The Institute's Future IX: A Strategic Plan for
The Alan Guttmacher Institute, 1999-2003
Moving Toward a More Comprehensive View of Reproductive Health & Rights
Moving Toward an Integrated Global View
Managing Institutional Resources
Projects & Activities: 1999-2003
Since The Alan Guttmacher Institute's (AGI's) inception, its program and activities have been led by a series of three-year strategic plans developed and adopted by its Board of Directors. These plans are intended to guide the staff regarding the scope and priorities of the organization and to serve as a formal representation to the outside world of the AGI program directions and priorities. The Board usually reevaluates the plan at midterm and, if necessary, redirects its emphasis at that time. Each planning process has differed somewhat from the one before it. However, each has had similar components.
The recommendations of the Science Advisory Panel and those of the Institute's executive staff have been presented to the Board of Directors. These recommendations have then been thoroughly reviewed and shaped by Board discussions, which have culminated in the formal adoption of a new plan. In recent years, every attempt has been made to secure each Board member's active participation in the process. Practically, this has entailed preliminary discussions in small groups as well as full Board oversight and review of the draft document as a whole.
The current strategic plan, which originally covered the 1999-2002 period, has been extended by one year to 2003. The reason for this is that the mid-term review was particularly intensive in light of the transition to a new AGI president at the end of 1999. The broad goals of the plan remain the same but there is increased emphasis on sexual health, HIV/AIDS, behavioral research and building even more than in the past on the Institute's capacity to work globally in ways which strengthen its important work in the United States.
This plan is organized under the following four headings:
• consolidating gains;
• moving toward a more comprehensive view of reproductive health and rights;
• moving toward an integrated global view; and
• managing institutional resources.
The Scope of the Plan
The effective dates of this long-range plan are somewhat fluid, for a number of reasons:
• Some activities are ongoing from year to year. Foremost in this category is the publication and dissemination of the Institute's peer-reviewed journals, Family Planning Perspectives and International Family Planning Perspectives, as well as the relatively new review The Guttmacher Report on Public Policy (launched in 1998) and the related media outreach.
• Many projects are long-term in nature. Examples include work undertaken to monitor the U.S. family planning program under a five-year grant from the Department of Health and Human Services; recently completed three-year projects that culminated in the publication and dissemination of the international reports Into a New World: Young Women's Sexual and Reproductive Lives and Sharing Responsibility: Women, Society and Abortion Worldwide; and the current comparative study of sexual and reproductive behavior of youth in the United States, Canada and selected countries of Western Europe.
• Some activities are recurrent. Such efforts are predicated on the need to update essential data--collected solely or mainly by AGI--at regular intervals or to analyze and utilize, to best advantage, data generated by large government or other national studies. Prime examples in this category are AGI's monitoring of the availability of abortion services nationwide; its surveys of financing mechanisms for various reproductive heath services; and its periodic analyses of the U.S. National Survey of Family Growth and international health and fertility surveys.
Criteria for Project Development
As mentioned above, many AGI activities (as distinct from specific projects) are ongoing and reflect the broad aims of the long-range plan, such as the selection of articles in the Institute's peer-reviewed journals or The Guttmacher Report as well as the attending media and public education outreach. Similarly, the activities of the Public Policy Division in Washington are intended to respond to short-term policy challenges and opportunities, as well as to foster the advancement of the long-term goals of the organization.
Specific projects, however, are selected with narrower aims, and their undertaking is constrained by the availability of funds granted by foundations, government agencies and others. Nevertheless, they must
• conform closely to the Mission, Values and Guiding Principles of the Institute, both in terms of its philosophical approach to human rights and social justice and in terms of the scope of the work and public education efforts to be undertaken in any projected activity;
• meet strict research standards and guarantee the protection of human subjects of research;
• provide for full disclosure of research findings through appropriate publication;
• in no way compromise--or appear to compromise--AGI's independence and credibility;
• fulfill or attempt to fulfill one or more strategic aims of the plan;
• incorporate a comprehensive approach to reproductive health issues and to the commonality of reproductive health and rights concerns and experiences;
• give special attention to the needs of those who are relatively disadvantaged in their own societies;
• place emphasis on the selection of international projects that have global or wide cross-national or regional application and, domestically, on projects that have national or broad implications; and
• be developed with clear strategies for communications intended to maximize the use of the information developed for a broad range of targeted audiences.
Strengthening Public Support
Given the continued and, indeed, heightened opposition to family planning and reproductive health issues among some well-organized U.S. constituent groups, AGI clearly will have to devote a considerable amount of energy to strengthening public support for existing domestic and international family planning programs. While the opposition's public support may wax and wane in the next few years, these groups are certain to remain entrenched and powerful. It will require a great deal of ingenuity and effort to dispel the widespread perception of the absence of an international population "crisis" or, of a convincing threat to domestic reproductive rights. The goal will be both to bolster the tacit but largely "unengaged" support of the general public or even that of influential policymakers and to resist further encroachments in law and policies in regard to abortion rights and the rights of minors.
The achievement of the broad goals of this Plan has undoubtedly been made more difficult by the national elections which occurred at its mid-point. Perhaps the greatest challenge facing AGI will be to remain undeterred in the pursuit of these goals--even as the Institute is called upon to redouble efforts merely to ensure that past gains are not lost. Indeed, given a president and Congress, as well as a raft of governors and state legislatures, whose interest in sexual and reproductive health and rights issues ranges from disinterest to outright hostility, simply maintaining the inadequate status quo and making modest progress may prove a difficult challenge for the near term.
