Author(s): Amy J. Higer
Explaining the Influence of the International Women's Health Movement
Many in the population field began to take seriously the concerns of the women's health movement when they realized that population programs which ignore women's concerns will be ineffective over the long-term. They saw a need to create programs that would go beyond mere distribution of contraceptives in order to meet a range of women's reproductive health needs. In this way, the IWHM offered an alternative approach to population control that promised better results.
Changes in the political context over the past decade also facilitated feminist influence. Paradoxically, in the hostile climate to women's reproductive rights of the Reagan-Bush years, U.S.-based women's health and rights groups working transnationally began to attract significant financial support from private foundations to strengthen their international efforts.3 This influx of funds to women's health groups enhanced the movement's ability to disseminate its message and heightened its visibility in policy circles. Equally important, it also aided efforts to establish or strengthen ties with disaffected, but poorly-funded and politically marginalized feminist health groups around the world. Such transnational networking has contributed to transforming the IWHM from a loose array of scattered oppositional groups into a global lobbying force of considerable strength, as evidenced at the Cairo Conference.
The work of women's health advocates has been aided also by the increased presence of feminists within foreign-aid bureaucracies. More than ever before, women are occupying the higher ranks in agencies that were formally the exclusive domain of male bureaucrats. Although women in positions of power may not necessarily be advocates for a women's health agenda, they are more likely to be sympathetic to women's health concerns than their male colleagues. Finally, the Clinton administration's renewed interest in population issues and its more favorable position on women's reproductive rights have lessened the ideological resistance within the government to the IWHM's ideas and agenda.
Although helpful in explaining the IWHM's increased salience as a political actor in U.S. population policy, these factors are insufficient in explaining the movement's influence on the current policy agenda. To understand recent accommodation to feminist concerns in AID, we must also recognize the existence of two feminist views about population policy and social change, both of which represent strands of the IWHM. The first takes a more reformist stance to policy change, while the second is more radical in its perspective.
The reformist strategy calls for a reproductive health approach to family planning and "population stabilization." This would provide women with access to a broad range of contraceptive method choice and reproductive health services, including treatment of sexually transmitted diseases, HIV/AIDS, and reproductive-related illnesses; access to safe abortion services; provision of sex education; and inclusion of men in family planning programs, education, and outreach. It accepts, though does not necessarily endorse, the idea that a demographic rationale continues to underlie U.S. population expenditures, and that "women's reproductive health" is, in the current context, insufficient on its own as a rationale for the allocation of money and resources.
An alternative, more radical view repudiates the idea of population policy entirely, and, as such, is an outlook not likely to be endorsed by AID's Office of Population. It turns on the notion that population sustainability or control tends to lead to coercion, and that only a women's health framework will result in programs that (1) do not treat women and their health instrumentally, (2) respect and promote women's needs and interests, and (3) do not hold funding for women's health care hostage to demographic results. In this alternative paradigm, family planning programs would be fully integrated with overall health care services. Although these positions are counterposed here, it is perhaps more realistic to regard them on a continuum, as there is, in practice, some overlap on important issues.4
Recent changes in AID's population program appear to reflect some accommodation to the reformist feminist agenda. However, because it is likely to result in programs that continue to treat women's rights and health as a means to the ultimate goal of population decline, the reformist strategy may prove to be a tenuous one for advancing women's health and overall status in developing countries.
Recent Changes in the U.S. Population Program
Broad changes in U.S. foreign aid over the past two years create the current structure for population policy. Under the Clinton administration, AID has undergone the most extensive reorganization in its history. The agency is under particular pressure to scale down, with Congress calling for ever deeper cuts in the foreign assistance program. When adjusted for inflation, the administration's FY 1994 budget request for foreign aid of $14.4 billion is the smallest in two decades. As part of the attempt to meet new budgetary constraints, AID has had to scale back its operations. Much to the disappointment of many in the wider development community, AID has chosen not to prioritize the poorest countries for its aid programs, but to continue emphasizing those with high birth rates. In addition, although the reorganization has signified a move away from functional categories for development aid and toward the support of broad global objectives, "population" has remained a discrete category for foreign aid. As AID Administrator J. Brian Atwood explains, population is one area in which the agency can point to real progress.5 "Progress" here is measured by increased contraceptive prevalence world-wide and declining global population. The skepticism of prominent Republicans in Congress about the whole enterprise of foreign aid has only intensified the pressure on AID to demonstrate program effectiveness.
