The world has changed markedly since 1994, when U.S. leadership in global sexual and reproductive health policy was on full display at the historic International Conference on Population and Development (ICPD) in Cairo. The agreements reached at this landmark event—actively supported by the United States—have been largely responsible for shifting the global discourse on population issues from one focusing on meeting macro-demographic targets for "population control" to a framework defined by recognizing the reproductive health and rights of women as the best way to promote development.

In the 15 years since the ICPD, even as U.S. policy regressed, the international community continued to move forward, embarking on a new development agenda outlined in the Millennium Development Goals (MDGs). Embraced by donor and developing nations alike (but largely ignored by the Bush administration), the MDGs established ambitious targets and goals related to reducing poverty and furthering development, including addressing women’s health and equality.

From its first week in office, the Obama administration has strongly signaled its intent to restore the country’s reputation and its commitment to a progressive foreign policy that prioritizes development assistance and embraces the MDGs. As expected, President Obama moved quickly to overturn some of the most heinous policies of the previous administration affecting U.S. international family planning and reproductive health assistance. But to truly demonstrate seriousness and significance when it comes to sexual and reproductive health and rights, more must be done. The United States must reclaim its leadership role in the international arena by fulfilling its commitments to Cairo and the MDGs, and by forthrightly promoting a global agenda on women’s sexual and reproductive health. It can take the first steps by reprioritizing women’s health in its own foreign assistance policy and by negotiating strongly on these issues at a series of upcoming international conferences.

The Legacy of the ICPD and MDGs

The "Programme of Action" that emerged from Cairo endorsed by 179 countries represented major strides in the area of women’s health and rights—gains strongly supported and negotiated by the U.S. delegation, under the chairmanship of Undersecretary of State for Global Affairs Timothy Wirth. At its heart, the ICPD embodied a breakthrough acknowledgment of the critical role of women—including the achievement of their legal rights and the elevation of their social status—as necessary and integral to "sustainable development" at the family, community and country level. Meeting women’s needs was officially recognized at the global level as the appropriate, fundamental goal guiding the formation and implementation of development and population policy.

Thus, after Cairo, it was unacceptable to promote population control as the raison d’etre for environmental sustainability, economic development or family planning programs. Instead, the ICPD affirmed the basic reproductive right of "all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health." To that end, countries committed to achieving universal access to reproductive health care by 2015.The following year, at the 1995 Fourth World Conference on Women in Beijing, the Cairo principles were reaffirmed.

Although the Cairo agreement signified important steps forward, the outcomes were by no means perfect. Political compromises over contentious issues such as abortion were necessary. Nonetheless, the consensus reached around even this controversial issue still represented progress. For example, while access to abortion was not recognized as a reproductive right per se, Cairo moved the discussion of abortion to the health impacts of unsafe abortion, which the final document recognizes as a major public health issue.

Six years later, the world’s leaders converged again to craft an agenda to end extreme poverty by 2015 outlined in the Millennium Declaration. At the New York headquarters of the United Nations (UN) in 2000, 189 countries pledged to meet eight development goals related to poverty, education, gender equality, maternal and child health, HIV/AIDS and the environment (see box). Attempts to promote an explicit reproductive health and rights agenda within the MDGs, however, were vigorously undercut during negotiations by the Bush administration and its allies within the so-called G77, a coalition of developing countries seeking to enhance their negotiating power within the UN by acting jointly. These deficiencies have been at least partly remedied over time. In the 2005 World Summit Outcome document, world leaders agreed to integrate the ICPD goal of universal access to reproductive health by 2015 into the strategies aimed at achieving the MDGs on maternal and child health, HIV/AIDS, gender equality and poverty. The UN Millennium Project, an independent advisory board commissioned by the UN to develop concrete plans to implement the MDGs, subsequently produced a blueprint endorsing the necessity of sexual and reproductive health to attaining the MDGs and describing interventions to that effect. Now, universal access to reproductive health is listed as a target for the MDG on maternal health, and fulfilling the unmet need for family planning is identified as a strategy for achieving this target.

The United States Retreats…

Although the ICPD marked the jumping off point for the world to move forward, U.S. policy regressed in the years immediately following. With the takeover of the House of Representatives by a conservative Republican leadership hostile not only to abortion rights but also to family planning programs, U.S. funding levels for international family planning assistance declined from their high-water mark in FY 1995, and by FY 2008, funding had dropped by nearly 40% when accounting for inflation. Policy restrictions subsequently imposed by the Bush administration further undermined U.S. credibility and leadership. From 2001 until President Obama rescinded it in January, the Mexico City policy (otherwise known as the global gag rule) prohibited U.S. funding for family planning to indigenous groups overseas that engaged in any services, dissemination of information or advocacy activities on abortion with other funds. And every year since 2002, President Bush blocked congressionally appropriated funding for the United Nations Population Fund on the basis of unfounded allegations of its complicity with coercive abortion practices in China.

