Background

The Programme of Action from the groundbreaking International Conference on Population and Development (ICPD) continues to be relevant 25 years after the 1994 conference in Cairo (UNFPA, 2020a). ICPD represented a paradigm shift from a demographic focus on reducing population growth to attention to gender equality and fulfilling sexual and reproductive health and rights (SRHR) (Dixon-Mueller, 1993; Hodgson & Watkins, 1997; Reichenbach & Roseman, 2009). ICPD shifted course from family planning programming that had too often relied on targets to reduce women’s fertility, which in some countries had led to coercive practices (Potts et al., 2018; Warwick, 1982).¹ ICPD reinforced that governments have a role to play in addressing population issues but in ways that respect human rights for people of all ages and address social and gender inequities (Barroso, 2015; Sen et al., 2019). ICPD linked reproductive rights to the obligations of States to provide the services that will yield positive reproductive health outcomes (Ngwena & Durojaye, 2014, p. 6).

The ICPD Programme of Action noted that reproductive rights were based on existing human rights recognized in international human rights documents and consensus statements that had been accumulating for nearly 50 years by the time of the ICPD, starting with the 1948 Universal Declaration of Human Rights that established the right to health, among other rights, and the 1968 International Conference on Human Rights in Tehran that proclaimed that individuals and couples have the right to decide freely and responsibly on the number and spacing of their children (United Nations, 1968). ICPD was one of several United Nations conferences that applied human rights principles, following closely after the World Conference on Human Rights held in Vienna in 1993 and by the 1995 Beijing Fourth World Conference on Women that reaffirmed women’s rights are human rights. These conferences, in particular the Cairo and Beijing conferences, “led to the recognition that the protection of reproductive and sexual health . . . can be addressed through the improved application of human rights contained in existing national constitutions and regional and international human rights treaties” (Cook et al., 2003, p. 148). The Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa, a human rights instrument established by the African Union in 2003, states that “States Parties shall ensure that the right to health of women, including sexual and reproductive health is respected and promoted” (African Union, 2003). This includes the right to make decisions regarding fertility and to have the information and services to act on those decisions.

Building on the Right to the Highest Attainable Standard of Health, articulated in Comment 14 to Article 12 of the UN Committee on Economic, Social and Cultural Rights (UNCESCR) as Availability, Accessibility, Acceptability and Quality (AAAQ), the same committee published General Comment 22 defining the elements of the right to the highest attainable standard of sexual and reproductive health (UNCESCR, 2016). It explains State parties’ obligations to respect, protect, and fulfill an individual’s SRHRs, specifically assuring that programs apply the principles of AAAQ and nondiscrimination and equality. With reproductive rights established as human rights, what has occurred in the intervening years since ICPD to get human rights into programming using human rights-based approaches and to ensure that duty bearers (States that have signed international human rights conventions and consensus documents) respect, protect, and fulfill the rights of rights holders (individuals and communities)?

Given that SRH (sexual and reproductive health) encompasses a wide range of health areas (see Box 1 for the 2018 Guttmacher–Lancet Commission list of essential SRH services), this article focuses on one aspect of SRHR, namely, contraceptive care, more commonly known as family planning. While some would contend that separating out one aspect of SRH obscures the need to address all aspects of SRH, this article takes the view that while there are commonalities—and rights apply to all aspects of SRH—programming for the components differs, so addressing family planning as one aspect of SRH is justified and has the potential to yield family planning programming that better reflects human rights. Some factors related to family planning, which distinguish it from some other health services, make it particularly susceptible to rights violations (Kumar, 2015). For example, family planning is related to sexuality and fertility, which has religious and cultural sensitivities and is subject to gender and power dynamics. Furthermore, government attention to population size, growth structure, and distribution runs the risk for pressure to reduce fertility through use of contraception.

Purpose

This article describes how human rights principles and standards related to the family planning component of SRHR have been articulated and assesses how these principles and standards have been integrated into programming, have strengthened accountability, and have been incorporated into monitoring and evaluation. The article also identifies ongoing challenges related to human rights and family planning.