To meet this near-term challenge, AGI will expand and intensify its public policy and information outreach activities in three specific ways that will better equip the Institute to pursue its longer-term goals as well. First, in a concerted and systematic way, AGI will take greater advantage of its role as a substantive and politically savvy action-oriented think-tank to convene various groups of federal-level advocates and researchers around specific policy challenges in order to increase understanding of the strengths and limitations of the findings of important research and their potential application to policy, advocacy and public education. Second, AGI will enhance its ability to inform policy debates at the state- level by expanding and carefully targeting its dissemination of policy analyses and state-focused fact sheets as well as by identifying and developing relationships with a manageable number of leading state policymakers and the key national and regional organizations that work with them on an ongoing basis. Finally, AGI will reexamine its internal "rapid response" processes to ensure that existing AGI data and analyses are being deployed with maximum efficiency and effectiveness at both the federal and state levels, and that new information or analyses that may be necessary, for either federal or state/local policy and advocacy, can be developed and disseminated quickly. AGI will also need to proactively prepare for the likelihood of administration assaults on international agreements such as those achieved at the Cairo and Beijing conferences. Significant review processes of the United Nations (UN) will take place during this period and the reimposition of the global gag rule signifies a highly disturbing shift in U.S. policy.
Making Successful Transitions
A major concern for AGI, which is specific to U.S. family planning and reproductive health programs, but can be generalized to many areas of the world, is the loss of attention and priority to reproductive concerns that often occurs in the course of major structural and financial reforms of the health care system. In the case of the United States, two decades of progress in broadening access for family planning services and related reproductive health care-and associated declines in unintended pregnancy and increases in the use of contraception-are being threatened by several factors.
Among the most significant factors are the growth of the uninsured population (most acute among women, the young, persons of color and recent immigrants) and the drastic changes in the financing of medical care for the poor, including the mandatory enrollment of Medicaid clients in managed care programs. These developments have ominous potential implications for access to and freedom of choice in reproductive health care. They will affect not only the millions of women who depend so heavily on publicly supported clinic services, but also teenagers, who need the kind of confidential information and services that many managed care programs may be unable or unwilling to provide.
Another by-product of the transformation of the U.S. health care system is the growth of mergers between institutions with diverse traditions and religious allegiances. The result in many cases is a curtailment of services deemed controversial by one or more of the parties involved. (Prominent among these services are medical treatment after rape, abortion, contraceptive sterilization, contraceptive services and many "assisted" reproductive technologies.) Legislative exceptions to certain health care mandates are proliferating and claimed on the basis of "conscience" objections of corporations and providers. As a result, they threaten the rights of the consumer/patient to obtain services deemed desirable or necessary according to his or her own conscience.
Preserving the core of the U.S. publicly subsidized family planning program while working to mainstream these and other reproductive health services into managed care systems will require major attention in the years ahead. It should also be noted that the national family planning program, given its popularity among the public (if not among some current congressional leaders), provides a reservoir of support for American population assistance abroad. Its disappearance or substantial weakening would have serious repercussions beyond our borders.
Achieving Universal Availability and Accessibility
Despite gains already achieved in the United States and abroad, it cannot be assumed that the progress made in extending the availability of family planning and abortion services in the last two decades is either satisfactory or complete. AGI recognizes that with some rare exceptions, significant obstacles to the availability of services remain everywhere, particularly in terms of acceptability, accessibility, affordability and quality of care. All four factors have substantial impact on the continued use and, even more, the effective use of a number of reproductive health services. A particular concern internationally, and one of growing significance, is the inadequacy of services suitable and accessible to teenagers and young adults and to those of any age who may be unmarried.
In the United States and in countries that already have well-defined national programs in place, a most important task remaining on the policy agenda is to integrate family planning and reproductive health services within the country's health and social policy. The most visible need in the United States, at the moment, is in the insurance sector. It has been more than four years since AGI publicized the fact that private insurance policies generally fail to provide contraceptive care on par with other needed medical services and prescription drugs and devices. It has been one year since the Veterans Administration, Medicare and now Medicaid opted to authorize payments for the impotence drug Viagra. It has been just under one year since AGI documented the minimal costs to health plans of adding prescription methods to their coverage. Yet, the majority of insurance plans continue to treat contraception as an "elective" service akin to cosmetic surgery.
One avenue to broadening the availability of sexual and reproductive health services for adolescents has been opened-at least in theory-by the congressional extension of health insurance coverage to much of the population under the age of 19. However, the fear of political controversy (or actual political opposition) will make the inclusion of these services into the individual state plans slow and arduous.
Although progress was made in 1998 in securing contraceptive insurance coverage for employees of the federal government, the attempts to secure universal coverage still encounter strong resistance-opposition based not on cost but strictly on stubborn opposition to the acceptance of modern norms. This resistance to the recognition of contraception as a responsible and imperative social practice is by no means limited to the insurance sector. Nevertheless, it is an egregious and potent symbol of how far there still is to go to achieve full cultural and societal support for universal access to contraceptive services-even on the domestic front and, by extension, on the international front as well, and exemplified in the foreign policy of the United States itself.