These policies have had repercussions beyond access to sexual and reproductive health services. Because the sexual and reproductive health of a country’s women and their partners is so integral to its ability to achieve other development targets, the larger objectives of social and economic development as espoused by the ICPD and the MDGs have also been crippled. Developing countries that do not provide or are impeded from providing adequate access to sexual and reproductive health care can only attain limited economic and social progress. Moreover, the global gag rule obstructed human rights and democratic values that the United States ostensibly cares about, such as civil and political rights related to speech and assembly, which are constitutionally protected for its own citizens and recognized in international treaties.

…But the World Moves Ahead

While U.S. policy has been lagging, other countries and regions have been forging ahead in their efforts to promote the sexual and reproductive health and rights of women across the developing world. Countries in Europe especially have moved in to fill the leadership void. Initiatives such as the Safe Abortion Action Fund, established in 2006 by the United Kingdom’s Department for International Development, were specifically developed to ameliorate the harmful effects of the global gag rule. European donor countries have also been proactively engaged in pushing progress on more politically sensitive sexual and reproductive health concerns. Indeed, countries such as Norway, Sweden, the Netherlands, the United Kingdom and Denmark have been at the forefront in funding programs in areas such as adolescent reproductive health, safe abortion services, and sexual health and rights. European countries have also been much more eager than the United States to adopt and encourage the language and policy framework of international human rights, as formally delineated by the UN system, in their own programs and policies.

European donor countries are ahead of the United States not only philosophically, but also financially. Although the United States remains the leading donor country in overall amounts for foreign aid, European and other developed countries contribute far more of their gross national income (GNI). (GNI comprises gross domestic product plus net income from abroad.) In 2007, according to the Organisation for Economic Cooperation and Development (OECD), the United States spent less than two-tenths of one percent (0.16%) of its GNI toward official development assistance, placing it last among members of OECD’s Development Assistance Committee (see table). Among committee members, only European countries have met the UN target of allocating 0.70% of GNI toward official development assistance.

Meanwhile, other progress in promoting a sexual and reproductive health agenda has been occurring at the global, regional and country levels. Although thwarted during high-level international conferences by the United States and other conservative countries, UN bodies and agencies have nonetheless made key advances in securing reproductive rights.The UN treaty monitoring system has developed a body of important jurisprudence through the committees that evaluate countries’ compliance with the six major international human rights treaties. For example, the Committee on the Rights of the Child, which monitors compliance with the Convention on the Rights of the Child, has interpreted the treaty to require governments that are a party to the convention to provide adolescents (defined by the UN as 10–19-year-olds) with access to comprehensive sexual and reproductive health information, "including on family planning and contraceptives, the dangers of early pregnancy, the prevention of HIV/AIDS and the prevention and treatment of sexually transmitted diseases," ensuring such access "regardless of their marital status and whether their parents or guardians consent."

Similarly, regional-level bodies have carved out important victories for reproductive rights. Again, Europe is at the forefront, as evidenced by the actions of the Council of Europe and of the European Court of Human Rights. For example, in 2008, the Parliamentary Assembly of the Council of Europe issued a resolution recognizing that the "lawfulness of abortion does not have an effect on a woman’s need for an abortion, but only on her access to a safe abortion" and urged restrictive member states to decriminalize abortion within reasonable gestational limits. The European court has also built important precedent for women’s reproductive rights. In a historic case against Poland in 2007, the court found that once governments decide to legalize abortion, they must ensure that obstacles do not impede access to the procedure.The African Union has also made progress through its Protocol on the Rights of Women in Africa, which requires states to "ensure that the right to health of women, including sexual and reproductive health, is respected and promoted." It goes even further by being the first international treaty to articulate a woman’s right to medical abortion on a number of grounds, including cases of rape, incest, endangerment to the physical or mental health of the mother or when the life of the mother or fetus is threatened.

Finally, at the country level, the trend toward recognizing the full range of women’s reproductive rights has continued.While the United States has been pushing for greater restrictions on women’s reproductive autonomy at the domestic and international levels through all branches of the government, 16 nations have liberalized their abortion laws over the last 10 years, and an additional two have expanded abortion access in certain jurisdictions. Only two countries have moved against the tide by removing all grounds for abortion access (see chart).