In its new population program, AID does seem, at first glance, to have accommodated some feminist concerns. Upon closer inspection, however, we can discern two contradictory tendencies. On the one hand, there has been substantial movement toward broadening the approach to family planning services, reflected in a rhetorical emphasis on "reproductive health" and "women's empowerment." This broadening trend has been reinforced by organizational restructuring of the agency that has sought to integrate to some extent the Office of Health with the Office of Population under a new umbrella structure called the Center for Population, Health and Nutrition (PHN). Further bolstering this new direction are some recent initiatives that are designed to address a more diverse array of issues, including some that clearly reflect feminist concerns.
At the same time, however, there appears to be strong pressure within the agency, including inside the Office of Population, to maintain the distinctiveness of the population program and to resist its "dilution" through a broader health approach. This pressure is indicated by the decision to retain senior officials who are outspoken defenders of old approaches. It is seen also in contradictory language found in the very same documents that espouse a new integrated approach. For example, official documents and speeches no longer contain the abrasive language of the past ("population stabilization" is now used instead of the coercion-tinged "population control," and "women" or "end-user" have replaced "population targets" and "acceptors"). Support for women's reproductive rights, moreover, has been given equal billing with the goal of stabilizing world population growth. At the same time, however, these documents repeatedly state that the Office of Population remains firmly committed to keeping family planning at the core of its population program. Further, family planning programs will still be "results-driven,"6 that is, they are to be oriented toward "population stabilization," rather than toward goals articulated by women themselves. In this sense, AID's policy objectives are ambiguous: are new reproductive health policies designed to promote women's reproductive health and rights; or are they intended to foster population decline? Is the former a policy objective on its own, or is it a means to achieve the latter? If the "new reproductive health interventions" touted by AID are merely a means to an end, will they be designed and implemented in a manner that addresses women's needs and interests?
Looking beyond written materials to new policy initiatives and organizational change, we get a somewhat clearer picture of what is going on, but, again, the overall mission of AID's population policy is still cloudy. The following initiatives reflect some movement toward reform. First, the creation of the PHN Center has lessened to some extent the bureaucratic and disciplinary divide between population and health by integrating the formerly segregated staffs of "Health" and "Population" and creating an opportunity for ongoing communication between the two offices. Second, a "reproductive health survey" was taken of both AID Missions overseas and organizations funded by AID in order to create a database of current or planned projects which go beyond family planning to incorporate "reproductive health interventions."7 Third, new demographic survey questions will address the incidence of STDs/HIV transmission, maternal mortality, post-abortion care, and domestic violence-all items on women's health agendas. Finally, efforts are also underway to expand methods and criteria for the evaluation of family planning program "effectiveness."8
Still, new policy initiatives, as well as the extension of some old ones, send mixed messages about AID's commitment to women's health perspectives. For example, a 1993 request for proposal for a Women's Studies Project to study women's experience with family planning programs in several countries aroused much interest in the women's health community and inspired optimism about new directions for AID's population program. Activists were disappointed, however, when AID awarded the grant to a mainstream family planning group, despite the fact that many new women's health groups submitted innovative proposals.9 In addition, several AID-funded research agencies continue to highlight long-acting, "provider-dependent" methods, such as IUDs, injectibles, and hormonal implants.10 These methods are precisely the ones that women's health activists have long lobbied against as inappropriate in Third World settings for a variety of reasons, and as serving better the interests of "population controllers," than women.
Finally, although there is some rhetorical commitment to giving greater attention to men in family planning programs, there is little concrete evidence of outreach efforts. Aside from increased condom distribution, which more reflects a stop-gap response to the AIDS crisis than a concerted effort to incorporate men into family planning efforts, new initiatives do not specify men's role in contraception and reproduction. Because men's sexual behavior is a major determinant of contraceptive use by women, (and women's health in general), resistance to movement in this direction could well be interpreted as back-pedaling on a commitment to a new approach to population.
This preliminary review of new policies at AID indicates that a gap between rhetoric and reality is at the moment serving to cloud what is actually taking place in U.S. population policy. There are two ways of understanding this current distance between what is being said and what is being done, each with different implications for outside advocates.
First, bureaucratic politics may explain current policy incoherence. In this regard, we find an office and an agency that are internally divided over its population mission. While some bureaucrats are deeply wedded to the view that population decline must remain the overriding goal, and that any new policy intervention must serve this end, others are more polygamous in their commitments, and see the possibility for incorporating multiple goals into population programs. These inside advocates have already achieved a measure of success in getting the more liberal members in the agency to acknowledge, and speak out against, coercion in population programs. In this way, they can been seen as allies for outside reformers seeking to effect change in AID's population agenda. If the explanation for the disjuncture in new policy rhetoric and initiatives is rooted in bureaucracy, feminist health advocates seeking to effect change over the long-term should be encouraged by recent movement in the agency. Accounting for lag-time, much appears to have changed in AID's population policy, and changed rather rapidly. With this interpretation, advocates would be well-advised to continue lobbying the agency, while using some of the new rhetoric to hold it accountable to the reproductive health and rights agenda.
