In 1994, official delegations from 180 national governments wrestled with some of the most basic—and controversial—issues facing individuals and countries around the world. At the United Nations (UN)-sponsored International Conference on Population and Development (ICPD) in Cairo, they agreed to a 20-year "Programme of Action" based on a revolutionary idea: that economic development and stabilization of population growth rates are inextricably tied, and that neither is possible without focusing on the role and status of women. Five years later, the UN is engaging nations in an assessment of the progress that has been made since Cairo—and, perhaps even more important, what remains to be done.

The United Nations Population Fund (UNFPA) initiated the "Cairo-Plus-Five" review process last year, with a series of roundtables and technical meetings on various key topics relevant to what has come to be known as the "Cairo consensus." The process will culminate at a UN General Assembly Special Session, June 30-July 2, at which a report of the UN secretary-general will be endorsed. Major input into that report will come from more than a week of meetings that took place in February in The Hague, Netherlands, where some 2,000 people gathered to discuss the successes and challenges in implementing the Cairo agenda.

The official governmental meeting—the so-called Hague Forum—was attended by representatives of 177 countries, but separate meetings among parliamentarians, nongovernmental organizations (NGOs) and young people immediately preceding the governmental meeting served to inform the discussions among the governmental delegations. The overriding message that emerged from the Hague Forum and related gatherings is that while huge strides have been made in terms of the political commitment countries have been willing to make to the Cairo agenda, some of the largest donor countries—prominently including the United States—have failed to fulfill their financial pledges to translate those commitments into actions.

Progress and Constraints

The charge of the Hague Forum decidedly was not to reopen the agreements that were reached, sometimes rancorously, in Cairo. Rather, the purpose was to bring together the many participants necessary for the implementation of the Cairo action program, with the discussion concentrating in five identified areas.

Creating an enabling environment

At the ICPD, it was agreed that good governance, "transparency," accountability and the promotion of democracy are essential to achieving "sustainable development"—and that the interrelationships among population, resources, environment and development efforts must be acknowledged by the world's governments and brought into balance. The final report from the Hague Forum notes the progress that has been made in many countries in terms of strong political commitment to this comprehensive approach. Among the main cited constraints, however, are recent economic crises (particularly in Asia and South America), natural disasters and continuing political instability and armed conflict in certain regions—all of which have distracted governments from addressing critical but more long-term concerns, such as the integration of population issues into environmental policy and their connection to poverty.

Achieving gender equality, equity and empowerment of women

The Forum report finds that the ICPD created enormous momentum toward the repeal of laws and policies that discriminate against women and the passage of statutes aimed at eradicating gender-based violence and protecting the rights and well-being of girls. In addition, it notes that the participation of women at policy and decision-making levels has increased notably. The major obstacles to progress, it concludes, are well-entrenched and pervasive social and cultural biases that will take a long time to alter. This is compounded, says the report, by the globalization of the economy, which has contributed to deepening the feminization of poverty.

Promoting reproductive health, including family planning and sexual health, and reproductive rights

The Forum report concludes that significant progress has been made in several important areas, including enacting laws promoting reproductive health and rights, removing demographic targets and quotas, promoting adolescent reproductive health and addressing the unique reproductive health needs of refugees. Moreover, the report asserts that there have been advancements in integrating reproductive health services as a core component of primary care, and in ensuring higher quality services involving a wider range of contraceptive choices and the guarantee of informed consent. Finally, the report finds that headway has been made in acknowledging unsafe abortion as a serious public health concern and establishing abortion services where legal, as well as in demonstrating that efforts to prevent sexually transmitted diseases, including HIV/AIDS, are cost-effective.

At the same time, the report points out that existing laws in many countries do not adequately reflect the "human rights" approach to reproductive health, nor is there sufficient political will in many places to rectify or implement the laws. It concludes that laws remain a particularly serious impediment concerning sexuality education and access of adolescents to reproductive health information and services. The report also finds that reproductive health programs often have been casualties of health-sector reforms.

Strengthening partnerships

This refers to the widely acknowledged need for the active support and participation of the public and private sectors if the goals of the ICPD are to be achieved. The Forum report observes that involvement of women's groups, advocacy organizations, youth groups and religious communities indeed has intensified and become more accepted since ICPD—and that countries "with economies in transition" (for example, the former Soviet states, which had no prior tradition of a private sector) have made particular progress in this regard. The main limitations in this effort, says the report, are the absence of clear legal frameworks for facilitating partnerships and the weakness of NGOs themselves in terms of human resources as well as institutional and financial capacities.