Forging a New Agenda

Repairing, rethinking and realigning U.S. foreign policies on sexual and reproductive health will be a formidable task, but President Obama has laid the groundwork.The Obama campaign formally expressed its commitment to the current global development agenda by incorporating the language of the MDGs into its campaign platform and promising to support and achieve the MDGs. With respect to foreign aid, the president has conveyed a willingness to ameliorate the low funding situation for family planning programs; as a senator, Obama endorsed increasing funding for international family planning programs to $1 billion.

However, it is one thing to rejoin the mainstream, but quite another to be a recognized leader.There is no doubt that President Obama and Secretary of State Hillary Rodham Clinton are committed to sexual and reproductive health and rights, and to placing a high priority on development assistance within U.S. foreign policy. Indeed, Clinton has been a long-standing champion of women’s rights in general and of reproductive rights specifically. At the 1995 Beijing conference, as head of the U.S. delegation, she forthrightly proclaimed that women’s rights are human rights—a sentiment she reiterated during her Senate confirmation hearing. And she endorsed development assistance—one of the "three legs of American foreign policy"—as "an equal partner, along with defense and diplomacy, in the furtherance of America’s national security." The challenge confronting the administration, then, is not one of philosophy, but one of priority.

There are several ways that the administration, assisted by a supportive congressional leadership, can begin to reestablish the country’s global leadership.The obvious first step would be to increase foreign aid to international family planning programs. As a donor nation, the United States, along with other donor countries, promised to provide one-third of the total funds needed to meet the ICPD benchmarks (with developing countries themselves supplying the rest); however, the United States has not carried its fair share. Accordingly, U.S. advocates are waging a concerted effort to more than double U.S. family planning assistance to at least $1 billion, based on the targets set at Cairo. Indeed, a recently released report by five former directors of the Population and Reproductive Health Program of the U.S. Agency for International Development (USAID) recommends that FY 2010 funding for USAID’s population budget be set at $1.2 billion and raised to $1.5 billion by FY 2014.

Along with bolstering the budget for family planning, and in keeping with the integrated goals of the ICPD and the MDGs, policymakers will need to robustly support other development programs that are crucial to ensuring the promotion of sexual and reproductive health, and vice-versa, such as those addressing girls’ and adult women’s education, and women’s access to vocational training and financial credit.

As Congress embarks on a long-term effort to reform and restructure U.S. foreign aid more broadly, policymakers must look comprehensively at the U.S. global health effort, and confront the reality that HIV/AIDS programs currently claim an extremely high proportion of the total resources allocated. Particularly in difficult economic times, it will be a challenge to "gross up" authorization levels for other critical global health portfolios, including but not limited to family planning and reproductive health.That, however, is what will be necessary to ensure that the country has an effective, global health strategy that in turn feeds into a comprehensive effort to combat poverty and promote sustainable development worldwide.

Although the administration has already dealt with some policy modifications such as rescinding the global gag rule, there are long-term restrictions within the 1961 Foreign Assistance Act that prohibit the United States from funding the full range of reproductive health services in its foreign aid. In particular, the 1973 Helms Amendment bans U.S. funding for most abortion services abroad. In fact, given the high toll paid by women in the developing world who obtain unsafe abortions, there is little reason other than politics that the United States should not join other donor countries in supporting the provision of safe abortion services abroad.Yet, even a more progressive Congress is unlikely to repeal the Helms Amendment anytime soon. Meanwhile, however, at least some of its harmful—and unnecessary, if long-standing—effects could be mitigated administratively through revised field guidance highlighting activities that are, in fact, permissible under the law. Such activities would include USAID support for clinical training under certain conditions; provision of neutral, abortion-related information; and funding of abortion services in cases of rape and incest or where the life of the woman is in danger.

Finally, while the administration works with Congress to ensure the appropriate role of sexual and reproductive health within overall U.S. global health and development efforts, it must not neglect the same advocacy at the international level, where issues of sexual and reproductive health are at risk of being lost among concerns of financial crisis and worsening poverty among both developing and developed countries. It is imperative that the United States reminds others of the integral role of reproductive health in economic development and fights to keep these issues on the world’s agenda.

The Obama administration will have plenty of opportunities in the coming months and years to demonstrate renewed leadership on the global stage, beginning with the ICPD+15 commemoration this year and the 10-year follow-up to the MDGs in 2010. At a range of important conferences, advocates will be looking to the United States to take a strong leadership role in negotiating progressive outcomes for consensus documents, so as to further a progressive and effective policy agenda for population and development. In particular, the world will be watching as the U.S. delegation negotiates a likely MDG+10 outcome document, with advocates monitoring its commitment to tearing down barriers to the vindication of the sexual and reproductive health and rights of millions of individuals across this planet.