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U.S. Department of State

Great Seal Julia V. Taft
Assistant Secretary for Population, Refugees, and Migration

U.S. Response to the UN Population Fund on Implementation of the International Conference on Population Development (ICPD) Programme of Action, July 1998

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UNFPA Inquiry of Country-Level
Experience Since ICPD

I. Population Concerns and Issues

1. Please describe current major population issues and concerns within your country, and any measures that have been taken to address these issues since ICPD.

The United States has a diverse and growing population; despite fertility levels below replacement, it is the fastest-growing industrialized nation, due to the momentum of past growth and increasing immigration. The United States does not have a national population policy or any policies aimed consciously and directly at these demographic trends. Various U.S. national policies, such as immigration policies, are recognized as having a demographic impact, however. Increasingly, consideration of the demographic, economic, and social impact of immigration are playing a role in the formulation of U.S. immigration policy.

The U.S. Government recognizes the impact of population growth in the United States on the prospects for environmentally sustainable development and is taking measures to, among other things, reduce greenhouse gas emissions, promote energy efficiency and alternative fuels, and develop more sustainable agriculture. National standards are in place to regulate, for example, pesticides, effluents, ambient air quality, water quality, noise emissions, and ocean dumping. A few measures, such as restrictions on housing in national parks, directly affect human settlements. At the State and local levels, authorities may implement zoning, infrastructure requirements, taxation, and other measures to influence housing or economic activity in geographic areas under their jurisdiction.

While significant progress has been made in recent years on major indicators such as life expectancy, infant mortality, maternal mortality, and contraceptive prevalence, substantial disparities among socioeconomic groups remain within the United States and continue to be a source of concern.

The U.S. Government, as reflected in the "Healthy People 2000" report, aims to achieve 17 broad objectives and an additional 28 subobjectives targeting at-risk populations. These broad objectives include reducing the infant mortality rate to no more than 7 per 1,000 live births by the year 2000; reducing the maternal mortality rate to no more than 3.3 per 100,000 live births by the year 2000; reducing low birth weight to an incidence of no more than 5% of live births and very low birth weight to no more than 1% of live births by the year 2000; reducing severe complications of pregnancy to no more than 15 per 100 deliveries by the year 2000; increasing to at least 75% the proportion of mothers who breastfeed their babies in the early postpartum period and to at least 50% the proportion who continue breastfeeding until their babies are 5 to 6 months old; increasing abstinence from tobacco by pregnant women to at least 90%, increase abstinence from alcohol by pregnant women to at least 90% and increase abstinence from cocaine and marijuana to 100% by the year 2000; and increasing to at least 90% the proportion of all pregnant women who receive prenatal care in the first trimester of pregnancy by the year 2000 (see "Healthy People 2000" pp. 366-390). A "Healthy People 2010" to update "Healthy People 2000" is now under preparation and is expected to be released by the end of 1998.

The U.S. Government also is concerned about the impact of other demographic changes on the health and well-being of the nation's population. In particular, low levels of fertility and mortality have resulted in an aging population. The government has supported studies of the impact of aging and has developed policies to maintain strong programs of social security and other care for the elderly (as called for in paragraphs 6.16-6.20 of the ICPD Programme of Action). The government also has been committed to improving programs for children, youth, and families, as exemplified by the Community Health and Migrant Health Centers, funded by the Bureau for Primary Health Care in the Health Resources and Services Administration of the U.S. Public Health Service. These centers are especially designed with underserved populations in mind. However, the U.S. Government has not sought to determine the most desirable balance among age groups or to design policies to influence the balance.

Approximately 40,000 new HIV infections occur in the United States every year. Racial and ethnic minority populations (Blacks, Hispanics, Asian and Pacific Islanders, and American Indian/Alaska Natives) are disproportionately affected by this disease. More than 50% of all new HIV infections in the United States are in racial and ethnic minority populations, despite the fact that they constitute approximately 25% of the U.S. population. Of specific concern are the increasing rates of HIV infection in women, youth, and heterosexuals. Intravenous drug use associated with HIV infection cases now accounts for almost 40% of all new HIV infections. AIDS is the leading cause of death in black men and women aged 25-40 and the second-leading cause of death in Hispanic men aged 25-40. Furthermore, the incidence of sexually transmitted diseases--an estimated 12 million new cases occur each year in the United States--and the considerable health and economic consequences associated with STDs are of concern.