The United States experience, well documented by AGI, should amply demonstrate that the availability of contraception does not automatically lead to the effective prevention of unplanned or unwanted pregnancies and births. Neither does the availability of safe and legal abortion eliminate the need for preventive services. While the use of contraception in the United States is extremely widespread, the rates of unplanned pregnancy, unwanted birth and abortion are still quite high and certainly higher than in most developed countries. This is a clear signal that accessibility and availability of family planning services-even "high-quality" services in this country or elsewhere-are not enough to eliminate unplanned pregnancies and unwanted births. Neither is the availability of abortion, because a sizable group of women will not avail themselves of this option for cultural, religious or personal reasons.
Therefore, in the years to come AGI intends to turn an increasing part of its attention to improving contraceptive practice by • actively seeking the removal of structural impediments to effective contraceptive use, such as those mentioned above; • promoting the development, introduction and adoption of new contraceptive methods and early medical abortion; and • exploring and addressing some of the cultural and social attitudes that foster sporadic, inconsistent and ineffective contraceptive use.
The facts that-for the first time in several decades-pregnancy rates among U.S. teenagers have begun to decline, racial and ethnic differences in sexual activity have narrowed, and condom use has begun to increase-particularly among groups at highest risk-are all reasons for guarded optimism. Internationally, increases in contraceptive use, strides made in women's education and empowerment, and sharp declines in preferred and achieved family size provoke a similar sense of hope.
Moving Toward a More Comprehensive View of Reproductive Health & Rights
Addressing the Needs of Prospective and New Parents
AGI has, in the past, undertaken projects and activities aimed at the preservation of fertility-mainly through a focus on the prevention of sexually transmitted diseases (STDs) and the availability of infertility services. It has also conducted analyses of the financial or other obstacles faced by women in obtaining prenatal and maternity care. While AGI is committed to sustaining these activities, it intends to devote new attention to other aspects of childbearing in addition to health and medical issues. Other concerns of women and men in deciding to start a family and in being able to nurture their infants and young children warrant much more attention and societal support, which is often sorely lacking in the United States at this time. In addition to its previous endeavors, the Institute can do much more: by working in coalition with groups with similar agendas, by publishing and disseminating relevant research findings and by identifying and developing specific projects of its own both in this country and internationally.
Consulting with experts on parents and families, AGI has concentrated on drawing connections between the challenges facing new and prospective parents and the concerns of men and women as they form relationships and make decisions about whether and when to have children. With the changes in the social safety net resulting from welfare reform, there is a great urgency to improve understanding of the impact of poverty, as well as the effect of youth and marital status on parenting. It has become clear that policies and programs aimed at families intersect with those aimed at reproductive health and rights, and there is also much to be learned from other countries in the advantages of supporting those who are raising our next generation. As a first step, AGI will seek opportunities to examine the impact of the presence or absence of societal supports for parents and parenting in the course of its work on unintended pregnancy, mistimed births and other appropriate issues.
Improving Knowledge and Understanding of Sexuality
AGI's comparative studies of sexual and reproductive behaviors in selected developed countries indicate that-although the mechanisms of action are not always clear-attitudes toward gender and sexuality are major contributors to ambivalence about and conflict in sexual relations and, by extension, childbearing, contraception and the prevention of STDs, including HIV. It is also clear that much is to be done to promote the development of responsible and healthy sexuality that allows for cooperation, mutual respect and equality among sexual partners, goals that are certainly "good" in and of themselves.
However, efforts to provide comprehensive and balanced information about sexuality have also met with potent political opposition practically everywhere. One major opposition strategy in the United States has been the promotion of "abstinence-only" school curricula to the exclusion of discussion of contraception and of any realistic exploration of the value systems involved in adolescents' sexual decision-making and behavior. While other organizations play a substantial role in this arena, AGI has-or should have-much to contribute in this debate by presenting well-developed factual information and framing the issues in a broad societal context.
It has become increasingly clear that quantitative data alone cannot provide a full understanding of sexual behavior in general and risky behaviors in particular. While the number of unintended pregnancies, abortions and cases of many sexually transmitted diseases (STDs) can be quantified, we still cannot fully explain why women and men engage in unprotected sexual intercourse when they do not desire a pregnancy or fail to use a condom despite the risk of acquiring or transmitting HIV or another STD. Finding answers to these vexing questions and others will require qualitative research on the impacts of sexual experiences, relationship dynamics and concerns about sexual pleasure have on behavior. A fuller knowledge of the factors that motivate sexual behavior should better equip the Institute to advocate for sound and effective public policies that will more successfully reduce risky behaviors that result in high levels of unintended pregnancy, unwanted childbearing, abortion and sexually transmitted infections. Whenever appropriate, therefore, AGI will include qualitative and behavioral components in its research to improve knowledge and understanding of sexuality.
Exploring the Roles of Men--as Individuals and as Partners
One particular aspect of the current cultural adjustment, or shift toward a broader view of reproductive and sexual health, is the increased recognition of the importance of the attitudes and needs of men-in the United States and elsewhere-and their interactions with their sexual partners. The substantial decreases in average family size occurring in most less-developed countries over the last 20 years have been facilitated and fostered by the diffusion and widening acceptance of female methods of contraception. Yet, even if this trend were to continue-a questionable assumption-the HIV/AIDS epidemic forces reevaluation of the emphasis on a single, female-based approach. Even where there is low incidence of and little exposure to HIV infection, increased knowledge about the prevalence of STDs and their adverse health impact (particularly on women and the children they bear) has prompted a rediscovery of the importance of male sexual behavior and condom use.
