs and the private sector."15
Another thorny issue related to adolescents concerned sex education, and this was resolved as part of the same last-minute compromise as the passages on parental rights. One paragraph on including sex education in schools had been disputed since negotiations began. Among many other issues, a number of participants, including Brazil, the European Union, Ghana, India and Switzerland, wanted the passage to specify"sexual and reproductive health education,"while some delegations, such as the Holy See, Libya and Sudan, argued for use of text from the Programme of Action ("education about population issues"). The final compromise text reads "education about population and health issues, including sexual and reproductive health issues."16
Finally, concerns about the availability of resources were a constant in discussions on almost every issue. Many representatives from developing nations believed that they had done a better job of meeting their Cairo pledges than the industrialized nations had, and that they might have done even better if some countries had not simultaneously struggled with "structural adjustment" policies imposed by the International Monetary Fund and with unforeseen financial crises. Developed countries, however, also pointed to the effects of unanticipated economic problems and the difficulty of mobilizing the necessary political commitment.
That overall funding had failed to reach promised levels was only one of the resource-related difficulties, however. At the Hague meetings, some participants asserted that governments do not always share donor funds with NGOs—or, if they do, they fund a few large NGOs but ignore smaller, more grassroots organizations. Others noted that many developing countries fail to budget enough money to meet health needs in general, and that the services needed to implement the Programme of Action are often considered less pressing by health ministries than more immediate health care needs, such as treatment of infectious diseases.
The final text of the report to the General Assembly includes separate paragraphs on resource mobilization in developed and developing countries, recognizing that they differed in the extent to which they had met the commitments they made in Cairo. In particular, the document urges donor countries to step up their efforts to provide the resources for implementing the costed elements of the Programme of Action, which rise from almost $6 billion in 2000 to more than $7 billion in 2015. In addition, they are asked to significantly increase the amount of funding provided for other elements of the Programme of Action, particularly improving women's status, basic health care and education, and emerging health challenges, and to take any needed action to reverse the current decline in development assistance.
The process of conducting a five-year review of the Programme of Action was laborious, and the exhausting negotiations ballooned the text from 79 to 106 paragraphs. Moreover, the usual controversies were aired once again, as the Holy See and a small number of allied delegations sought to have the document reflect their conservative views.
But the slow pace and frustrating arguments over subtle wording issues are not unusual for UN reports: The General Assembly is a deliberative body, and the committees that shape official documents must operate by consensus. As a result, every word is closely reviewed and discussed before agreement is reached.
Nevertheless, the five-year review advanced the Cairo agenda by once again bringing together NGO representatives, activists and government officials from around the world. And as was true in Cairo five years before, people learned about what their counterparts in other regions were doing, how they were coping with difficulties and what they hoped to accomplish next.
This may have been the most important product of the five-year review of the Programme of Action's implementation: It served as an occasion for all parties to the Cairo document to renew their commitment to the core principles of Cairo, to discuss with each other the ways in which the agenda was being implemented, to analyze the ways in which they have fallen short of achieving Cairo goals and to imagine new ways of implementing the Programme of Action.