Development, 2005, 48(4), (43–51)

r 2005 Society for International Development 1011-6370/05

www.sidint.org/development

Thematic Section

Population Politics and Women’s Health in a Free

Market Economy

SUMATI NAIR, ABSTRACT This article looks critically at the paradigm shift that so
PREETI KIRBAT AND many claim occurred at Cairo. It summarizes the thinking of some
of the key critical thinkers in the current debate on sexual and
SARAH SEXTON 1 reproductive health and rights in the context of neo-liberalism.

KEYWORDS ICPD; family planning; maternal mortality; women’s

health movements; neo-liberalism

Introduction
The 1994 UN International Conference on Population and Development (ICPD) in Cairo
was heralded as a‘quantum leap’ forward2 and a‘paradigm shift in the discourse about
population and development’ (Presser and Sen, 2000: 3). Its Programme of Action, en-
dorsed by179 countries and intended to establish international and national population
policy for the following two decades, was the first and most comprehensive interna-
tional policy document to promote the concepts of reproductive rights and reproductive
health. This was largely as a result of the concerted organizing and lobbying of women’s
groups.
The Programme’s recommendation ^ that population programmes provide reproduc-
tive health services rather than just family planning ^ assumes that women’s fertility
will not drop until children survive beyond infancy and young childhood, until men
also take responsibility for contraception, and until women have the right to control
their fertility and enough political power to secure that right.
One decade later, however, maternal mortality worldwide remains high. Some
600,000 women die each year, 95 per cent of them in sub-Saharan Africa and Asia,
and 18 million are left disabled or chronically ill because of largely preventable compli-
cations during pregnancy or childbirth. Such figures indicate that many women do not
have access to essential and emergency obstetric care from skilled health workers, let
alone access to more comprehensive reproductive health services.
Women in some countries are still coerced into being sterilized. During 1996, for
instance, family planning providers intimidated and humiliated indigenous, poor and
rural women in some towns in the Peruvian Andes into being surgically sterilized
after offers of food and clothing had not persuaded them. In other countries, such as
Development (2005) 48(4), 43–51. doi:10.1057/palgrave.development.1100192
Development 48(4): Thematic Section
Indonesia, poorer women do not have access to The Cairo Programme of Action calls for family
contraception, even though these countries were planning programmes to be broadened to repro-
held up at Cairo as exemplars of family planning ductive health services provided within primary
provision. health care systems. However, because of pres-
Indeed, many positive trends in the health of sures to reduce government spending and service
women the world over, from North to South, East provision, this has not happened. Despite encour-
to West, have been reversed over the past decade, agement and support, the (usually unregulated)
while reproductive health and rights remain private sector cannot fill the gap: the commercial
threatened, particularly for poorer women, mi- sector finds it unprofitable to do so; the nonprofit
grant women and women of colour. sector does not have the resources to handle the
Meanwhile, in several sub-Saharan African job. Many women therefore have little or no access
countries, infant mortality rates have increased. to reproductive health services or even any
Some 70 per cent of young child deaths can be decent health services at all, because they are not
attributed to diarrhoea, pneumonia, measles, provided or are not affordable.
malaria and malnutrition, the incidence of which Even before the 1994 Cairo conference, influen-
is on the rise. An estimated 330 million people are tial policy makers such as the World Bank were
infected each year with sexually transmitted dis- advocating changes in the role of governments in
eases of which HIV/AIDS accounts for six million; financing, providing and regulating health
women and children are disproportionately services. They were urging cuts in public health
affected. services, the introduction of ‘user fees’for the pub-
These negative health trends can be attributed lic services that remained, and incentives to create
in large part to the implementation of neo-liberal a ‘free market’ in the health care sector (Mackin-
economic and health policies over the past two tosh, 2003). The World Bank’s 1993 World Develop-