There is also growing awareness of the complexity of the interaction and "negotiation" process between men and women over sexual matters, power sharing in the family, decisions about family-size preference and the use, especially the effective use, of contraceptive methods. While understanding of these issues is still in its infancy, it is clear that they are of utmost significance for the redress of inequities in gender relations and for the eventual success of reproductive health and population programs. Given the difficulty and slow process of change-particularly cultural change-and the huge size of the current generation of adolescents in many countries, high priority must be directed to the needs and attitudes of young and adolescent men (and boys) and, of course, their female counterparts.
The policy attention paid to male reproductive health at the Cairo International Conference on Population Development (ICPD) and in the United States, where it is a top priority of the Title X family planning program, has not been matched by concrete programmatic advances. In investigating this area in depth-for the United States and internationally-the significance of men's role in sexual and reproductive health and well-being has become increasingly clear. Despite persistent stereotypes, new analyses are documenting the extent to which men are caring, concerned partners and fathers. Yet, there is also compelling evidence that much more can be done to provide information and services to men, that those who are younger or poor are particularly needy, and that renewed attention must be paid to improvements and innovations in male methods for preventing unintended pregnancy and for protection against STDs. Therefore, AGI will document the status of male sexual and reproductive health domestically and internationally, highlight what is working and what is not and propose policy and program priorities.
Anticipating the Impact of New Reproductive Technologies
The continuing relative lack or slowness of progress in the development and introduction of new contraceptive technologies, particularly those that might have the potential to prevent both pregnancy and STDs (including HIV), remains a matter of concern and priority. In addition, however, other technological developments relating to the processes of conception and pregnancy will need to be closely monitored by AGI and dealt with in the political arenas in the years to come.
Most of these developments, at the current time, are limited to medically and technologically advanced societies and, even then, affect relatively small numbers of individuals and families. However, they are redefining the status of the embryo, and they play a powerful role in forming public perceptions and even actual practices. Indeed, one example may suffice to illustrate the point: the introduction of the sonogram as a method of prenatal diagnosis. In the United States, for many, it made "real" the development of the fetus and powerfully influenced attitudes (although not necessarily practices) toward abortion. In India and other countries, on the other hand, it made possible the selective abortion of female fetuses.
The development and introduction of new technologies such as emergency contraception and medical abortion present new opportunities for the safe and effective delivery of contraceptive and abortion services. At the same time, they spur new or renewed political controversies and present new challenges for their acceptance and adoption by medical delivery systems and for their coverage by health insurance (public and private). In addition, contradictions arise as fertilization outside a woman's body becomes a well-known way of producing multiple embryos and, eventually, babies (with resulting controversies about how many embryos it is responsible to produce or implant and the validity of "pregnancy reduction"). The increasing viability of very premature infants also plays a role in the formation of public opinion and the fueling of controversies about the permissibility of later abortion. In this regard, and at the other end of the spectrum, public opinion will be affected by the introduction of medical abortion.
New advances in the understanding of genetics and the role of new technologies in identifying predisposition to chronic disease will also challenge our notions of choice. Prenatal genetic testing, advanced by some as a way of expanding reproductive choice, may ultimately raise the stakes in the area of who and what criteria determine whether a pregnancy is carried to term or whether a conception should even occur in the first place. While it may be tempting to succumb to the potential of new scientific breakthroughs, they present a number of ethical dilemmas in assuring reproductive rights.
It would be nearly impossible, at the moment, to define a systematic program to deal with these issues. But it is equally impossible to ignore the potential impact of these innovations (and the debates they will precipitate) not only in the United States and other technically advanced countries, but also-given the speed of communications-worldwide. They will powerfully affect the future directions of reproductive health policies and, indeed, the scope of reproductive rights, and promise to touch each of AGI's core concerns. As such, they need to be closely monitored by the Institute, publicized in its journals as appropriate and made the subject of special projects and activities when warranted.
Political controversy continues to surround some new reproductive technologies, raising questions about their availability in both the short and long term. The Food and Drug Administration's long-awaited approval of mifepristone offered the promise of easier access to safe medical abortion early in pregnancy, however the new administration has already indicated its intention to revisit that decision and conservatives in Congress have proposed legislation that would severely limit women's access to medical abortion. The willingness of physicians to offer the method in the face of this ongoing controversy remains a question. Similarly, awareness and use of emergency contraception has increased, but it is generally not available over-the-counter, which seriously impedes access to the method and the jury is still out on how it will affect unintended pregnancy and abortion rates. Meanwhile, the implications of stem cell research and the successful mapping of the human genome for reproductive rights are being debated, and the development of microbicides to prevent transmission of STDs and HIV, as well as the development of a vaccine against HIV, are proceeding slowly. In the face of these realities, AGI must continue to monitor the development, availability and implications of these technologies, report on problems with access or development and, when appropriate, make these technologies the subject of special reports and other activities.