The special needs of adolescents also are a major concern of the United States. In particular, the U.S. is concerned with individuals bearing children at too young an age (thus interrupting school or university), out of wedlock childbearing, the welfare of adolescent mothers, and the welfare of children born to adolescents.

Finally, private insurance coverage of family planning services in the United States is inadequate, although legislation to change this coverage appears imminent. At present, most private insurance companies do not cover screening and contraceptive services. Fully half of all large insurance plans cover no method of prescription contraception. As a result, women of reproductive age in the U.S. pay 68% more in out-of-pocket health care costs than men the same age.

2. Have there been any major developments in your country since ICPD on improving the access to reproductive health care?

a. No major developments
b. Yes (Please describe some of the key developments.)

Yes. The Freedom of Access to Clinic Entrances Act of 1994 (FACE) was enacted in response to a nationwide campaign of often violent and obstructive interference with access to reproductive health services, specifically aimed at facilities and individuals that provide abortions. FACE makes it a federal crime to use or attempt force, the threat of force, or physical obstruction to injure, intimidate, or interfere with providers of reproductive health services or their patients. FACE also outlaws damaging or destroying the property of a reproductive health facility. Violations of FACE are criminally prosecuted by the U.S. Department of Justice and also are subject to civil protections.

The federal Title X family planning program provides family planning services to all qualified persons (on the basis of income) who want them. More than 4,000 clinics nationwide serve nearly 5 million clients each year. Services are provided at no cost to persons with incomes below the Federal poverty level and on a sliding-fee scale to all others. Other programs, including the Medicaid program and the Maternal and Child Health and the Social Services Block Grant programs also provide family planning services to low income persons. Although these programs predate the ICPD Programme of Action, the United States, in agreement with the document's tenets, continues to support them.

The federal Title X family planning program has provided services to adolescents since it was enacted in 1970; about 30% of Title X clients are less than 20 years of age. Services also are available to men, although adult and adolescent men represent only 2% of Title X clients. Beginning in 1996, the Title X program began special initiatives to increase male involvement in family planning. Supplemental funding was provided to each region to begin demonstration projects employing adolescent males in Title X clinics while also providing them with reproductive health and family planning education and services. The program also awarded research grants, in 1997, to organizations providing other social and educational services to males, to implement and evaluate the addition of a reproductive health and family planning component to their existing program.

Since the ICPD, recognition in the academic and scientific fields of women's health has become more widespread in the United States. Many medical practitioners have come to address the needs of women as the primary caretaker in the family by modifying their practices to be more conducive to women's needs and requirements. Medications are now tested on both women and men. Breast, ovarian, and cervical cancers are now given just as much attention as typical "male" cancers, like prostate or colon cancer. One example of this is the creation of six National Centers of Excellence in Women's Health that provide state-of-the-art comprehensive and integrated health care services and multidisciplinary research and public and health care professional education targeted toward the special needs of women.

Since the ICPD Programme of Action was adopted, the U.S. Department of Health and Human Services (DHHS) has continued its many programs for prevention and treatment of, as well as research on, STDs, including HIV/AIDS. The leading agencies in this effort are the Centers for Disease Control and Prevention and the National Institutes of Health. In addition, various parts of DHHS support and/or provide STD-related clinical services.

In 1997, the U.S. Food and Drug Administration approved the relabeling and marketing of oral contraceptive pills as emergency contraception, which was aimed at preventing unintended pregnancies.

Finally, as referred to in question 1, both the U.S. House and Senate recently approved a law requiring insurance companies to cover most prescription contraceptives for federal employees.