Human Rights Principles and Standards Related to Family Planning

Much of what was written about human rights immediately following ICPD focused on SRH broadly, with scant specific mention of family planning. Instead, family planning programming in the 1990s and 2000s focused on improving quality of care, a movement that started in the late 1980s and gained momentum after ICPD as a way to offer more client-centered care (Bertrand et al., 1995; Bruce, 1990; Jain et al., 2012; Kumar, 2015; Lynam et al., 1993; Rama Rao & Mohanam, 2003). The movement on client-centered care also emphasized voluntarism and informed choice in family planning programming (Bongaarts & Sinding, 2009; Kim et al., 1998; RESPOND Project, 2013). For example, programming funded by the U.S. Agency for International Development (USAID), the largest international funder of family planning assistance for more than 50 years, is guided by principles of voluntarism and informed choice:

The need to articulate explicitly the application of human rights to family planning gained salience leading up to the 2012 London Summit on Family Planning with the announcement by the organizers—the Bill & Melinda Gates Foundation, the UK Department for International Development (in DFID), and the core conveners, the USAID and the United Nations Population Fund (UNFPA)—of an ambitious goal of expanding access and enabling use of contraception by an additional 120 million women and girls by 2020 (Brown et al., 2014).² While the renewed attention to and resource commitments for family planning were applauded by many, to some civil society organizations, the numeric goal harkened back to “pre-ICPD” numbers-driven rather than client-centered family planning programming that had led in some instances to coercion (Hardee, Harris, et al., 2014). Civil society organizations were concerned that the numeric goal signaled a retreat from the human rights-centered approach that emerged from ICPD (Girard, 2012; Khosla, 2012; Krishnan, 2012). A group of nongovernmental organizations (NGOs) signed on to a petition and succeeded in getting the business plan for the summit to reflect the need for rights to be respected.

Taking the months of criticism leading up to the summit to heart, a press release from the 2012 summit clarified that, “The London Summit on Family Planning will mobilize commitments to support the rights of an additional 120 million women and girls in the world’s poorest countries to use contraceptive information, services and supplies, without coercion or discrimination, by 2020” (FP2020, 2012). The criticism and pushback were instrumental in shaping the agenda for programming. The Family Planning 2020 (FP2020) Partnership, constituted to achieve the goal of the 2012 London Summit, comprising governments, civil society, multilateral organizations, donors, the private sector, NGOs, and with support from a secretariat, has sought to ensure that human rights were at the center of programming, grounded in the ICPD framework for SRH (FP2020, 2012; Hardee & Jordan, 2019). Since the summit, a number of resources have been developed to articulate the rights standards and principles associated with family planning and to develop practice tools and approaches to implement voluntary human rights-based family planning programming, including for adolescents. These resources are described in relevant sections of this article.

The UNFPA published a family planning strategy, underpinned by human rights, to guide its work on family planning from 2012 to 2020 (UNFPA, 2012):

Over the life of this strategy . . . we are working to expand access to information, services and supplies for women, men and young people. We are improving quality of care, generating demand and meeting unmet need. We are supporting the efforts of countries to strengthen health systems for a reliable and secure supply of modern contraceptives, going the last mile to reach the poor, marginalized and underserved. Human Rights is at the core of our implementation.

(UNFPA, 2012, p. iii)

Earlier, UNFPA and the Center for Reproductive Rights (CRR) produced The Right to Contraceptive Information and Services for Women and Adolescents, a briefing paper that highlighted human rights related to contraception (UNFPA & CRR, 2011).

To understand what a voluntary, rights-based family planning program should include and how to effectively implement it, a group from the Futures Group (now Palladium) and EngenderHealth developed a programming framework that provides a vision for what a voluntary, rights-based family planning program entails at the policy, service delivery, community, and individual levels (Hardee, Kumar, et al., 2014). This work was undertaken to bridge the “chasm between theory and practice . . . in translating human rights norms into concrete programming guidance applicable in diverse policy contexts and national circumstances” (Arbour, in OHCHR, 2006, p. 3).

The framework provides a practical tool that illustrates a holistic family planning program that respects, protects, and fulfills human rights—expressed in programmatic terms; in other words, translating and operationalizing the rhetoric of human rights into actual programming. In addition to family planning programming literature and experience, the framework drew on human rights work by Erdman and Cook (2008, p. 537), who identified three broad categories of reproductive rights among the composite of human rights that are “guaranteed in national laws, constitutions, and regional and international treaties that can be applied to protect against the causes of ill health and promote sexual and reproductive well-being.” These categories include:

Subsequently, the World Health Organization (WHO) produced guidance on ensuring human rights in contraceptive information and services (WHO, 2014). The document notes WHO’s mandate to help member states achieve the goal of the highest attainable standard of health for all, including sexual and reproductive health. Provision of contraception is integral to achieving this goal, and respecting, protecting, and fulfilling human rights is critical for family planning services. The guidance provides stakeholders with needed actions to ensure that relevant dimensions of human rights are integrated into contraceptive information and services (WHO, 2014). Box 2 lists the nine rights highlighted in the WHO guidance. FP2020 also published Rights and Empowerment Principles that reinforced its commitment to rights (FP2020, 2015a).