Recognizing the Implications of HIV/AIDS
An area that is central to sexual and reproductive health-one to which AGI intends to devote even more attention- is HIV/AIDS. An estimated five million people became infected last year alone and more than 36 million are currently living with HIV/AIDS. Women and children are increasingly vulnerable, and now account for half of new infections worldwide. Changing the course of the epidemic is a daunting task, but AGI can no longer afford to press for improved sexual and reproductive health and rights without fully acknowledging the impact of HIV. It is essential that new knowledge inform U.S. and international policies and the allocation of sufficient resources, and that future efforts to stem the epidemic exploit the strengths of family planning providers and activists in STD prevention and treatment to meet the needs of those who are most vulnerable. Even as major advances are made in AIDS treatment, they remain beyond the means of the vast majority of the world's HIV-positive people, and the development of new methods of HIV prevention, such as vaccines and microbicides, is still years away. In the face of these realities, AGI will undertake both qualitative and quantitative research designed to deepen understanding of what behavioral and service system factors place some women and men, including adolescents, at greater risk of infection, document the reproductive health needs of HIV-positive people, and explore those interventions which have the greatest chance of being effective.
Moving Toward an Integrated Global View
Stressing the Universality of Needs and Experiences
AGI's involvement in international population issues has always been predicated on two assumptions. The first is that given the influence of the United States (and of its financial resources) in the world, AGI, as a domestic institution, has a responsibility to closely monitor the activities of the U.S. government and help channel them into directions both humanitarian and effective. The second assumption is that the best approach to the problems of rapid population growth is to foster the ability of women and men to make informed and free decisions about whether or when to have children and to ensure societal support for these choices.
Much of the Institute's work in recent years has been devoted to drawing out the commonalities and discontinuities of experiences among countries in regard to some fundamental issues of human existence. Predominantly, they are the conditions under which sexuality is expressed, families or unions are formed, and children are conceived and born.
This is partly in response to the explosion of mass communications and increasing exposure to other cultures, customs and mores that is occurring around the world and is such a major component of youth culture. As a result, some issues and controversies-such as the provision of sexuality education, the frank and public discussion of sexual matters, the provision of services to adolescents and the availability of safe abortion-have become transnational, with lessons to be learned and shared without regard to national boundaries.
At the same time, these issues have deep ethnic, religious and country-specific aspects that must be given respectful attention and culturally sensitive treatment. This makes all the more important the provision of factual knowledge, useful comparisons and the promulgation of generalized experience to deal more effectively with universal issues.
Even more than in the past, AGI will build on its unique capacity to work from a global perspective to promote and advance sexual and reproductive health and rights in the United States, in other industrialized countries and in the developing world. In addition, AGI will continue to place emphasis in its international work on program efforts that have the greatest relevance to other regions and countries, including the United States.
As it continues work on its core focus areas of global work-adolescent reproductive health and abortion-the Institute recognizes and is increasing attention to two major interrelated challenges: the HIV/AIDS epidemic and the reproductive health of men. The Institute is currently addressing in-depth and with a global perspective a vastly neglected area, the sexual and reproductive health needs of men, documenting the current situation and identifying and clarifying needs in the United States and throughout the world.
While the Institute has long collaborated with overseas partners, we anticipate increased opportunities to work on a more in-depth basis with project partners on both research and advocacy in ways which are both practical and appropriate. By doing so, both the collaborating organizations and AGI itself will benefit from increased knowledge and greater insights.
AGI must respond to a major change in U.S. government policy regarding international funding for reproductive health. One of the first acts of the Bush Administration was the reimposition of the global gag rule, a policy that undermines the health of women and the integrity of nongovernmental reproductive rights organizations in developing countries. AGI is committed to working with other groups to educate the American public about the impact of this policy and to ameliorate its effects.
Making Optimum Use of New Communications Technologies
Over long distances, with little regard to time or place, advances in computerization and electronic communication have transformed the way in which information is gathered and shared. These advances have brought a new level of exposure to a broader range of related research, emerging scientific breakthroughs and the diversity of public discussion of issues related to sexuality, reproductive health and population. At the same time, the interactivity afforded by the Internet has facilitated and forged new relationships and has presented ever-expanding opportunities for the use of research and analysis to shape programs, policies and public opinion on a worldwide scale.
While AGI has implemented several adaptive strategies to take advantage of these technological developments, it also recognizes their limitations. Disparities in access to these new technologies-particularly among rich and poor nations-on the one hand and information overload on the other will demand that the Institute continue to utilize and constantly evaluate multipronged efforts to disseminate its findings. The Institute's traditional role in identifying, synthesizing and publishing the highest quality research and policy analysis is likely only to intensify with the steadily increasing stream of information requiring a trusted and authoritative guide. As consumers, including decision-makers, demand information that will affect their own decisions, AGI will be challenged to provide it in ways that resonate at the regional, country and, to the extent possible, community levels. Going hand in hand will be the need for translated materials-both in print and electronically-in as many languages as is feasible, given available resources.
Although AGI confers extensively with a wide variety of advisors to ensure the quality of its research and test the appropriateness of its "messages," the Internet is already enabling more extensive consultation and collaboration. As a result of the Institute's greater international involvement and ventures into new areas of inquiry, AGI will need to give special care to making contact with and soliciting the involvement and advice of a wider array of individuals and groups with special expertise and varied perspectives.
