Since President Lyndon B. Johnson created the USAID population program in 1965, it has evolved in tandem with the global discourse on population and demography. “The agency’s family planning program is as relevant today as it ever was, and is necessary,” said Jennifer Adams, deputy assistant administrator of the U.S. Agency of International Development’s Bureau for Global Health. The bureau houses the Office of Population and Reproductive Health, which implements U.S. development and relief efforts to expand access to modern contraceptives, fight HIV/AIDS, reduce unsafe abortions, and protect the health of women and children. 

In a detailed look at the Office’s history, impact, and future, the current director of the Office of Population and Reproductive Health, Ellen Starbird, joined five former directors at the Wilson Center on the 50^th anniversary of the program.

Achievements and Hindsight

The former directors – Steven Sinding (1983-1986), Duff Gillespie (1986-1993), Liz Maguire (1993-1999), Margaret Neuse (2000-2006), and Scott Radloff (2006-2013) – shared some of their proudest accomplishments and biggest regrets, including:

• The creation of the Demographic and Health Surveys, which added health metrics to its predecessor, the World Fertility Survey. The surveys continue to provide some of the best demographic data from developing countries and were a major milestone.
• Preparations for the landmark 1994 International Conference of Population and Development in Cairo, which went on to establish the global agenda for international population work for years to come. The Office organized a major conference during the lead up to the event where more than 600 participants helped set the technical direction and programmatic issues to be discussed.
• The Office’s role in the initiation of the President’s Emergency Plan for AIDS Relief (PEPFAR), whose integration of HIV/AIDS programming strengthened connections between the Office to other work being done by the Bureau of Global Health. The groundwork laid for expanding access to family planning provided valuable lessons to other parts of USAID for combatting HIV/AIDS.

The directors also reflected on lost opportunities. Gillespie, for example, noted that in hindsight, he would have placed more emphasis on the Millennium Development Goals. “We fell asleep with the MDGs,” he said. Not only did the Office of Population and Reproductive Health not give them much credence early on, neither did the UN Population Fund – a frequent partner – and the Department of State because each organization assumed others were addressing the goals, Gillespie said. This lack of focus set the program back, as the MDGs proved integral in spurring an enormous global poverty reduction movement. The Sustainable Development Goals (SDGs) are set to replace the MDGs later this year with population dynamics and reproductive health and rights included.

Another regret was how the role of population in development has changed. The Office requested a 1986 National Academy of Sciences study in the hope that researchers would produce a report similar to a 1972 one that affirmed the importance of population growth as an economic development issue. Instead the authors came to different conclusions, finding a middling to neutral relationship that undermined the macro linkages between population and development. This made it much harder to establish a rationale for the population program and set the program back conceptually, Sinding said. Despite research since linking the two, “we haven’t succeeded to getting it back to where it once was,” he said.

The Shifting Sands of Politics

The directors noted that part of their job is to navigate political vagaries and defend the Office’s core mission. Sinding highlighted that a bipartisan consensus on the importance of population and reproductive health issues carried over from the Office’s founding until the Reagan administration. But the 1984 adoption of the so-called “Mexico City Policy” ended this unanimity by barring non-government organizations that receive federal funding from performing or promoting abortion services as a method of family planning in foreign countries, even with non-federal money. The policy has generally been rescinded under Democratic administrations and reinstated by Republicans since then.

With the exception of Peter McPherson, USAID administrator during Reagan’s term and a vocal advocate of the population program, both Democratic and Republican administrations were either indifferent or hostile to the Office, Gillespie said. He notes that even today, the Obama administration has chosen a conservative interpretation of the Helms Amendment, which predates the Mexico City Policy and bans the use of U.S. funds for the promotion or performance of abortion in foreign assistance.

It wasn’t necessarily just these political shifts that were detrimental, said Sinding, but the U.S. government declaration that population growth was a neutral force in development. In his view, this was a huge blow to the rationale that had driven the Office since its inception. “We really saw rapid population growth as a fundamental development issue, not just as a rights issue, and not just as a health issue,” he said.

Gillespie noted that in this atmosphere, implementing restrictive policies in ways that minimized damage to the poor and marginalized populations the Office was trying to reach was key. After the 1994 midterm elections, political pressure led to budget cuts, delayed funding, and a metering system for the Office. “As a team, we were determined not to let Congress kill the population program,” said Maguire. With the help of Radloff, a strategic budgeting plan was implemented that focused resources on countries with greatest need. The budgeting changes, coupled with a “graduation” program for countries where U.S. support is no longer needed, shifted resources towards sub-Saharan Africa, where population growth remains rapid and access to modern contraceptives limited.

Many Latin American countries have graduated from U.S. assistance, and several partner countries in sub-Saharan Africa have experienced notable gains in reproductive health indicators alongside declining fertility rates. The 2011 Ouagadougou Partnership united U.S. and French institutions to focus on francophone West Africa, a region lagging far behind in terms of access to family planning. As sexual and reproductive health needs vary widely throughout Africa, the hope is that this regional focus will produce more tailored and effective results.

Through occasional political turmoil, the Office has developed a reputation for strong technical skills and a presence in the field, putting development workers in touch with on-the-ground realities. “When you go out to the field now, the cooperating agencies are local,” said Neuse, but that wasn’t always the case.

Resilience and Partnerships: Moving Forward

After the 1994 Cairo conference, governments agreed to approach population issues primarily from a human rights perspective, hoping to put an end to problematic population programs (such as forced sterilization) and protect women and marginalized populations. Though voluntarism is a principal pillar of the Office’s mission, today’s leadership has also brought back more discussion about demography’s role in poverty reduction and other macro considerations, said Starbird.

“Resilience” has come to represent a push for more cross-sectoral programming for development and humanitarian relief and “population dynamics are at the core of thinking about resilience,” said Neuse. The Office has expanded its purview throughout the years to include gender and women’s empowerment, adolescent health, female genital mutilation, male involvement in family planning, political demography, and the environment-population link.

“We are at a moment when we can talk about linkages to population dynamics and that balance, the right for women to choose the number, timing, and spacing of their children, and the health piece all together,” said Starbird.

USAID is also increasingly working with non-government partners, such as CARE and Save the Children, to look for innovative solutions. Neuse mentioned the Reproductive Health Supplies Coalition as an example of this collaboration, which helps ensure access to critical medicines and supplies through the coordination of more than 300 government, private sector, non-profit, and civil society groups.

However, the United States does not occupy the same leadership position on global reproductive health and population that it once did, said Starbird. The United States accounts for 45 percent of donor funds for family planning, but Starbird said she expects the Office will increasingly need to lead with knowledge rather than funding. Besides political challenges, USAID and other donors may need to take a more hands-off approach to avoid crowding out in-country programs trying to achieve the same aims, said Neuse.

Family planning requires sustained commitment for it to be successful, said Radloff. He warned that discontinuing USAID programs has caused problems in the past, citing cases in Tanzania, Pakistan, and Nigeria where positive demographic and health trends reversed after funding was cut. With the exception of Iran, which created its own surprisingly progressive reproductive health program after the 1979 revolution, the loss of U.S. support has proved significant for many countries, he said.

Maguire echoed these sentiments and urged the program to keep looking forward. “Yes, we fought because we cared so deeply about this mission. And we have innovated, and taken risks, and encountered a great deal of resistance along the way… But we have to keep fighting…and to encourage the young generation to really step up and keep moving because there is so much still to do.”

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Written by Josh Feng, edited by Schuyler Null and Roger-Mark De Souza.