In 1994, the United States participated with nearly 180 other countries in the International Conference on Population and Development (ICPD) in Cairo. Despite the complexity of the issues before them, participants reached an unprecedented consensus on a comprehensive 20-year Program of Action designed to achieve gender equality, improved reproductive health. and population stabilization as well as a wide range of sustainable development goals.

Among the key recommendations adopted in Cairo were those calling for universal access to integrated family planning and reproductive health services, and specific measures to advance the economic, educational, and health status of women. The Program of Action also emphasized the need for cooperation among donors, governments, and all elements of civil society in achieving the Cairo goals.

Working with other government agencies under the leadership of the State Department, the U.S. Agency for International Development (USAID) was actively involved throughout the Cairo process and joined in enthusiastically endorsing the Program of Action. As the largest bilateral donor of population and health assistance, USAID has played a particularly critical role in helping countries implement the core objectives of Cairo in family planning, maternal health, prevention of HIV/AIDS and other sexually transmitted infections, and other aspects of reproductive health.

In addition, USAID programs for women in development, democracy-building, environmental protection, and humanitarian assistance all contribute to the broader Cairo agenda.

Helping Countries Help Themselves

USAID's role in implementing the Cairo Program of Action has been shaped by more than 30 years of experience in the global effort to help women and men achieve a basic right -- the right to plan the number and spacing of their children. Through technical leadership and innovation and working in collaboration with U.S. institutional partners, we have sought to help countries build their own capacity to provide voluntary family planning and reproductive health services. The U.S. institutions providing technical assistance -- including universities, nongovernmental organizations, private businesses, and other government agencies -- bring a wide variety of expertise to USAID-funded programs.

With the involvement of these partners, USAID has helped host country institutions in both the public and private sectors to bring together all of the elements of comprehensive programs. USAID assistance has helped countries to improve the quality and effectiveness of family planning and reproductive services, train medical professionals and community-based health workers, design innovative media and communications campaigns, develop new and improved contraceptive methods to prevent unwanted pregnancies and protect against sexually transmitted infections, manage supply and distribution systems for contraceptives and other health products, and carry out the research and data collection needed for informed decision-making.

USAID provides population and health assistance only at the request of host governments and seeks to be flexible and responsive to country needs. The countries we work in are culturally diverse and geographically spread across Latin America, Subsaharan Africa, Asia, and Eastern and Central Europe -- over 60 in all.

Many countries have made remarkable progress since our assistance began. Mexico, Colombia, Egypt, Morocco, Tunisia, Indonesia, Bangladesh, and Kenya are among the countries in which couples have dramatically increased their use of contraception, and where there have been significant improvements in maternal, infant, and child survival rates. Worldwide, the average number of children per family has dropped from more than six to less than four in countries assisted by USAID. Last year alone, we estimate that USAID programs have contributed directly to increasing the number of new users of family planning by 12 million, and to saving the lives of millions of children by providing immunizations, oral rehydration therapy, and other interventions. As a result of helping couples to plan their births, not only are families smaller, but they are healthier, and the lives of millions of women and children have been saved.

Putting Cairo to Work

The Cairo conference strongly reinforced USAID's commitment to programs where the needs of clients come first and where informed choice and quality of care are guiding principles. Although USAID was working on many aspects of the Cairo agenda long before 1994, efforts in a number of areas of reproductive health have been strengthened since then. These include helping countries to expand the choice of contraceptive methods, to undertake programs to ensure safe deliveries and promote maternal health and nutrition, and to develop new approaches to prevent and manage HIV/AIDS and other sexually transmitted infections.

In most countries, there is increasing integration in planning and providing reproductive health services. From fiscal year 1994 through 1998, USAID will have committed more than $3,000 million to national programs in population and reproductive health as defined and costed in the Cairo Program of Action.

USAID's leadership role in response to Cairo is reflected in a number of individual special projects and initiatives. These include:

• Building on years of experience prior to Cairo in training women managers of family planning programs, USAID has been helping countries to engage women leaders and work with women's groups and organizations to expand the availability of reproductive health information and services. In Turkey, for example, with support from USAID, a women's network was formed that has recently advocated successfully with top political leaders for increased funding for family planning. In other countries, including Nepal, Nigeria, Peru, and Jordan, USAID is supporting programs integrating reproductive health with other initiatives to enhance women's education and political participation.
• Growing concern about continuing high levels of deaths and illnesses associated with pregnancy has led us to strengthen our efforts in maternal health and nutrition. Family planning, by contributing to birth spacing as well as by reducing abortions, is vital to maternal health. At the same time, USAID programs are giving increasing attention to essential obstetric care and nutritional interventions before and during pregnancy, as well as community-based efforts to help in recognizing pregnancy complications and bringing women for timely treatment. Significant initiatives in these areas have been undertaken in Indonesia, Bolivia, Egypt, and Nepal, among other countries.