decades, first by means of structural adjustment ment Report, Investing in Health (note the title),
programmes (SAPs) and more recently by interna- proposed that the public sector should provide
tional ‘free’ trade agreements and national-level essential services only as ‘clinical packages’ for
policies. A retrospective look at these trends sug- the needy and that governments should open up
gests some lessons for the next decade of women’s the rest to full global competition. The model
health organizing and activism and avenues for health service was like that of the US: a combina-
more fruitful alliances with other social move- tion of privately run and -financed curative
ments. It also suggests that the Programme of services with public health programmes targeted
Action, together with the political organizing at certain classes of patients. The Bank’s report
that accompanied it, undermined itself by not included family planning services in ‘essential’
challenging neo-liberalism sufficiently. In fact, it public health activities, but suggested that
endorsed it in several respects. ‘constraints’ on the availability of contraceptives
should be removed (World Bank,1993: 84).
In the past decade, ‘health sector reforms’ in
A few health services for the few
many countries have followed the World Bank’s
The general consensus among women’s rights approach: vertical, disease-oriented programmes
activists is that, more than a decade later, the (LaFond, 1995); limited public expenditure on a
Cairo Programme of Action is still far from being narrowly defined package of services; user fees
implemented. This has variously been attributed for public services; and privatized health care and
to lack of political will on the part of governments financing (Sen, 2003). ‘Reform’ has focused exclu-
or lack of donor funding. But other forces are also sively on the cost and economic value of public
at work. Health services in many countries are in health services (Sen, 2001) to the detriment of
decline and the underlying conditions determin- ensuring that everyone has access to the health
ing women’s health and their control over child- care they need, and often has ‘little or nothing
44 bearing are deteriorating. to do with economic justice or human rights’
 Nair et al: Population Policies in a Free Market Economy
(Petchesky, 2003) or ‘health care for all’.3 The basic Introducing competition and new costs into the
package of health services that public health health sector, after all, discriminates against the
systems now attempt to provide ^ family planning poor and sick who are most dependent on publicly
(primarily to women), prevention and treatment provided health care. Studies from Ghana, Swazi-
of sexually transmitted diseases, child health, land, Zaire and Uganda suggest that user fees
control of communicable diseases and some result in decreased use of public health services,
curing of diseases ^ is much narrower than the especially by poorer people and women. One
essential services outlined in the Programme of outcome has been a rise in maternal and infant
Action (Standing, 2000). mortality rates (Nanda, 2000; 2002:127^134).
Meanwhile, the goal of gender equality, women’s In Zimbabwe, for instance, one of the first
empowerment, and reproductive and sexual African countries to‘reform’ its health sector, user
health outlined in the Cairo Programme of Action fees have been linked to a marked fall in women’s
is conspicuously absent. Health researcher Mere- attendance at ante-natal clinics and a doubling in
deth Turshen comments that women’s health care rates of women dying in childbirth. Similar results
has been reduced: have been observed in Tanzania and Nigeria. In
Swaziland, attendance at government facilities to
to services during childbirth, showing once again treat sexually transmitted diseases dropped when
that women are valued only for their reproductive fees were introduced, without an accompanying
role. Governments will subsidise family planning
services, but, because little money is intended for increase at mission hospitals.
physician services (or the training of nurses and User fees come on top of other costs. In Uganda,
midwives in these tasks), women will receive contra- for instance, poor rural communities had to con-
ceptives without medical supervision (Hartmann, sider not only user fees, which were relatively low,
1995). but also a wide range of informal, illicit payments
to health staff ^ effectively subsidies to underpaid
Cairo undermines itself
health workers (Standing, 2002). Women going
