Executive Summary

The 1994 International Conference on Population and Development (ICPD) in Cairo codified views long advocated by women's health activists the world over. Their humanistic and feminist goals became cornerstones of Cairo's landmark accord, which recognized the rights of all people to reproductive health, called for special attention to women's empowerment and clients' needs, and repudiated reliance on contraceptive services as the tool for achieving demographic targets. The ratification of the ICPD Programme of Action marked a turning point in the history of the population field—one that brought reproductive health and women's rights to the forefront of the international population agenda.

A new book published by the Population Council, Responding to Cairo: Case Studies of Changing Practice in Reproductive Health and Family Planning, examines global efforts to translate the Cairo commitments into practice.

The case studies in this book examine past and present practice in a variety of settings, highlighting changes, however incremental they may be. Drawn from 22 projects in 18 developing countries, they present the stories of policymakers, program managers, health workers, health advocates, and clients.

The case studies document some seminal changes in policy and practice that have taken place, notably the following:

• Some of the population policies that impinged on women's rights and freedom of choice were abolished or modified—including in India and China. Nonetheless, strong pressures to achieve demographic goals by promoting contraceptive use persist in some settings.
• Sexuality is increasingly regarded as a legitimate part of reproductive health care and is being incorporated into some programs. However, deeply entrenched gender biases remain, and concerted, long-term efforts will be required to eliminate these ingrained obstacles to change.
• A wider range of reproductive health needs is being addressed. Efforts to broaden the content of services have met with considerable success, often at low or no additional cost. Progress in this area has been enhanced by some technological innovations (e.g., the development and distribution of manual vacuum aspiration for early abortion or the treatment of abortion complications), and has been hindered by some technological gaps (e.g., the lack of simple, low-cost methods to diagnose reproductive tract infections and of female controlled methods of sexually transmitted infection prevention, such as microbicides).
• The social and economic antecedents of women's reproductive health problems can be successfully addressed and overcome. Efforts to empower women as health care consumers, equal partners in sexual relationships, and important members of their families and communities are feasible and desired.

Part I: Moving National Health and Family Planning Systems Toward a Client Center

Violations of women's reproductive rights have occurred throughout the world, but some of the most widely condemned took place in India under its contraceptive target system, in China under its birth planning program, and in South Africa under apartheid.

Following the Cairo conference, policies that permitted abuse in these settings were abandoned or modified. In each country, change in national-level policy was necessary before meaningful change could occur in service-delivery systems. While national policy change sets the stage, responsibility for the details of implementation typically falls to officials at the state, province, county, and district levels. Part I chronicles examples of such field-level implementation efforts in each setting.

For example, in 1996 India abolished its contraceptive target system, under which health workers were evaluated based on the number of individuals recruited for particular contraceptive methods, particularly sterilization. The districts profiled in this chapter demonstrate considerable variation in the degree to which centrally-defined contraceptive targets have been replaced by goals health workers set themselves after assessing community reproductive health needs. 

In 1995 China initiated an experiment to improve quality of care, primarily by expanding contraceptive choice. However, absolute limits on the number of children remain. Chapter 3 documents the experiment's implementation and effects in Deqing county. 

In 1994 South Africa ended apartheid and in the ensuing years began restructuring its health care system to overcome decades of racism and neglect of primary care. 

Chapter 4 profiles an innovative project, carried out by a women's health organization and the government, to improve the system by making existing services more client centered. The underlying principle was that discrete reproductive health services could not be layered onto existing services until the latter had undergone significant reform.

Part II: Reorienting Programs to Meet the Needs of Clients and Health Workers

Part II explores what can be done to reorient providers to a new service-delivery paradigm, give them new protocols, and support them in their new roles. The two examples are found in Southeast Asia and East Africa, but the service-delivery challenges they concern are commonplace.

Chapter 5 describes a simple analytic tool designed to assist community outreach workers in the Philippines to understand their clients' needs. Rather than start with the assumption that all women of reproductive age need to use contraception, the tool helps workers to elicit information about—and to respect—women's reproductive intentions and desires. Women who are pregnant, who want to become pregnant, or who want to delay or cease childbearing are all given appropriate information and services.

Chapter 6 recounts the efforts of staff and supervisors in a government hospital in Tanzania to improve the quality of family planning services using such tools as COPE (Client-Oriented Provider-Efficient) and QMT (Quality Measuring Tool). Using these tools, staff assess themselves using written guides that prompt reflection about issues ranging from clients' rights to privacy to providers' needs for facilitative supervision. Staff then institute changes to address the deficiencies they identify, and iteratively assess their progress.

Part III: Addressing Sexuality, Gender, and Partners in Services

The ICPD agenda highlighted the role of social factors that facilitate or impede women's attainment of reproductive rights and health. Service providers cannot effectively care for clients without grappling with factors related to women's sexual partnerships and social context. In providing reproductive health care, providers come face to face with inequities in gender relations; norms that inhibit women from discussing sexual matters and that condone male promiscuity; and substantial numbers of women facing coercive sexual relations.