3. Have there been any major developments in your country since ICPD addressing the special needs of adolescents in reproductive health care?

a. No major developments
b. Yes (Please describe some of the key developments.)

b. Yes. The special needs of adolescents are a major concern of the United States, as noted in question 1 above. There are several government programs in place to address the issues of concern, including Title XX Adolescent Family Life Program; Community Coalition Partnership Program for the Prevention of Teen Pregnancy, U.S. Centers for Disease Control and Prevention; Abstinence Education Block Grant program, U.S. Department of Health and Human Services, Maternal and Child Health Bureau; the previously mentioned Title X family planning program; the Medicaid program; and the Maternal and Child Health and Social Services Block Grant programs provide federal funds for family planning and reproductive health services. Adolescents make up a substantial proportion of the client population of these programs.

The Department of Education is funding the development of a resource directory that informs educational practitioners; health professionals; federal, state, and local agencies; parents; and adolescents about issues and school-linked programs affecting the outcomes of adolescent pregnancy and parenting.

The United States has set a goal for the year 2000 to increase to at least 90% the use of contraception among the sexually active, unmarried people aged 19 and younger.

4. Have there been any major developments in your country since ICPD on protecting the rights of women and promoting the empowerment of women

a. No major developments
b. Yes (Please describe some of the key developments.)

Yes. The United States is a leader in recognizing the rights and advancing the status of women. In 1995, President Clinton set up an interagency council to follow up on the United Nations Fourth World Conference on Women. The President's Interagency Council on Women is charged with coordinating the implementation of the Platform for Action, including the U.S. commitments announced at the conference. The Council also is charged with developing related initiatives to further women's progress and engage in outreach and public education to support the successful implementation of the conference agreements. Secretary of State Madeleine K. Albright is the Chair of the Council, and First Lady Hillary Rodham Clinton is Honorary Chair.

Both as a result of the Interagency Council's work and the momentum gained at the ICPD in 1994, there have been several significant developments in the United States in protecting and promoting the empowerment and human rights of women, in particular, those in the areas of preventing and eliminating violence against women and increasing women's capacity to participate in decisionmaking and leadership. Following are several specific examples of initiatives and programs that have been put in place since ICPD.

Violence Against Women. The Violence Against Women Act of 1994 combines tough new penalties with programs to better prosecute offenders and help victims of violence. In 1996, President Clinton announced the opening of a federally funded 24-hour National Domestic Violence Hotline to provide crisis assistance and local shelter referrals to victims of domestic violence throughout the country.

Immigration (Battered Spouses and Children). The Immigration and Naturalization Service published an interim rule in 1996 allowing battered spouses and children of citizens or legal permanent residents to become legal permanent residents themselves. Under this new procedure, family members who would otherwise be eligible for permanent residency will no longer be forced to rely on an abuser to remain in the United States.

Female Genital Mutilation (FGM). In 1996, the U.S. Congress passed legislation requiring the Department of Health and Human Services to compile data on females subjected to female genital mutilation (FGM) and to design and implement educational outreach on the practice in relevant communities. Government officials have held community meetings with immigrants, and organizations working with immigrants, to learn how best to develop outreach programs to provide education on the dangers of FGM and training materials are being developed for public health professionals who may encounter complications from the procedure. In addition, the U.S. Congress passed legislation in September 1996 to criminalize the practice of female genital mutilation.

Coercive Family Planning Practices. The Immigration and Naturalization Service is implementing a new law which provides that a person who has been forced to abort a pregnancy or to undergo involuntary sterilization, or who has been persecuted for failure or refusal to undergo such a procedure, shall be deemed to have been persecuted on account of political opinion for purposes of granting asylum.

Working Women's Rights. Since ICPD, the Department of Labor has launched a new campaign to encourage women to get the facts about women in the labor force; help women to understand their rights on the job; and increase women's access to information from employers, unions, and organizations nationwide that are making positive changes in the workplace.