The Cairo Programme of Action went along all too into hospital to give birth had to take their own la-
readily with the World Bank approach. It accepted tex gloves, water, soap, syringes and plastic sheets
the neo-liberal economic approach to the detri- (Nanda, 2002). Medicines, food and transport to
ment of its rights agenda, and urged governments hospital are other considerations. In Bangladesh,
to introduce user fees in health services and social even though maternity care is free, the average
marketing schemes (Bandarage, 1997: 91) aimed cost for a normal delivery in the capital, Dhaka,
at distributing contraceptives. It encouraged has been estimated at one-quarter of the average
governments to ‘promote the role of the private monthly household income; one-fifth of families
sector in service delivery and in the production surveyed spent from half to all of their monthly in-
and distribution y of high-quality reproductive come on a hospital delivery (Standing, 2002).
health and family planning commodities and Poorer people have to set all these health care
contraceptives’ (ICPD Programme of Action, costs against other goods and services they need
15.15(b)) and urged countries to ‘review legal, reg- to buy, such as food. Moreover, women who do
ulatory and import policies ... that unnecessarily not have their own access to cash find it harder to
prevent or restrict the greater involvement of the access health care services for themselves or their
private sector’ (ICPD Programme of Action, 15.18). children.
These aims undermined the Programme’s own Out-of-pocket expenditures by individuals and
groundbreaking principles and goals of reproduc- families now account for more than half of health
tive health, as did its recommendations that the care spending in many countries. Families are
bulk of available resources should be allocated going into debt, consuming less food or taking
to family planning within publicly supported girls out of school. One of the most common
services while the market should be relied upon causes of rural indebtedness in India is now
for everything else. the cost of medical care (Sadasivam, 1999). If not 45
Development 48(4): Thematic Section
having health care is one of the causes of poverty, donors were reluctant to fund health infrastruc-
so is having to pay for it (Mackintosh, 2003). ture, while structural adjustment requirements
Many people may simply not use health care were curtailing domestic investment in them.
services at all ^ and it is women of reproductive Moreover, according to the Asia-Pacific Re-
age who are most likely to leave untreated condi- source and Research Centre for Women:
tions, such as reproductive tract infections, that
are chronic but not incapacitating, contributing The new global economic context has badly affected
to greater disease and cost burdens at a later stage sexual and reproductive health worldwide causing a
decline in health education, [increased] delivery of
(Rosen and Conly, 1999). reproductive health services by private doctors, over-
priced drugs and the ineffective self treatment of
reproductive tract infections to name a few’ (ARROW,
Reproductive health services within a 1999, 2000).
free market
The ICPD Programme of Action recommended Women’s groups around the world are now well
that comprehensive reproductive health care ser- aware that health sector reforms are affecting
vices should be provided within the primary women’s access to health services ^ and that many
health care system. Country surveys carried out policymakers are either unwilling or unable to
by several women’s organizations conclude that integrate reproductive health services into na-
this recommendation is far from being implemen- tional health systems (CHANGE)/The Population
ted because health infrastructure, particularly in Council, 1999; Ford Foundation, 2003). Yet merely
southern countries, has deteriorated so rapidly in calling upon policymakers to do so is ineffective
the past decade. In many areas, there are no in challenging the interests behind the reforms.
primary health care facilities through which Nor does it clarify the reasons why governments
reproductive health care services could be imple- have less money for health care, why politicians
mented, or only shambolic ones. The Programme believe free markets are the best way to provide
of Action did nothing to reverse the damage to health care, nor that the reforms are linked with
primary health care that SAPs had been causing, other global financial and trade processes, agree-
even with funds continuing to flow for family ments and interests (Richey, 2003, 2004).
