Hundreds of health care advocates from around the world gathered in London last week to celebrate the midway point of a two-decade journey to achieve universal access to sexual and reproductive health care services by 2015. But hurdles in their path cast a shadow over the meeting, leaving participants with mixed feelings as they departed from the three-day conference.

To be sure, advocates savored their successes over the last decade. Since 1994, access to and quality and usage of contraceptives has been on the rise, the rate of population growth has slowed and government and nongovernmental officials now take the role of women into account when devising population and development policies. Nevertheless, delivery of sexual and reproductive health services has slowed, if not stalled, in some regions of the world, thanks to the rapid spread of the HIV/AIDS virus, a shortfall in funding for reproductive health programs and the rise of a anti-choice government in the United States. Meanwhile, the rates of teen pregnancy and maternal mortality remain high. "In general, there was a certain ambivalence," Frances Kissling, president of the Washington, D.C.-based Catholics for a Free Choice, recalled upon her return from London. "The big question on everyone’s mind was whether the glass was half empty or half full."

The Cairo Consensus

In 1994, international delegates from 179 United Nations member states met in Cairo, Egypt, and set a 20-year time frame for curbing the population explosion, reducing poverty and advancing women’s rights by improving access to sexual and reproductive healthcare. By 2015 they committed the world to being a place where all people who wanted access to sexual and reproductive health services could have it. Participants at that International Conference on Population and Development pledged to invest billions of dollars in, among other things, programs to improve the lives of women and girls in the hopes that better health care, better education and more work opportunities would enable them to improve their family and community well-being.

The plan represented a radical break from previous population meetings because it involved interviews with local men and women and onsite evaluations of area clinics - a more personal approach to population and development planning than had previously existed. In the past, planners had taken a more numbers-based approach, using statistics and demographics to plan public health initiatives. Now, at the midway point of the two-decade schedule, some 700 health care professionals from Non Governmental Organizations around the world attended the "Countdown 2015" conference to assess how to overcome the key setbacks that have slowed the delivery of reproductive health care services.

Time for Plan of Action

"It’s time to have a plan of action," says Amy Coen, President of Population Action International, an advocacy group in Washington, D.C., that promotes reproductive health. "It’s time to once again . . . make sure that the last 10 years really, really does what it can". This conference marked the beginning of a protracted assessment of the Cairo Consensus this fall.

On September15, the United Nations Population Fund released a report on progress toward implementing the agreement. Throughout the fall, health care professionals will hold meetings in several U.S. cities and around the world. On October 14, the United Nations General Assembly will devote a day to commemorate the 10th anniversary of the agreement. During these meetings, advocates will wrestle with strategies to overcome setbacks over the last decade. One of the major challenges is a considerable funding shortage.

In 1994, participating countries pledged to invest a combined $17 billion per year by 2000, $18.5 billion by 2005, $20.5 billion by 2010 and $21.7 billion by 2015. More affluent donor nations promised to put up one-third of the total investment while developing countries agreed to do the rest. But the donor nations, including the United States, have not made good on their promises, according to Kristin Hetle, a spokesperson at the New York-based United Nations Population Fund. Developing countries have fulfilled 80 percent of that promise while donor countries have given only 50 percent, she said, adding: "There are very few countries that have actually paid their bill in full."

At the same time, the spread of HIV/AIDS and the largest-ever generation of young people has put an added pressure on the need for resources for contraceptives and reproductive and sexual health care services. In addition, the Sept. 11, 2001, terrorist attacks and the lackluster economy have drawn resources and attention away from non-profit programs.

Strings Attached

Moreover, U.S. funding now has strings attached thanks to the policies of the Bush administration.

In 2001, President Bush, on his first day in office, reinstated the so-called Mexico City Policy, also known as the global gag rule. That was a policy put in place by the Reagan administration in 1984 and revoked under the Clinton administration. It bars U.S. family-planning assistance to any foreign health care agency that uses funds from any source to perform abortions, provide counseling and referral for abortion or lobby to make abortion legal or more available in their country. To receive U.S. funding, the agencies may perform abortions only when there is a threat to the woman’s life or the pregnancy is the result of rape or incest.

Many clinics were forced to shut down in the wake of Bush’s decision; still others lack funding needed to operate and face closure. In Kenya, for example, three family planning clinics shut down after Bush made the change and six more face closure; In Bangladesh, seven clinics closed after the policy’s reintroduction and services were suspended in seven others. And in Tanzania, three clinics in hard to reach areas face closure.

The lack of clinics prevents men, women and children from receiving basic health services such as pap smears and treatment for respiratory infections, health care advocates maintain. It also takes away distributors of condoms and other means to combat the spread of HIV/AIDS and other sexually transmitted diseases.

The Bush administration has also scaled back funding for the United Nations Population Fund, the world’s largest international source of funding for population and reproductive health programs. Funding shortfalls have led to unwanted pregnancies, unnecessary abortions and the deaths of mothers and children in many countries, program officials say.

Abstinence Until Marriage

Meanwhile, the Bush administration has promoted a policy of abstinence until marriage, a transition that Coen called "really scary." The administration’s so-called ABC policy - A for abstinence, B for be faithful and C for condoms when necessary - undervalues the need for condoms to prevent sexually transmitted diseases, health care advocates say. They also complain that a percentage of U.S. funding for HIV/AIDS is also directed to abstinence before marriage, taking funds away from other programs they consider more important.

"The Bush administration is really an obstacle to achieve the Cairo goals", said Odette Salden, who works for the World Population Foundation, a Dutch organization that advocates sexual and reproductive health rights. "It will be very difficult to overcome this administration". To address these problems, advocates agreed at the London conference to continue lobbying the U.S. government for greater access to sexual and reproductive health care services and to continue to use the media as a pressure point to push for more funding and to overturn conservative anti-choice policies.

In the meantime, advocates will continue to celebrate a decade’s worth of victories, one of the most stunning of which has been the declining rate of population growth: In 1994, the world’s population of 5.6 billion was growing at 93 million people per year. Today, the 6.4 billion people on earth are growing at a rate of 77 million per year.

And despite funding shortages, the Cairo Consensus has drawn money and attention to the dearth of reproductive health services that otherwise would not have been there.

The Cairo goals were "totally ambitious," said Jill W. Sheffield, founder and president of Family Care International, a nonprofit organization based in New York and dedicated to improving the safety of pregnancy and childbirth. "There really has been progress," Sheffield said. "There’s been a lot of progress."