A second possible explanation for the present incoherence in U.S. population policy, however, suggests caution for women's health advocates seeking to reform AID's population program. A gap between what AID is saying and what it is actually doing may be due to the fact that the goals articulated in the new population strategy are incompatible. The dual purpose of promoting population decline and increasing women's reproductive freedom may ultimately turn out to be unworkable in practice. Clearly, there will be instances in which women's reproductive rights and population policy aiming to bring down birth rates will come into conflict as a result of a strategy in which family planning programs are designed and intended to curtail female fertility. Indeed, historically, these two goals have always come into conflict when governments have instituted population policies, whether they be anti- or pro-natalist. From the historical record, we know that it is virtually always women's reproductive freedom that is compromised when governments seek to regulate birth rates.
We can see the seeds for this conflict in AID's strategy today. Despite frequent invocations touting the new "synergy" in the population and health strategy, the population framework continues to isolate women's need for contraceptives from related health needs, and to view women's health only through the prism of how it affects, and is affected by, their childbearing capacity. AID's population program seems still focused on the question of how it can get women to practice family planning, rather than how it can help women and men meet their own goals. Surely women's health activists must remain engaged in the debate to ensure that U.S. population policies are not administered in a coercive and unhealthful manner. Ultimately, however, if the goal of activists and reformers is to secure from government a genuine commitment to advance unconditionally the reproductive freedom and health of individuals, they may need to look beyond the population paradigm for a more promising international agenda.
1. The bulk of U.S. population funding is channeled through AID and is expended by the Office of Population, an office within the Agency.
2. The bureaucratic structure of the agency and commitment to past funding obligations-with typical projects lasting five to seven years-render budgetary appraisals difficult at this point. Policy innovation in the Office of Population is also constrained bureaucratically by the fact that the Office must make an internal argument to convince the rest of the Agency, as well as Congress, that it is spending limited resources in the most efficacious way.
3. Indeed, by the end of the 1980s, the Ford Foundation, one of the original funders of international population programs, went so far as to rename its population program "Reproductive Health." (See Reproductive Health: A Strategy for the 1990s, A Program Paper of the Ford Foundation, June, 1991.)
4. For example, both sets of feminist are generally wary of contraceptive methods that do not prevent STDs and HIV/AIDS, and which render the user overly dependent on the provider both for the administering and particularly for the removal of the method. Moreover, both perspectives advocate the right to safe, legal and affordable abortion.
5. J. Brian Atwood, "More Than Words: US-AID's Approach to the Population Problem," Harvard International Review, (Fall, 1994), p. 29.
6. Population, Partnerships, Opportunities and Challenges Appendix F; and "Strategies for Sustainable Development."
7. USAID Reproductive Health Baseline Survey: A Survey of Projects and Activities Implemented and Planned by USAID Missions and Cooperating Agencies, Report Prepared by Barbara Pillsbury and Gisele Maynard-Tucker for the Reproductive Health Task Force, USAID, (June, 1994, revised August, 1994), p. 22.
8. This initiative part of an ongoing project called the EVALUATION Project, run out of the University of North Carolina. [Guide to the Offices of Population, Health and Nutrition, (Draft Version), February 1994.] Both initiatives suggest that qualitative indicators, in addition to quantitative ones, will be used to assess the effectiveness of family planning services, and as such, may potentially result in extensive programmatic change.
With regard to its abortion policy, AID has been restricted since 1973 by the Helms' amendment in its funding of abortion services abroad. Under the Clinton administration, the Agency has sought to push the boundaries on what it can do under current law. Its present policy of addressing complications stemming from botched abortions as a medical emergency probably extends the boundaries as far as they will go. In light of the limitations imposed on abortion during the Reagan-Bush era, AID's current "post-abortion" initiative represents a dramatic change in U.S. policy. Still, this assessment must be placed in context; given the shockingly high incidence of morbidity and mortality resulting from unsafe abortion worldwide, pressure to repeal the Helms' amendment must be seen as an essential component of any policy that purports to address women's health needs in developing countries.
9. The organization that received the grant is Family Health International, based in North Carolina.
10. See Guide to Office of Population, Health and Nutrition, descriptions of the following cooperative agreements: Training in Reproductive Health II and III; Central Contraceptive Procurement; Association for Voluntary Surgical Contraception Program; and Contraceptive Social Marketing III.'