planning (Richey, 2001).
A 50-country survey of government action on
Neo-liberalism’s impacts on health
women’s health carried out in 1999 by the
Women’s Environment and Development Organi- As Peggy Antrobus of Development Alternatives
zation (WEDO), a network of women’s groups and with Women for a New Era (DAWN), an interna-
activists around the world, pointed out: tional feminist network of southern activists, has
argued, neo-liberal economics depends upon the
All respondents ... cite economic reforms as exploitation of women. The problem is not just that
paramount constraints in implementing the ICPD it assumes women are ‘outside of development
Programme. Health sector reform in particular is
emerging in most countries as a challenge to expan- and need to be brought in (via accompanying
sion of reproductive health services (Sadasivam, compensatory programmes)’ but that it is
1999:10). ‘grounded in a gender ideology, which is deeply
and fundamentally exploitative of women’s time/
Another survey found that widespread cost work and sexuality’(Alt-WID).
recovery schemes and privatization of health care Since women tend to be more economically dis-
services ‘keep the poorer populations (rural, advantaged than men in many countries, they
women, old persons) away from hospitals and also tend to suffer more from SAPs and the re-
health centers’ (DAWN, 1999). Most of the 23 quirements of bilateral, regional and international
countries surveyed in five geographical regions neo-liberal trade agreements, such as those of
46 were dependent on international aid, but aid the World Trade Organization, that reduce their
 Nair et al: Population Policies in a Free Market Economy
access to food, clean water, sanitation, decent a negative impact upon the determinants of
housing, livelihoods, quality education, and a health other than to endorse them.
healthy working and living environment. The Programme of Action did recognize the
And as Indian public health specialist Imrana devastating impact that SAPs, public sector re-
Qadeer points out, when neo-liberal economic po- trenchment and the transition to market econo-
licies are implemented, ‘the family, particularly mies had had on health, especially among the
women within it, acquire the role of shock absor- poor. And it urged governments to improve struc-
bers in the absence of any other form of social tural conditions that have an impact on health,
security’ (Qadeer, 1998; Sen and Koivusalo, 1998). such as housing, water, sanitation, and workplace
The result has been a rise in women’s poverty and neighbourhood environments.Yet, as with its
and ill-health. A large proportion of maternal and health service recommendations, to implement
infant deaths in India, for instance, is attributable all these goals, the Programme opted for the very
not to a lack of contraception, or even little or no neo-liberal market-oriented policies that had
access to quality health care services, but to un- widened income, mortality and morbidity gaps
dernutrition, anaemia and communicable dis- between and within countries in the first place. It
eases stemming from lack of food, poverty and did not calculate how much funding would be
inequity. Access to the three-monthly injectable needed for primary health care, emergency ser-
contraceptive, Depo-Provera, or an IUD, cannot vices, education, sanitation, water or housing ^
compensate for this ill-health, and can even yet did cost out family planning.
exacerbate it. Women cannot exercise their The Programme of Action defined ‘reproductive
reproductive rights unless other fundamental rights’ as the right of women ‘to decide freely and
rights ^ to food, work, freedom of movement and responsibly the number, spacing and timing of
education, for instance ^ are met. their children and to have the information and
At the end of the 1975^1985 UN Decade for means to do so’.Yet it did not explain, as US politi-
Women, when the impacts of structural adjust- cal scientist and activist Rosalind Petchesky
ment policies were becoming evident, a group points out, how a woman can:
of women activists, organizers and researchers
concluded that: avail herself of this right if she lacks the financial re-
sources to pay for reproductive health services or
the transport to get to them; if she is illiterate or given
with a few exceptions, women’s relative access to eco-
no information in a language she understands; if her
nomic resources, incomes and employment has wor-
workplace is contaminated with pollutants that have
sened, their burden of work has increased, and their