Based on this work, the Family Planning Quality of Care Framework, which has guided programming since 1990 and is an integral component of rights-based family planning (Kumar, 2015), was revised to “better align it with quality in the rights-based approaches and the way quality in family planning has been applied in practice” (Jain & Hardee, 2018, p. 171).

Integration of Human Rights Standards and Principles Into Family Planning Programming

Strengthening Accountability for Family Planning

Accountability, a cornerstone in the human rights framework linking duty bearers and rights holders and encompassing “monitoring, review, and redress at the local, national and international levels” (Hunt & Gray, 2013), is critical for family planning among other components of SRH (Boydell et al., 2019). Accountability supports rights holders to seek redress for human rights violations and also to hold duty bearers responsible for their human rights commitments.

Given past instances of rights violations related to family planning, civil society called for a focus on reproductive rights with strong accountability systems associated with programming to achieve the goal of the 2012 London Summit on Family Planning. Among the nine rights principles and standards for ensuring human rights in contraceptive information and services, the WHO (2014) described accountability as being achieved through a variety of processes and institutions involving national and international human rights mechanisms with various administrative, social, political, and legal forms of review and oversight, and mechanisms for registering complaints.

In making pledges at the 2012 London Summit on Family Planning and again at the 2017 Family Planning Summit, governments made financial, policy, and programmatic pledges to contribute to achieving the FP2020 goal of expanding access to contraception. The WHO (2014) notes the important role of civil society in the developing and monitoring of laws, policies, budgets, and the use of public funds to hold governments accountable for their commitments. Countries engaged in the FP2020 Partnership include civil society representatives—and youth representatives—as members of their FP2020 Focal Point groups along with governments and donors.

Since 2012, a number of initiatives have strengthened accountability for family planning. As a Partnership, FP2020 developed an accountability framework that linked outcome tracking with commitment tracking (FP2020, 2018a). FP2020’s model focuses on collaborative accountability, focusing on dialogue among commitment makers and their stakeholders and constituents and shared responsibility to achieve goals (FP2020, 2019). Family Planning Costed Implementation Plans include sections on accountability.

Much of the focus on accountability related to FP2020 at the country level has been strengthening the capacity of country-based civil society to hold their governments accountable for FP2020 commitments. While some civil society advocates might have been involved in developing the country commitments, this work has focused on ensuring that a wide range of civil society advocates know about the FP2020 commitments and that they understand accountability structures and how to engage in them. For example, women leaders in Malawi mapped accountability linkages for implementing youth-friendly health services, in place since 2007, but still with gaps in the quality of services. With this mapping, the women leaders understood the complexity of the system and were able to engage with stakeholders responsible for improving the services (HP+, 2018a). Similar work in Pakistan related to Sindh province’s Family Planning Costed Implementation Plan resulted in improved confidence, capacity, and connections for the participants. In additional to recommendations related to implementing the Costed Implementation Plan, one participant said, “At the Sindh Human Rights Commission, I encouraged the inclusion of health and family planning matters in the human rights discourse” (HP+, 2018b, p. 18). Making this link is important so that national human rights commissions monitor family planning as part of their human rights monitoring.

Piloted in Uganda by the civil society organization (CSO) Samasha Medical Foundation as a tool for accountability, civil society and other family planning stakeholders have used the motion tracker in Uganda, Burkina Faso, Côte d’Ivoire, Ethiopia, Indonesia, Kenya, Nigeria, Tanzania, Togo, and Zambia to track those countries’ FP2020 commitments (HP+, 2017). Using the motion tracker, the CSO has led the process with other stakeholders

. . .of identifying and deconstructing the commitments to clarify them. The lead CSO then develops a set of process indicators to track the commitments. The process indicators are then validated by all stakeholders including government, donors and civil society—a key step to creating ownership.