Finally, AGI will need to balance all of these new opportunities with time-tested methods. No matter how revolutionary the Internet and other means of mass communication have been or will be, the persuasiveness of an individual presentation, the strength of a face-to- face dialogue and the power of learning firsthand about a community's problems and the efforts to overcome them will continue to be forceful tools for the Institute to use as wisely and effectively as possible.
While e-mail and the internet have enabled AGI to provide information more quickly and inexpensively to health care providers, the media and other key opinion leaders, these technologies have also challenged the Institute to provide shorter, more consumer-friendly materials such as factsheets and policy analyses. Whenever possible, AGI will strive not only to produce materials that are conducive to list serves, Web presentations and media alerts, but also to make these materials relevant to grassroot concerns in this country and abroad, reflective of the diversity of the Institute's stakeholders and available in multiple languages. AGI has just begun to harness new developments in communications and internet technologies to facilitate research, convene advisors, enable distance learning, solicit financial support, and employ the talents of a workforce beyond the Institute's New York and Washington, DC offices and will continue to do so in the future.
Managing Institutional Resources
While the issues covered above will guide AGI's program agenda over the next three years, equal attention must be paid to institutional development. Within the last three years, the Institute's budget and staff have grown by 25%, largely as a result of increased involvement in the international arena. As AGI has grown, it has been fortunate to recruit several new and outstanding demographers, policy analysts, editors and writers, as well as many recent graduates to assist in all elements of AGI's work. In the period ahead, the imperative to closely monitor and foster this growth and to ensure AGI's financial security presents its own set of priorities. AGI will be obligated to commit the time and energy needed to make room for new visions and yet also preserve a sense of continuity and history by
• continuing to focus on diversification of funding sources and balancing large, multiyear projects with smaller, more flexible initiatives;
• carefully assessing and planning for the implications--financial, programmatic and managerial--of potential growth;
• continuing to invest in organizational accountability--including greater involvement on the part of the Board and staff--in project development, management and evaluation;
• nurturing AGI's particular institutional values and approach--of integrating research, policy analysis and public education and of working by consensus--through greater internal communication, orientation and opportunities for sharing information;
• reaffirming the importance of recruiting staff and Board members with a diversity of experiences and perspectives;
• accommodating greater exposure externally to new areas of inquiry, emerging developments, wider audiences and a variety of domestic and international issues;
• preserving, managing and sharing the knowledge and perspective acquired over AGI's 30-year history;
• recognizing that because broad-based fundraising among individuals has limitations for institutions like AGI, the Institute must concentrate on the demonstrated commitment of donors to help ensure its long-term future; and
• acknowledging the necessity for continued upgrading of software, equipment and technological competence and the resulting demand on existing resources
Downturns in the U.S. and world economies undeniably threaten AGI's institutional strength and capacity as we work to meet the ambitious goals set forth in the current strategic plan. While ensuring that every resource is being used to maximum effectiveness, AGI must also continue to seek new sources of support. Engaging those who, despite the downturns, have amassed wealth, capitalizing on the commitment of aging Americans to the Institute's Mission and tapping developed-country interest in the types of analyses and information the Institute produces must be part of any future fundraising strategy. Without a significant endowment, AGI is particularly vulnerable and is limited in its flexibility to undertake rapidly needed initiatives. Therefore, the highest priority must be placed on ensuring that the Institute is able to weather financial setbacks. In recognition of this vulnerability, in 2000 The Andrew W. Mellon Foundation awarded AGI a $1.5 million matching grant for building an endowment to begin to build a secure foundation for the Institute.
This opportunity will enable an evolution in fundraising strategy that will also challenge AGI to more effectively articulate its goals and achievements, and to involve every member of the AGI staff in promoting AGI's financial sustainability. AGI has no greater resource than the individuals who work hard to ensure that every Institute initiative is innovative and responsive to the needs of the women and men for whom sexual and reproductive health is an essential-but too often elusive-human right.
Projects and activities: 1999-2003
As noted in the introduction to the plan, many of AGI's activities-such as publications, communications/media and advocacy (and, of course, fundraising)-are ongoing and generally supported by core support grants and general revenue. Individual projects, on the other hand, may be recurrent or multiyear in scope and are often dependent on the timing and availability of major data sources and on the funding interests and priorities of individual foundations, government agencies and other donors.
I. Projects 1999 to mid-2001
During the first half of the period covered by this Strategic Plan, AGI completed or began work on a number of projects which focused on key areas of its work: 1. Healthy sexual relationships, 2. Prevention of unintended pregnancies, 3. Prevention and treatment of sexually transmitted diseases, including HIV, 4. Assurance of a woman's right to choose abortion, and 5. Support of achievement of healthy pregnancies and births, and balancing parenting with other roles. Projects have been placed under only one heading although many would fit under multiple categories given the interdisciplinary nature of AGI's work. Some projects, such as the field visits to Ghana and The Philippines, do not fit well under any of the specific headings because their intention was to strengthen our overall institutional capabilities and to provide a basis for meeting new challenges.
Healthy sexual relationships
• Monitor overall trends and subgroup differences in teenage sexual behavior.
• Analyzing trends in sexual activity among adolescent American women.
• Investigating gender differences in the timing of first intercourse in 14 countries in Asia, Latin America, sub-Saharan Africa, Great Britain and the U.S.