Trafficking in Women and Children. In his March 1998 Presidential Directive, President Clinton called for strengthening the U.S. Government response to trafficking of women and children. The President's Interagency Council on Women created an interagency working group on trafficking, which involves participants from law enforcement, migration, health, and labor to review and implement measures to combat trafficking in women, specifically in the areas of prevention, enforcement, and victims assistance. Prevention measures include public awareness, overseas deterrence, and programs for economic alternatives. Enforcement measures include enacting and enforcing laws and regulations against trafficking, reviewing existing criminal laws, developing stronger penalties for trafficking, and training of law enforcement officials. The Department of State and the U.S. Information Agency are expanding public awareness campaigns targeted to potential victims. Thus far, the United States has launched joint initiatives with the Governments of Italy and Ukraine and is considering a public awareness campaign to prevent the trafficking of Slavic women and girls into Israel.

Global Women in Politics. The Global Women in Politics program supported by the U.S. Agency for International Development (USAID) is designed to accelerate sharing of models, strategies, and techniques that are working in different countries to advance women's full participation in the political process. Other USAID programs address women's empowerment across all sectors of sustainable development.

International Leadership Forum for Women with Disabilities. The Department of Education supported an international leadership forum for women with disabilities held in Washington from June 15-20, 1997, which drew 614 participants from all over the world. The forum addressed overcoming obstacles of employment, education, adequate health care, and other issues, and will develop leadership skills in women with disabilities from all over the world.

5. Please describe any major contribution of or collaboration with non-governmental organizations or other civil society organizations in, a) improving the access to reproductive health care, b) addressing the special needs of adolescents in reproductive health care, c) protecting the rights of women and promoting the empowerment of women, and/or in other initiatives in the area of key population issues.

Non-governmental organizations, on their own and in conjunction with the U.S. Government, have made a very substantial contribution toward achieving U.S. Government goals in many areas related to population and development and women's rights. NGOs provide important advice and information to both the administrative and legislative branches of the U.S. Government and help to implement the laws and regulations of the country in all of the areas addressed above. The following are examples in which NGOs have collaborated with the U.S. Government to create programs that target reproductive care, adolescent needs and women's empowerment:

Improving access to reproductive health care. NGOs in the United States play a key role in ensuring access to reproductive health services. Their work focuses on increased research and services to prevent unintended pregnancy, improved quality of reproductive health care, ensured access to abortion, reduced transmission of HIV/AIDS and care of AIDS patients, and increased research into contraceptive methods. They work to expand family planning programs, guarantee equity in insurance coverage for family planning, make improved contraceptive methods more widely available, ensure there are trained providers of comprehensive reproductive health care, ensure confidentiality of medical records, improve access to early medical and early surgical abortion, and prevent violence at reproductive health care facilities. As an example, a group of U.S.-based NGOs is pursuing research on microbicides to prevent the spread of sexually transmitted diseases, including HIV/AIDS. They are now doing clinical human testing, and a microbicide could be available in 2-5 years.

Addressing the special needs of adolescents in reproductive health care. NGOs work to ensure that every teenager is offered honest, responsible sex education and pregnancy prevention programs.

Protecting the rights of women and promoting the empowerment of women. NGOs have worked in close coordination with the President's Interagency Council on Women, as well as individually with the federal agencies represented on the council to protect and promote the rights and empowerment of women. The Interagency Council holds quarterly public meetings to exchange information with NGOs.

In general, civil society has somewhat of a comparative advantage over the government in program policy research. As representatives of local communities who invest time and energy in the communities in which they work, these groups have an essential knowledge and regard for the issues and concerns of the people in those communities. They are often better informed about the cultural attitudes and practices that affect the types of research and interventions that are needed in those communities.

II. International Assistance to Population Programmes

6. In the context of international assistance, what does your country perceive as the positive changes in developing countries induced by the Programme of Action on policies and programmes in population and development field?

Since ICPD, the United States has seen an increased awareness of population, reproductive health, and gender issues at all levels, including by both political leaders and the public in developing countries around the world. We perceive increased efforts by governments to formulate policies affecting key aspects of reproductive health, including family planning, maternal health, and sexually transmitted infections. Increased NGO advocacy activities on behalf of ICPD goals is another key area of positive change since 1994. In some cases, but clearly not all, there has been an increased mobilization of domestic resources.