Mobilizing and monitoring resources

Donor countries have increased their assistance for population activities from $1.3 billion in 1993 to just under $2 billion in 1997, raising the percentage of total development assistance that is being devoted to population activities to an all-time high. Recipient countries, which promised to contribute two-thirds to the total amount spent on these activities globally, exceeded their target amount, spending $7.5 billion in the most recent estimate. This, says the Forum report, is the encouraging news. The problem, according to the report, is that the combined support from donor countries amounts to less than one-third of the sum they promised by this time. (Only Denmark, Sweden, Norway and the Netherlands have managed to meet their funding goals.) The fact that development assistance as a whole is dropping among donor countries is a primary cause of insufficient funding for population programs, concludes the report. This is only compounded, it says, by regional economic crises, the need for additional resources resulting from the faster-than-anticipated spread of HIV/AIDS and the increasing demand for special services for adolescents.

New Directions

Perhaps what was most significant about the various gatherings in The Hague was the overall lack of controversy. Instead, the meeting appears to have served its primary purpose, which was to provide a forum for nations and NGOs to reaffirm their policy commitments to the Cairo agenda and to pledge to work harder to appropriate the funds to follow through on those commitments. Still, some new directions were identified.

Issues pertaining to the special needs of adolescents have only been magnified since the Cairo conference, partially because of the sheer number of the world's people in this age-group—an estimated one billion—but also because of the significant increase in HIV/AIDS among them. In recognition of that, the Hague Forum report incorporates a new goal, emanating from the Youth Forum, that 20% of all donor allocations for reproductive health be earmarked for adolescent-oriented initiatives. Acceptance of this new funding target was viewed by many as one of the most significant accomplishments of the entire Hague Forum. Beyond their important substantive contribution, moreover, the large and energetic participation of young people at their own forum was widely perceived, by itself, as a key indicator of the ICPD's success.

The fact that the Forum report specifically identifies, as a means of reducing unsafe abortion, the use of postcoital, so-called emergency contraception—a method that has largely come to prominence since the Cairo conference—also was an important achievement. Predictably, this action provoked protests from the Vatican, which considers postcoital contraception itself a form of abortion. (Meanwhile, a call for "sexual rights," which were endorsed subsequent to the ICPD at the UN-sponsored Fourth World Conference on Women in Beijing in 1995, was not included in the Hague Forum report because it was deemed to fall outside the Cairo program of action; the final report, however, does contain an NGO-initiated proposal to review laws that punish women who have undergone illegal abortions, which is based on a recommendation from the Beijing conference. Similarly, calls from the Youth Forum for information on sexual orientation within the context of sexuality education and for the provision of abortion services without regard to legality—seen as significant in and of themselves—were not incorporated into the final Hague Forum report.)

The U.S. Role

Undoubtedly, the most significant obstacle to implementing the Cairo agenda is the financial shortfall. The ICPD calls for a total expenditure of $17 billion for reproductive health care in developing countries by the year 2000—and right now it appears that the total funding available is only about half that amount.

The United States is still the single largest donor to reproductive health programs worldwide, providing almost $600 million in FY 1998 for family planning, HIV/AIDS, maternal health and nutrition, and related reproductive health activities. This amounts to only about one-third the amount that the United States had pledged in Cairo, however. Moreover, because of its huge economy, the United States stands in eighth place in terms of its expenditures as a percentage of gross national product.

Despite the failure of the United States to deliver on its financial promises, conference attendees were inspired by the remarks of First Lady Hillary Rodham Clinton, who both spoke at the NGO Forum and delivered the keynote address at the official Hague Forum. The First Lady spoke passionately, using many examples from her visits with poor women in developing countries, about the importance and momentousness of the Cairo agenda. "I wanted to come here today," she said, "to reaffirm my government's commitment to carry out the ICPD Programme of Action, and my husband's administration's renewed determination to continue to work with other governments and NGOs to meet the goals we have set."

Unfortunately, given the failure of the United States to live up to its own Cairo commitments, Mrs. Clinton's first challenge, it would appear, is right here at home.