(Guerrier, 2020, p. 1)

At the country level, “National Human Rights Institutions [NHRI] are key to the promotion and protection of human rights in their respective countries. Yet, in practice, many NHRIs have not addressed sexual and reproductive health concerns or have done so only partially” (UNFPA, 2019, p. 9). UNFPA has been engaged with NHRIs to strengthen their capacity to include SRHR, including family planning, in their monitoring effects (UNFPA, 2019; UNFPA, DHRI, & OHCHR, 2014). Countries report into the Universal Periodic Review (URP), a mechanism put in place by the United Nations since 2006 to assess the fulfillment of human rights obligations and commitments by each UN Member State every 4 and one-half years. In reviews of the first two cycles of the UPR to assess attention to SRHR issues, UNFPA has identified that contraception gets scant attention compared to some other components of SRHR (UNFPA, 2014, 2019):

Similar to the first cycle, second cycle recommendations . . . highlight stark differences in attention to different SRHR issues by reviewing States. For example, gender equality and violence against women received more than 4,000 recommendations in total. Whereas other SRHR issues such as sexuality education, early pregnancy, and contraception received 23, 35, and 48 recommendations, respectively.

(UNFPA, 2019, p. 4)

Still, the UPR process offers a platform to bring together state and nonstate actors and provides civil society an opportunity to advocate for issues raised during the process. The third cycle of the UPR (2017–2021) provides an opportunity to further highlight the neglected components of SRH, including contraception.

Social accountability, which “refers to the efforts of citizens and civil society to scrutinize and hold duty bearers (politicians, government officials, and service providers) to account for providing promised services, actions that most often take place at the sub-national or community level,” can improve access and use of contraceptive services through bringing communities and providers together to identify and solve challenges and bottlenecks in the health system (Boydell & Keesbury, 2014, p. 2). Assessment of the implementation of a social accountability intervention that included family planning and reproductive health in Uganda found “a web of accountability relationships at play,” ranging from opportunities for community participation in institutional processes, relationships between clients and health care providers, and relationships between the community and local officials. (Boydell et al., 2019, p. 73). Community participants noted increased confidence when interacting with health care providers, in their health-seeking behavior, or in their ability to represent themselves. The research highlighted ways that social accountability and family planning programming could be combined, such as incorporating civic and rights education with family planning outreach. This linking could “extend the reach and credibility of these services among community members while also counteracting barriers to women’s and young people’s participation” (Boydell et al., 2019, p. 73). In a district in Malawi, use of CARE’s community score card approach to social accountability in a randomized control trial resulted in a 57% greater current use of modern family planning in the intervention area (Gullo et al., 2017). A social accountability study in one province in Kenya that evaluated use of community dialogues about gender norms and family planning found that exposure to family planning dialogues, which addressed persistent myths and misconceptions about contraception and increased acceptability of family planning, was associated with 1.78 times higher odds of using a modern contraceptive method at end line for women (Weggs et al., 2016).

Boydell et al. (2019) explain that the contested nature of SRH, including contraception, which is affected by social and gender norms and by power distribution within societies, needs to be made explicit in accountability efforts. These conditions also affect people’s ability to demand their rights and duty bearers’ ability to respond. Continued vigilance against pressure on individuals to use contraception, or to accept certain methods, is needed (Senderowicz, 2019; Yirgu et al., 2020). Civil society is employing human rights to call out governments for practices that violate those rights. For example, calling a mid-2019 bill in India that would penalize people for having more than two children misguided, the executive director of the Population Foundation of India said that:

The policymakers, MPs and the government should reaffirm India’s commitment towards a rights-based approach to family planning. The government should raise budgetary allocations in order to ensure expanded contraceptive choices for delaying and spacing births and better access and quality of health care for young people.

(Sharma, 2019, p. 3)

The bill did not go through, in part due to the visibility brought by civil society advocates, but some states in India are also considering child limitation policies, highlighting the need for continued vigilance by rights advocates. Advocates in India also demanded change from the government when 13 women died and 65 others experienced complications in a sterilization camp in Chhattisgarh State in 2014 in which the doctor used unsterile practices (Muttreja et al., 2014); a ruling in 2016 from the Supreme Court ordered that sterilization camps be stopped (Mohanty & Bhalla, 2016). In 2020, China received widespread condemnation for “taking draconian measures to slash birth rates among Uighurs and other minorities as part of a sweeping campaign to curb its Muslim population.”⁸ These tragic incidents are vivid reminders that human rights violations related to family planning, while uncommon, continue to occur and that vigilance remains crucial.