The first three case studies presented in Part III explicitly acknowledge clients as sexual beings in relationships. Chapter 7 documents the institutional change process undertaken by Profamilia in Colombia to incorporate sexual health services into its nationwide family planning program. As is often the case, program staff needed as much assistance as clients in dealing with social norms and biases regarding sexuality and gender. A manual, developed by the counselors themselves, provides guidance on the types of sexual health issues to address with clients with different needs and backgrounds.

Chapter 8 profiles the evolution of an adolescent program in Nigeria from a gender-neutral, school-based effort focused on abstinence to a more comprehensive, gender sensitive sexuality education program. 

Chapter 9 describes the process and effects of incorporating sexuality counseling into government family planning clinics in Egypt. Even in this conservative cultural setting, providers were able to address issues of sexuality with clients and women sought and valued these discussions.

The final two chapters in this section offer specific suggestions for involving clients' partners. One describes a program in Egypt to involve men in postabortion care, the other an effort in Turkey to increase men's support of their wives during the pregnancy, delivery and postpartum periods.

Part IV: Addressing Neglected Reproductive Health Concerns

Perhaps the most widely discussed element of the ICPD agenda has been the charge to expand narrowly conceived family planning services to include neglected aspects of reproductive health care. Women have a range of pressing reproductive health concerns, including infertility, unwanted pregnancy and the complications of abortion, cervical and other gynecologic cancers, reproductive tract infections (RTIs) and HIV/AIDS, postpartum care, emergency contraception, symptoms of menopause, obstetric fistulas, genital or uterine prolapse, and female genital cutting (FGC).

Part IV focuses on efforts to broaden the spectrum of services beyond customary contraceptive service delivery. Chapter 12 describes the integration of compartmentalized family planning, gynecologic, and obstetric services in a Nigerian hospital into a center that brought these disparate elements together. In this case, as in others, the reinvention of reproductive health care did not require substantial additional resources. Rather, it required creativity, political will and persistence to overcome entrenched patterns of service organization.

Improving the quality of postabortion care in a hospital in Mexico by assessing and then improving providers' interpersonal skills, technical capacity, and postabortion family planning counseling is the focus of Chapter 13. Chapter 14 describes how a family planning organization in Venezuela began to screen for gender violence among its clients and to support women who had experienced abuse.

Concluding Part IV are two chapters that explore the challenge of managing reproductive tract infections in the context of family planning and general reproductive health care. 

Chapter 15 profiles an innovative project in Mexico that sought to address sexually transmitted infections (STIs) among family planning clients. Women were given the opportunity to choose their own contraceptive method after receiving information about contraceptives and STI prevention, including the risks involved in IUD use when an infection is present. More than 50 percent of women who had infections chose not to use the IUD. By contrast, only 5 percent of infected women whose risk was assessed by physicians were correctly advised not to use the IUD. 

Chapter 16 provides an overview of RTI prevalence and consequences, challenges in RTI management in low resource settings, and potential avenues for intervention.

Part V: Working with Communities and Women to Improve Reproductive Health and Rights

The previous parts of this volume dealt with changes at the policy level and attempts to improve services. These efforts can go only so far without addressing the social norms that perpetuate restrictive gender roles, tolerate or even foster abuse between partners, encourage unsafe sexual behavior, and limit women's power in intimate relationships and in interactions with health care providers.

Improving the quality of services and making them more responsive to women's needs requires some degree of community change. Clients' low expectations and passivity, the historical paternalism of the medical profession, and limited community engagement in the design of most health programs have curtailed the efficacy of service reform. The first three chapters in Part V document activities that empower clients to challenge the health care status quo and to demand more as consumers.

Chapter 17 recounts the transformation of a family planning organization in Belize from a clinic-based program founded on contraceptive service delivery to one that facilitates community discussions on a broad range of reproductive health concerns and responds to the priorities identified by community members. 

Chapter 18 describes the work of a consortium of feminist organizations in Peru to provide women with a sense of their rights as health care consumers and sensitize providers to quality of care and clients' rights, ultimately bringing these two constituencies together to improve the quality of reproductive health services. 

Chapter 19 documents a project to improve the quality and quantity of municipal reproductive health services in Brazil on the basis of intensive community participation in the identification of priorities and development of appropriate responses.

Two chapters (20 and 21) describe efforts in Peru and Nepal to empower women through group formation. Women were given the opportunity to identify the reproductive health and gender concerns most important to themselves and their communities and to begin to address these concerns in ways that clinic-based services cannot. These chapters also suggest lessons for involving men without diminishing women's autonomy. The sequencing of activities is critical: Once women have gained a better understanding of their own needs and a sense of solidarity with other women, they themselves often seek to involve men.

Chapters 22 and 23—set in Tanzania and Kenya—document an incremental process of revolution: programmatic efforts to change how entire communities regard women and to replace norms and rituals that perpetuate violence against women and girls.

The successes and challenges documented in this volume offer many ideas and much encouragement to those engaged in efforts to realize the ICPD agenda. These efforts are works in progress. Certainly much remains to be done; but many creative activities in many places are taking the Cairo vision out of the realm of theory and into the realm of practice. This is the ground-level arena of real change in women's lives.