• Collect and summarize existing information on oral sex among adolescents in the United States.
• Analyze patterns of sexual relationships and age differences between sexual partners in the United States.
• Investigate men's sexual and reproductive behavior and health and their roles in sexual and reproductive partnerships: two major reports-one domestic, the other international.
• Examine religious differentials in sexual behavior, contraceptive use, number of partners, pregnancy, birth and abortion among adolescent females in the United States.
• Review adolescent sexual and reproductive health in Nigeria and sub-Saharan Africa.
• Examine the provision of accurate and comprehensive sexuality education in public schools.
• Surveying public school district policies regarding sexuality education policies, abstinence promotion and the provision of information about contraception.
• Assessing state-by-state implementation of the federal abstinence-only program.
• Surveying teachers of sexuality education in grades 5-6 and 7-12 in U.S. public schools throughout the U.S.
• Analyze regional differences in sexuality education.
• Identify gender differences in adolescent sexual behavior and contraceptive use in sub-Saharan Africa and Latin America.
• Estimate condom use and dual protection among men ages 15-59 in sub-Saharan Africa.
Prevention of unintended pregnancies • Monitor levels and trends in pregnancy, birth, abortion and intention status.
• Documenting teen pregnancy and abortion statistics at national and state levels.
• Assessing of the roles of changing sexual behavior and contraceptive use in recent decreases in rates of teen pregnancy in the U.S.
• Analyzing pregnancy levels by ages of women and of men.
• Documenting levels and trends of teen pregnancy, birth and abortion rates in developed countries.
• Evaluate contraceptive failure rates, over time and across sociodemographic groups.
• Assess factors related to insurance coverage among men and women.
• Explore the roles of societal attitudes about sexuality, service delivery and socioeconomic disadvantage in the sexual and reproductive behavior of young people in 5 case-study countries (Canada, France, Great Britain, Sweden and the U.S.) and identify relevant program and policy examples.
• Review of insurance coverage of reproductive health services.
• Analyzing laws and policies regarding contraceptive coverage in private insurance.
• Working with employers and plans to improve contraceptive coverage in private health insurance.
• Monitoring the state-by-state inclusion of reproductive health services for adolescents under the Child Health Insurance Program.
• Updating and documenting the extent to which private insurance plans cover contraceptive supplies and services.
• Investigating the impact of institutional, corporate or employer-based "conscience" clauses on the "freedom of choice" of individual consumers.
• Assess the accessibility of family planning services.
• Summarizing the U.S. family planning program and Title X's three decades of accomplishment-A chartbook.
• Evaluating the provision of family planning services in Medicaid managed care systems.
• Investigate the publicly supported family planning programs in the United States.
• Monitoring of federal and state funding for family planning services.
• Documenting U.S. women's use of reproductive health services from public and private providers.
• Assessing the availability and client levels of publicly-funded contraceptive services at national, state and county levels.
• Exploring service components, programs and policies of family planning agencies.
• Estimating the numbers and characteristics of women at risk of unintended pregnancy and in need of publicly subsidized contraceptive services and supplies.
• Documenting needs for reproductive health services among uninsured or underinsured populations.
• Identifying other gaps in coverage and their specific impact on various population subgroups.
• Investigate the state-by-state impact of the expansion of eligibility for family planning through Medicaid waivers and other means, identifying barriers to expansion and full implementation and recommending potential remedies.
• Estimate impact on women and children in developing countries from changes in the level of USAID funding.
• Analyze the global gag rule on USAID funding for family planning programs.
• Investigate and evaluate AGI's effectiveness in providing research and other information to various audiences in the developing world, with site visits in Ghana and the Philippines.
• Monitor the impact of welfare reform.
• Investigating the impact of welfare reform and declining Medicaid enrollments on access to reproductive health services.
• Analyzing welfare reform policies and practices as they relate to women's sexual and reproductive rights.
• Analyze birth control service provision in school-based health centers.
• Assess refugee reproductive health: A Family Planning Perspectives Special Report and an International Family Planning Perspectives Special Section.
Prevention and treatment of sexually transmitted diseases, including HIV
• Investigate sexual partnership patterns in the U.S. as a behavioral risk factor for sexually transmitted diseases.
• Review policy issues regarding HPV and cervical cancer.
• Monitor public policy and provide information and education regarding the development of microbicides.
• Document levels and trends in STDs among youth in developed countries.
• Assess methodologies and data systems for monitoring HIV infection in Nigeria.
• Review STD prevention- and treatment-seeking behavior worldwide.
• Assess STD prevention programs for youth in developed countries.
• Estimate women's interest in vaginal microbicides (the chartbook came out in late 1999).
• Examine determinants of trends in condom use in the United States.
Assurance of a woman's right to choose abortion
• Explore the sociodemographic characteristics and contraceptive use patterns of U.S. women having abortions, through a survey of 13,000 women.
• Analyze laws and policies regarding abortion, public funding for abortion, restrictions on types of abortions and on minors' access to services.
• Review state laws regarding minors' right to consent to health care.
• Track and analyze trends in the provision of abortion services and use in the United States, including the impact of the introduction of medical methods of early abortion.
• Assess changes in access to reproductive health care when hospitals merge.