an adverse effect on pregnancy; or if she is harassed
relative and even absolute health, nutritional and
by parents, a husband or in-laws who will abuse
educational status has declined (Report of a Com-
or beat her if they find out she uses birth control’
monwealth Expert Group on Women and Structural
(Petchesky, 2003:18^19).
Adjustment, 1989: 83).
Moreover, in its advocacy of the education of wo-
A Report of the Commonwealth Expert Group on men and girls and of gender sensitive health ser-
Women and Structural Adjustment categorically vices, the Programme ignored ‘the deep-lying
attributed a general decline in women’s nutrition imbalances of power and the social structures
and health in many southern countries, espe- and practices of subordination that characterize
cially in sub-Saharan Africa, to IMF/World Bank relations between women and men in most socie-
SAPs (Bandarage,1997: 203). ties’ (Asdar Ali, 2002). As health and reproductive
rights activist Jael Silliman points out, women’s
rights and reproductive rights were promoted
Cairo endorses neo-liberal policies
only ‘within the context of the dominant
Yet neither the Cairo Programme of Action nor neo-liberal agenda, which negatively affects
its institutionalized concept of reproductive women’s health and aspirations for empower-
rights addressed the forces that were having such ment’ (Silliman, 1999:151). 47
Development 48(4): Thematic Section
The upshot, according to Petchesky, was that the framework firmly linking reproductive and sexual
Programme of Action, despite its ‘groundbreaking health issues to both human rights and macroe-
advances’, was ‘fragile and contradictory’ because conomic policies. Access to contraceptive infor-
it failed ‘to address macroeconomic inequities and mation, safe and legal abortion, services to
the inability of prevailing neo-liberal, market-or- prevent and treat sexually transmitted diseases
iented approaches to deliver reproductive and sex- and reproductive cancers, prenatal care and men-
ual health for the vast majority’. These fault lines tal health services needs to be combined with
‘continue to block any real progress in transform- ‘access to housing, education, employment, prop-
ing the reproductive and sexual health/rights erty rights and legal equality in all spheres’as well
agenda from noble rhetoric into actual policies as ‘freedom from physical abuse, harassment, geni-
and services’ (Petchesky, 2003: 35^36). tal mutilation and all forms of gender-based vio-
Indeed, putting reproductive health and rights lence’ (CorreŒa, 1994: 58). In the run-up to the Cairo
at the centre of population policies has encour- ICPD, Loes Keysers fromWGNRR stressed that:
aged policymakers to continue to think of women
only as wombs to the neglect of their wider eco- reproductive health and justice ... has to do with con-
nomic and social roles, and of the conditions that traceptive services, with eradication of hunger, with
education, with health, with income, with clean
could advance health for women. Imrana Qadeer water, etc. All of which can be achieved only in a
believes that the ICPD ‘converted women’s health completely overhauled system (Keysers, 1993: 28^29;
into issues of ‘safe abortion’ and ‘reproductive 1994: 6).
rights’ and ‘marginalized the issue of comprehen-
sive primary health care, social security and Many more women’s groups now work more ex-
investment in building infrastructural facilities’ tensively on macroeconomic and trade issues, but
(Qadeer, 1996). She argues that policymakers (and even in the early 1990s, several groups were stres-
many reproductive rights activists): sing that they had to be addressed.
Women’s groups have also tended to focus on
never really examined either the epidemiological ba- single-issues such as reproductive and sexual
sis of reproductive health or the reasons behind some health, violence against women, or women’s la-
women’s silence vis-aØ-vis reproductive health pro- bour and economic conditions, and not to interact
blems. Had they done so, the immensity of women’s sufficiently with those outside their focus. But as
health problems and social constraints on women’s
lives would have revealed the inadequacy of their iso- New Zealand lawyer Jane Kelsey concludes:
lated strategy in the context of the expressed needs
of women for land rights, freedom from atrocities, Those who focus on narrow sectoral concerns and
food, security systems, minimum wages and commu- ignore the pervasive economic agenda will lose their
nal harmony (Qadeer, 1998a, b). own battles and weaken the collective ability to resist
(Kelsey, 1995: 372).