Despite passage of the landmark Responsible Parenthood and Reproductive Health Act of 2012 in the Philippines that guarantees universal and free access to nearly all modern contraceptives for all citizens including impoverished communities at government health centers, among other provisions such as reproductive health education in government schools and postabortion care, opponents of reproductive health sought to ban the sale of hormonal contraceptives. With strong advocacy by civil society and other stakeholders, in 2017 the Philippines Food and Drug Administration recertified the contraceptives, effectively lifting the ban imposed by the Supreme Court in 2015.⁹

Incorporation of Human Rights Into Monitoring, Evaluation, and Research

Ongoing Challenges and Opportunities

Application of human rights to family planning programming, which has gained speed particularly since 2012, has strengthened policies and programming and has provided civil society with tools to hold governments accountable. Still, there is much more to do. In a review of progress on advancing rights-based family planning in 2019, undertaken under the auspices of FP2020, 23 key informants from governments, civil society, implementers, and multilateral and bilateral organizations gave a number of practical recommendations to advance this work through 2030 (Box 4). The participants recognized that institutionalizing rights-based family planning will take time. Among the suggestions were to maintain a focus on rights and to be flexible with rights language where it is sensitive to talk about rights directly in countries that do not recognize rights generally; this is where fluency with rights principles and standards is important. Another suggestion was to expand work at the country level through promoting political support for rights, fostering rights literacy, linking rights with budgets, increasing attention to adolescents, and promoting their participation and strengthening accountability. Continued dissemination of tools and documentation of programming outcomes were also recommended.

The global COVID-19 pandemic was unfolding as this article was written in 2020 and 2021 and the full scale of its effects on individuals, communities, health systems, and countries will eventually be fully revealed going forward. Experience around the world has highlighted the particular effects on women and has reinforced the importance of ensuring reproductive rights and access to SRH services, including contraception, as essential services. The director general of the World Health Organization has emphasized that “All countries must strike a fine balance between protecting health, minimizing economic and social disruption, and respecting human rights.”¹¹

The consequences of deeming SRH services as nonessential are dire (Hussein, 2020). “When SRHR is deemed non-essential, health systems may be unable to fulfill these rights, and communities will lose a formal justification for claiming them” (Schaaf et al., 2020, p. 1). Disrupting access to contraception will have strong negative consequences. An estimated 15 million unintended pregnancies over a year could result from a 10% reduction in the proportional use of short- and long-acting contraception in lower- and middle-income countries (Riley et al., 2020). Plans for ensuring access to contraception has implications for providing clients with full, free, and informed choice of methods and includes a renewed focus on self-care, with potential increased interest in contraceptive pills, condoms, patches, rings, emergency contraception, Standard Days Method, and self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) (Weinberger et al., 2020).

The pandemic has highlighted that women’s rights, including to SRH, remains contested and clashes with social, cultural, and gender norms and with power dynamics (Oronje et al., 2011; Pizzarossa, 2018). The language—and legal teeth—of human rights provide the foundation for ensuring access to SRH, including family planning:

The principles of human rights can help us think through how to take action: through fostering community participation; focusing on non-discrimination; working to ensure the availability, accessibility, acceptability and quality of services; providing access to information; and striving to ensure transparency and accountability in the response to the pandemic.

(Hussein, 2020, p. 2)

In 2020, the secretary general of the United Nations issued a Call to Action for Human Rights—to refocus attention on respecting, protecting, and fulfilling universal human rights, noting that “human rights and human dignity will never be realized without a special emphasis on the human rights of women” (UN, 2020, p. 3). Among these rights is for SRHR to include family planning. In the face of continued political, religious, and social pushback by conservatives on reproductive rights, more work is needed by countries, donors, civil society, and implementing organizations to guarantee that rights are respected, protected, and ensured.

In 2020, the FP2020 Partnership was extended to 2030 based on a vision that does not include a numeric goal:

Working together for the future where all women and adolescent girls everywhere have the freedom and ability to make their own informed decisions about using modern contraception and whether or when to have children, lead healthy lives, and participate as equals in society and its development. Building 2030

FP2030’s work will be underpinned by principles that include, among others, voluntary, person-centered, rights-based approaches, with equity at the core. While the focus remains women and girls, FP2030 recognizes the need to also work with men and boys and to build intentional and equitable partnerships with adolescents, youth, and marginalized populations to meet their needs, and to support country-led global partnerships, with shared learning and mutual accountability for commitments and results.

Work since ICPD, reaffirmed on its 25th anniversary in 2019 (UNFPA, 2020a), has provided the guidance, tools, and language to strengthen family planning programs through a human rights lens and hold governments accountable for programs that support individuals and couples in exercising their rights to choose the timing and spacing of their pregnancies, to have the information, services, and agency to act on that right, and to be treated respectfully, equally, and without discrimination by providers.