• Encourage increased and higher-quality research on induced abortion in Latin America, through collaborating with The Population Council to plan a scientific meeting on abortion.
• Review the characteristics of women throughout the world who obtain induced abortion.
• Review evidence on European experience with provision of medical abortion.
Support of achievement of healthy pregnancies and births, and balancing parenting with other roles
• Analyze policies and practices of insurance coverage for infertility treatment.
• Analyze policy proposals for adoption promotion in the Title X family planning program.
• Analyze policy concerning human embryo and fetal research.
• Investigate the benefits of better control over the timing of pregnancies and births for women's opportunities and family well-being.
• Document the positive impact of family planning on women's and children's health, internationally.
II. Potential Projects to Be Developed
As it develops new projects, the Institute continuously seeks to balance its program of activities by taking into account new priorities and issues while fulfilling its long-term commitment to issues of ongoing importance. The following outline of potential projects is a selective but illustrative list, and is not ordered according to the priority of projects. Priority may change over time, depending on the vagaries of the political and cultural environment over the next few years. New projects and activities not included on this list may be developed over the course of this plan in response to unforeseen challenges or opportunities. AGI anticipates an increase in behavioral research and combining qualitative and quantitative methodologies in order to increase understanding of the root causes or "drivers" of sexual and reproductive health. The Institute also intends to pay increased attention to race/ethnic diversity and its implications for our mission. While projects are listed only once under their major focus area, this classification is somewhat artificial, since projects often have overlapping and mutually reinforcing topic areas, purposes and applications. Indeed, one major criteria for project development is maximizing the interrelationships between subject areas and issues.
Healthy sexual relationships
• Explore the links between sexual behavior, method choice and effective contraceptive use.
• Examine the extent to which family planning service providers are meeting the needs of lesbians-for a Special Report in Family Planning Perspectives.
• Define the components of reproductive health care and estimate their relative unmet needs and consequences of those gaps, both domestically and internationally.
• Assess the extent to which reproductive health services are being "mainstreamed," domestically and internationally.
• Investigate how sexual abuse and violence are linked with sexual and reproductive behavior, including contraceptive use and prenatal care.
• Synthesize and disseminate information on the relationship between sexuality education, sexual initiation and experience, and contraceptive use among younger and older teens. • Document the use and need for reproductive health services worldwide and examine existing barriers to increasing political and financial support for the acceptance and effective provision of the needed services.
Prevention of unintended pregnancies
• Document the differential "costs" of unintended and unwanted childbearing and the impact of the timing of pregnancies and births for various population subgroups.
• Explore and better define the concepts of "intendedness" and "unintendedness" and their significance and differential impact on various age and population subgroups.
• Examine cross-country differentials (beyond the United States and Western Europe) in social and cultural support for contraception and the impact of these differences on the provision and use of contraceptive services and unintended pregnancy rates.
• Evaluate the impact of the availability of emergency contraception and of changing patterns in the use of contraceptive methods.
• Develop and publish a chartbook on contraceptive use in the United States.
• Investigate the potential for a similar publication with an international focus.
• Evaluate the impact and the value of U.S. international assistance with regard to family planning, reproductive health and population.
• Estimate the cost of further reductions to unmet need for contraceptive services in the United States.
• Evaluate the role of contraceptive supply costs on levels of use and on method choice.
• Undertake increased state and local public education initiatives regarding the importance of improved availability and accessibility of contraceptive services.
• Determine how many minors currently involve parents in their decision to obtain contraceptive services from family planning clinics and what they would do if parental involvement were mandatory.
Prevention and treatment of sexually transmitted diseases, including HIV
• Assess the HIV and other STD risk and prevention attitudes and behaviors of adolescents so as to inform and improve policies and programs, with particular emphasis on and in collaboration with researchers in sub-Saharan Africa.
• Investigate American men's interest in and willingness to support their partners' use of microbicides and, themselves, to use microbicides and hormonal contraceptive methods.
• Assess HIV and STD risk and prevention behaviors and attitudes in the United States and the Netherlands.
Assurance of a woman's right to choose abortion
• Deepen understanding, domestically and internationally, of the relationship between contraception and abortion, and the potential of improved contraceptive availability and use to reduce recourse to abortion, with focus on and in collaboration with project partners in Nigeria and the Philippines.
• Work collaboratively with project partners in Pakistan to explore access to abortion.
• Develop centralized archive of state abortion data with the National Bureau for Economic Research.
• Estimate levels of abortion, abortion morbidity and abortion among HIV -positive women in Bangladesh, Guatemala and Uganda, in collaboration with European and in-country project partners.
• Track and analyze trends in the provision of abortion services and use, internationally, including the impact of the introduction of medical methods of early abortion.
• Monitor public attitudes toward reproduction, childbearing, contraception and abortion.
• Undertake increased state and local public education initiatives regarding the importance of improved availability and accessibility of abortion services.
• Undertake a national survey on reasons why women have abortions in the United States.
• Follow up abortion providers to assess trends in provision of medical abortion in the United States.
• Explore the differences between the United States and other developed countries in financial, social and other supports for parenting young children, particularly for working and single women.
• Document the current legal framework addressing women's and men's responsibilities vis-à-vis sexual relationships, pregnancy, childbearing and parenting.
• Assess the impact of the introduction of new reproductive technologies on public attitudes, individual behavior and public policy.