Indian public health activist and academic Mohan

Rao goes further to argue that ‘under the rhetoric
Conclusion
of reproductive rights, the rights of the vast majority
of women to access to resources, the most basic de- In the past decade, it has become much clearer
terminant of health, are being denied’. When repro- that the struggle for reproductive health and
ductive rights are divested of rights to food, rights is nothing less than the ‘democratic trans-
employment, water, health care or security of chil- formation of societies to abolish gender, class, ra-
dren’s lives and taken out of the contexts of women’s cial, and ethnic injustice’ (CorreŒa and Petchesky,
and men’s lives, they ‘fit in well with the neo-liberal 1994).
agenda of the day’ (Rao, 2004). Many movements, groups and individuals
What is needed instead, Women’s Global are already engaged in this struggle. As Betsy
Network for Reproductive Rights (WGNRR) and Hartmann (see her interview in this issue of
48 DAWN among others have long contended, is a Development) concludes:
 Nair et al: Population Policies in a Free Market Economy
While feminists may find some space within the itics and priorities are being sent to others by its
[Cairo] consensus to negotiate for higher-quality members and its alliances? What are the effects of
contraceptive, abortion and health services and in- compromises that may be made? What is gained
creased access to economic and educational re-
sources, the real political space will remain outside, and what is lost? What is included and what is left
in an alliance with progressive development agen- out? Whose voices are heard and whose are
cies, social justice environmentalists, and anti-ra- silenced in alliance building?
cism organisers. In the New World Order not only are Organizations such as WGNRR now collaborate
reproductive rights at stake, but basic economic sur- not just with women’s groups but also with a range
vival and political freedoms (Hartmann, 1995:155).
of social movements striving for health and social
Defence of women’s reproductive and sexual justice. Working with the People’s Health Move-
rights has been most successful not just where ment, for instance, WGNRR highlights general
NGOs and governments are supportive but also health issues as well as the reproductive and
where popular movements are strong, as in Brazil, sexual rights aspects of health. By rejecting the
the Philippines, India, South Africa and Peru. population framework, it seeks to avoid losing its
To be effective, such movements need to build critical edge, dulling its tools of analysis, divorcing
networks and alliances with each other. After all, itself from the women it is supposed to represent
peace, health, environment, women’s, indigenous, and placing too much faith in official rhetoric. It
antiracist and economic justice movements are opts instead, together with many others, for a
confronting many of the same forces and interests broader politics of social and economic transfor-
that are ranged against them. Building such net- mation (Hartmann, 1995: 309).
works and alliances might sound straightforward, Feminist activists from different parts of the
but ‘we operate in an increasingly murky world’ South and North have made their presence felt at
where ‘everyone from Shell Oil to neo-fascist intel- international gatherings such as the World Social
lectuals now talk the language of ‘empowerment’, Forums in recent years. In doing so, they pave the
‘community’, ‘environment’ and ‘participation’ way for reproductive and sexual rights to be incor-
(Hildyard, 1996). With whom should groups work- porated within the larger agendas of other social
ing for social, economic and gender justice make movements and of society in general. Numerous
alliances? And how? It is also worth considering encouraging initiatives at local and national levels
which alliances may weaken or divide movements. give hope for new ways of making alliances and
There is a difference, moreover, between a sin- working for change.
gle, one-off campaign and wider, longer-term New Zealand lawyer Jane Kelsey concludes that
movement building, of which a campaign or speci- activists need to ‘rethink identity and alliances ^
fic goal forms only one part. Groups committed to combine a critical analysis of economic, political,
deeper transformation and those in short-term cultural and social models of the past with a for-
campaigns need to consider the wider ramifica- ward-thinking vision of what a socially just future
tions of their different approaches. For instance, might look like’. The vision of women’s health
are the interests behind a short-term campaign of groups, antiracist movements, disability rights
a nature that can sustain a long-term alliance? Is groups, grassroots activists and others can be not
there a shared goal aside from working against just of social justice but of ‘an alliance which can
something? What signals about a movement’s pol- forge a new way ahead’ (Kelsey,1995: 372).

Notes
1 This article is an extract of The Corner House Briefing 31, which can be found on The Corner House website:
www.thecornerhouse.org.uk. It came out of a joint project between Women’s Global Network for Reproductive
Rights (WGNRR) and The Corner House exploring issues related to ‘Women, Population Control, Public
Health and Globalisation’. The joint project aimed to provide analysis and information for those confronted
with these issues and challenges, to generate debate, and to bring about change within policy circles, NGO
networks and public media. 49
Development 48(4): Thematic Section
2 UNFPA Executive Director Nafis Sadik, cited in McIntosh and Finkle (1995: 224).
3 ‘Health For All’ was the goal of the 1978 Alma Ata Declaration on primary health care, advanced by WHO and
UNICEF and signed by 134 states.

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