  As recognized in the ICPD Program of Action, a high priority is to improve treatment for women who have suffered the complications of unsafe abortions -- a cause of 75,000 preventable deaths every year. USAID-funded pilot efforts in Egypt and Kenya in post-abortion care are now being expanded nationwide, and research and training are underway in more than 10 other countries. (Longstanding law and policy prohibit use of USAID funds to support abortion as a method of family planning.)

• Young adults face particularly high reproductive health risks, and yet in most countries they have the least access to information and services. Nearly 1,000 million young people between the ages of 15 and 24 are entering their reproductive years. Through a new global project, USAID is helping to collect, analyze, and disseminate the most innovative approaches to youth programming, usually involving the participation of young adults themselves. USAID-funded programs in such countries as Ghana, Mexico, Bolivia, Jamaica, Egypt, and Bangladesh are increasingly addressing the special needs of this important age group.

• USAID has initiated an innovative effort to link reproductive health activities with community-based child survival programs assisted by U.S.-based private voluntary organizations (PVOs) active in humanitarian relief and development. PVO/NGO Networks for Health, a $51-million 5-year project, will be carried out by a global health consortium that brings together five leading PVOs, including Save the Children (the lead partner), CARE, Childreach/Plan International, the Adventist Development and Relief Agency (ADRA), and PATH.

Qualitative research in which women are interviewed individually or in focus groups has helped program managers to better understand women's perspectives on their family planning and reproductive health needs and the obstacles women must often overcome to use services.

Contraceptive research and development, which earlier had led to new and improved pills and intra-uterine-devices (IUDs), has broadened in the years before and since Cairo to include female-controlled barrier methods that are protective against sexually transmitted infections (STIs), such as microbicides and the new female condom. USAID has also helped develop cheaper and more accurate diagnostic methods for HIV/AIDS and other STIs as well as an innovative disposable needle and syringe to prevent transmission of HIV through injections.

Beyond USAID's population and health programs, the agency has adopted a Gender Plan of Action and has developed other programs across all sectors aimed at advancing women's social, economic, political, and educational status. In 1995, USAID launched a comprehensive Girls' and Women's Education Initiative in 12 countries to support advocacy for girls' education and help countries overcome barriers to girls' school participation.

Challenges and Opportunities Ahead

As we approach the five-year anniversary of Cairo, it is not only time to take stock of the progress the global community has made toward meeting its goals, but also to assess the challenges ahead. The goals contained in the Program of Action are ambitious, and critical questions remain to be answered: How do we keep pace with the enormous and still growing unmet needs for family planning and reproductive health services? How do we mobilize the financial and human resources necessary to keep the momentum going? How do we scale up successful pilot efforts to serve larger numbers of people?

Of course, the answers to these questions are not simple, and USAID is working with countries not only to find new resources but to help plan better and to set priorities within existing resources. Opening up the potential of the private commercial sector is an important avenue to pursue in some countries. In others, reliance on donor funding will continue for the foreseeable future, and USAID is cooperating closely with other donors to maximize the effectiveness of population and health assistance.

In areas where Cairo presented some particularly difficult challenges, USAID has successfully taken some first steps, and yet we know that we have far to go. These include addressing social and cultural barriers to advancement of women and the special issues surrounding violence against women; finding ways to involve men in their own reproductive health and in supporting women's use of family planning and other reproductive health services; and identifying approaches that will succeed with young adults, who are often particularly hard to reach through conventional clinic-based health programs.

Cairo also stressed the need for integrating population, environmental, and poverty eradication efforts. We have undertaken pilot efforts, but we have much more to learn about feasible and effective approaches, especially in helping communities to link reproductive health and environmental protection initiatives at the grassroots level.

Despite these challenges, there are reasons to be optimistic. The consensus of Cairo has contributed to much greater awareness of population and reproductive health issues worldwide, leaving a lasting legacy. The energy and resources to translate the Cairo goals into reality will come not only from governments but from people and organizations everywhere who were inspired by these goals. At the same time, technical leadership and funding from USAID and our U.S.-based implementing partners has proven to be unique and indispensable.

Global Issues USIA Electronic Journal, Vol. 3, No. 2, September 1998