7. Please describe what your country sees as major constraints faced by developing countries in implementing the Programme of Action.

The United States perceives that many developing countries face the joint challenges of insufficient financial, technical, and human resources. There appears to be a lack of complete and shared understanding of the concept of reproductive health, and, in some cases, religious and cultural opposition as well as denial of reproductive health conditions and needs. There is often insufficient availability, access, and use of data and analysis to help prioritize reproductive health interventions in developing countries.

Perhaps a more difficult challenge is the fact that, in a number of countries, there is a lack of political commitment to other key objectives of the Programme of Action, specifically in regard to gender equality and environmentally sustainable development. Also related to political commitment and will is a resistance on the part of some governments to greater NGO and private commercial sector participation.

8. Please describe constraints and challenges in your country in mobilizing resources for international assistance in the population field.

The United States devotes a higher percentage of overall development assistance to population assistance, including reproductive health, than any other donor. In addition, beyond U.S. Government assistance, there are extensive individual contributions to NGOs and large-scale philanthropy through private foundations which contribute significantly to the flow of international resources for population and development programs.

However, overall official development assistance has declined since 1994, and political pressures have made it difficult to mobilize the resources needed to implement the ICPD Program of Action. Since 1995, the U.S. Congress has reduced resources for international population assistance and has placed additional restrictions on such assistance.

9. Please describe any emerging opportunity and key future actions to overcome the constraints discussed above.

In developing countries, USAID technical and financial assistance through a wide variety of U.S.-based non-governmental partners and host country NGOs is seeking to reinforce positive changes and address the constraints identified above.

Broadly, the United States looks forward to the 5-year review of the ICPD as an opportunity to revitalize interest in and attention to the Programme of Action. The United States also appreciates seeing more private resources, including those of private foundations, being dedicated to population and development activities.

10. Have there been any major developments in your country since ICPD with respect to the role played by non-governmental organizations as channels of international assistance?

a. No major developments
b. Yes (Please describe some of the key developments.)

b. Yes. While NGOs have always played a key role in U.S. population assistance, more than half of all expenditures involve non-governmental host country institutions; major developments since ICPD include increased assistance to women's NGOs. In addition, a new program was launched in 1998 to strengthen the capacity of U.S.-based private voluntary organizations (PVOs) active in child survival, including CARE and Save the Children, to integrate family planning and other reproductive health services in their programs with host country NGO partners.

11. Please describe any major contribution of or collaboration with non-governmental organizations or other civil society organizations in the area of international assistance in the population field.

As noted in Question 10, collaboration with NGOs and civil society organizations is a prominent feature of U.S. international population assistance. This collaboration includes work with NGOs such as the International Planned Parenthood Federation and its affiliates, including the Planned Parenthood Federation of America, U.S.-based NGOs and private voluntary organizations such as the Population Council, CARE, AVSC International, Pathfinder International, and the Centre for Development and Population Activities; and many NGOs based in host countries. Universities also are important partners in research and training activities. Programs supported by the United States also have involved private commercial sector entities in a number of countries.

12. Please state any issues in international assistance that you would suggest to be considered at the International Forum and in the preparatory activities of the forum.

--Increasing political and popular support for ICPD objectives in both donor and host countries
--Mobilizing significantly increased resources for the costed components of the ICPD Programme of Action
--Increasing the role of the private commercial sector in financing and providing family planning and other reproductive health services
--Increasing donor support for inputs essential to core ICPD activities where countries cannot support these inputs themselves, such as commodities, specialized training, or data collection for monitoring and evaluation
--Increasing the effectiveness of international population and reproductive health assistance in the context of health sector reform and decentralization
--Addressing the challenges of implementing South-South cooperation

III. Partnership with Civil Society

13. Have there been any major changes since ICPD in the role non-governmental organizations play in the policymaking and/or delivery of reproductive health care services in your country?

a. No major changes b. Yes (Please describe some of the key changes.)

Yes. The Program of Action endorsed a comprehensive approach to population efforts, which helped to make women's health and reproductive rights, in particular, more legitimate among new and sometimes skeptical audiences. Among some policymakers, and many donors and program planners, the comprehensive nature of the ICPD led to a greater interest in and receptivity to efforts to address women's reproductive health needs and concerns. ICPD also has provided NGOs an opportunity to work more closely with colleagues in large, influential international organizations. In addition, the term "quality of care" has gradually evolved into a comprehensive theme in many NGOs' reproductive health programs.

The ICPD+5 process itself has stimulated the creation of a series of NGO task forces to promote U.S. domestic support for ICPD goals. The "U.S. NGOs in Support of the Cairo Consensus" is a consortium of NGOs representing the population, family planning, environment, women's rights, and development fields. It is comprised of four individual task forces to look at U.S. implementation of the ICPD Program of Action. In particular, the groups are assessing resource allocation and population research, as well as explaining the successes of the ICPD and expanding the grassroots base of support for implementation of the Program of Action in the United States.

Through these task forces and other mechanisms, U.S. civil society has been strengthening its informational and advocacy capabilities with U.S. policymakers.

14. Have there been any major changes since ICPD in the role private sector plays in the reproductive health care program in your country?

a. Private sector already playing active role
b. Private sector not active and no changes since ICPD (Please describe constraints in involving the private sector.)
c. Yes (Please describe some of the key changes.)

a. Private sector already playing active role. The private sector is the principal source of medical services, including reproductive health services, for the majority of the U.S. population. Private health care professionals, institutions, and retail outlets also are significant sources of reproductive health counseling, commodities, and related services in the United States. Additionally, the pharmaceutical industry contributes greatly to the distribution and marketing of contraceptives and medication for many women's health concerns.

In the United States, private foundations have long been leaders in setting up institutions to address population and reproductive health issues and needs (e.g., the Population Council was founded by the Rockefeller Foundation in 1952). Foundations have taken the lead in funding research into areas of reproductive health that are often not covered by the U.S. for-profit sector, specifically contraceptive development. They have become trendsetters by funding both domestic and international population programs where U.S. Government funding can often not be used because of various restrictions.

Support for population activities and programs by U.S. private foundations has increased significantly since Cairo. In 1995, for example, foundations provided approximately $88.3 million for international population activities. It is estimated that this amount will top $165 million in 1998. Addition millions fund domestic population programs and activities.

15. Please describe constraints or challenges faced in strengthening the partnership with non-governmental organizations and other civil society organizations.

The partnership between the government and civil society in the United States is already very strong, and there are relatively few constraints regarding the ability to strengthen these partnerships. However, federal laws do restrict or govern some interactions between the government and NGOs, such as the establishment of outside advisory boards to counsel the executive branch on policies and programs.

Regarding NGO-to-NGO partnership, many NGOs face the challenge of limited financial resources with which to support their programs.

16. Please state any emerging opportunity and key future action that could be taken to overcome the constraints discussed above.

In general, NGOs in the U.S. recognize that coordinating their efforts is often more productive and beneficial than working separately. NGO collaboration has been a key element of the ICPD Program of Action's success in the United States.

17. Please describe constraints or challenges faced by non-governmental organizations in their effort to strengthen the partnership with government.

Most U.S. NGOs share the view of the government that the partnership is very strong. But as noted above, federal laws do limit some interactions between the government and non-governmental organizations. Also, from the perspective of U.S. NGOs, there are some constraints in dealing with political or governmental policies and regulations. For example, political opposition to abortion has resulted in decreased Title X funding and U.S. Government international family planning assistance, thereby causing increased rates of unsafe abortion and maternal and infant mortality around the world. Also, NGOs involved in advocacy and service provision sometimes prefer to be independent of public financing and official policy restrictions.

18. Please state any emerging opportunity and key future action that could be taken by non-governmental organizations to overcome the constraints discussed above.

In the U.S., a large part of the work of many NGOs is to play an advocacy role to get officials elected who support their positions and to promote favorable public policies. As representatives of distinct communities, NGOs have a unique perspective and regard for the issues and concerns of people they represent. They can nurture links with key groups or institutions in the community and are most aware of the available resources.

[End of Document]

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