Gender, equity and the right to sexual and reproductive health

1. Gender, equity and the right to sexual and reproductive health ***** Marge Berer Editor, Reproductive Health Matters Chair, International Consortium for Medical Abortion

2. History • In 2015, the Programme of Action of the International Conference on Population and Development (ICPD, 1994) will be two decades old, and the Millennium Development Goals (MDGs, 2000) will be one decade old. • Neither will have reached fruition by 2015, and though there have been many successes and some signs of improvements in many countries, the goals related to health in both these documents will remain unfulfilled. • Why?

3. Keeping the Promise 2010 • “Our world possesses the knowledge and the resources to achieve the MDGs.” • Significant progress towards increasing school enrollment, controlling the spread of diseases like malaria and tuberculosis, and improving child health. Progress = adequate investments and commitments • “Insufficient progress” on gender equality (MDG3). • “Least progress” on maternal health. • “Access to reproductive health services remains poor where women’s health risks are greatest.” Lack of progress = inadequate levels of investment, support and accountability.

4. Women have been mainstreamed !! • UN Secretary General has placed women and children in the centre of the global agenda. • Pledges of money have poured in. • Commitments made at the MDG Summit are remarkable. • There is a new UN Women.

5. WHO Reproductive Health Strategy • Five overarching activities necessary for accelerated progress in SRH: • Strengthening health systems capacity (including attention to financing, health workers, quality of service provision and barriers to use of services); • Improving information for priority setting; • Mobilizing political will; • Creating supportive legislative and regulatory frameworks; and • Strengthening of monitoring, evaluation and accountability. (WHO 2004)

6. Major legislative/policy changes South Africa 1994 Free public health services for pregnant women and children under six. 1995 Government ratified CEDAW. 1996 Choice on Termination of Pregnancy Act. 1997 Maternal death made a notifiable condition. 1997 Patients’ Rights Charter. 1998 New population policy introduced, delinked from population growth. • South African National AIDS Council. • Domestic Violence Act. 2000 National Guidelines for Cervical Screening Programme. 2002 Comprehensive programme of PMTCT services. 2002 National Contraception Policy Guidelines

7. Mixed gains • The ICPD Programme of Action represented a paradigm shift. • It replaced population control with reproductive health and rights and sexual health within a human rights framework. • Even so, gains in the past 15 years mixed. • Although the concepts of reproductive health and rights and to some extent, sexual health, have taken root within bureaucracies, NGOs and in the political arena, the impact on health outcomes has been less than anticipated. • Sexual rights, poorly understood, left out.

8. Effect of Millennium Declaration • The intimate link between maternal health and sexual and reproductive health and rights was one of the factors underlying ICPD paradigms. • One reason for lack of progress is the sidelining of sexual and reproductive health and rights issues following the adoption of the Millennium Declaration. • When the MDGs were agreed by governments around the world, maternal mortality reduction was singled out, and the maternal mortality ratio was made an indicator for the functioning of all components of reproductive health care and the underlying social determinants.

9. This was a big mistake.

10. Women? Or just mothers? • Maternal health = women survive not only their pregnancies but the outcome of their pregnancies – whether delivery, miscarriage or induced abortion. • In practice, the focus on MMR (though an important political commitment) has led to a narrowing of attention to maternal health, which has mutated into “mothers’ health”. • Moreover, we have begun to hear that mothers’ health is to be protected because it is associated with newborn health and mothers’ survival is important for the health and well-being of babies and children, especially girls.

11. This will drag us backwards 60 years… or maybe 160.

12. MMR remains high • Number of women dying due to complications of pregnancy and childbirth has decreased by 34% from an estimated 546,000 in 1990 to 358,000 in 2008, an average annual decline of 2.3%. • 10 out of 87 countries with maternal mortality ratios ≥ 100 in 1990 had an annual decline of 5.5% between 1990 & 2008 (= on target MDG5). • 30 countries have made insufficient or no progress since 1990. (WHO 2010) • Why?

13. …and rate of unsafe abortions • An estimated 33 million women each year will experience an unintended pregnancy while using a contraceptive method. (WHO 2003) • 21.6 million unsafe abortions worldwide in 2008, up from 19.7 million in 2003, a rise due almost entirely to the increasing number of women of reproductive age globally. (Shah, Åhman, RHM 2010) • The need for abortion is as much a part of women's life experience as the ability to become pregnant. Anyone who fails to support the right to abortion is anti-women and anti-RH.

14. .. unmet need for contraception and condoms • In 2000, donor governments provided 950 million male condoms out of 8 billion required (UNFPA 2000); in 2006, this rose to 2.3 billion against 18 billion condoms required. (UNFPA 2007) • UNFPA distributed only 16.5 million female condoms in 23 mostly African countries in 2008. • 700-800 million women/couples were using family planning; 137 million women with unmet need.

15. …sexual health problems enormous • 340 million new cases of bacterial STIs annually • Millions of viral STIs (herpes, genital warts, HPV, hepatitis B, HIV) • 490,000 cases cervical cancer diagnosed annually, 240,000 deaths, 75% in developing countries • 33.4 million people living with HIV and AIDS, 2.7 million new infections per year and 2 million deaths

16. … other aspects of SRH • Prevention and treatment of infertility. • Prevention and treatment of other gynaecological conditions, e.g. prolapse, fistula, menstrual problems, and urological conditions. • Addressing sexual problems, e.g. sexual dysfunction and consequences of sexual violence. • Prevention and treatment of breast, genital, anal, prostate and reproductive tract cancers.

17. Essential medicines • There is gross inequity in access to appropriate, essential, quality medicines globally, ranging from over-medicalization and over-supply to a severe lack of essential drugs and regular stock-outs in poor countries. • Moreover, in relation to SRH, there is gross under-investment in drugs and devices, including for EmOC, contraceptives, (female) condoms, microbicides, and medical abortion pills.

18. Importance of MDG 5b • It took until 2008 for “universal access to reproductive health” to be included in MDG5. • In practice, however, universal access to reproductive health still does not get the priority it deserves.

19. Gender perspective • Women have more reproductive health problems than men because of pregnancy. • Men have at least as many sexual health problems as women. • WHO review: sexual health needs of boys and men require attention. (WHO 2010)

20. Rights, equity and justice are missing.

21. Social determinants of health • Long-standing inequities in global wealth and resource distribution are not being reduced and have worsened with the economic crisis. • Inequity between and within countries growing: poorest countries are failing to improve. • Negative role of armed conflict, violence, environmental disasters, and displacement of populations.

22. Health services issues • Public health sector cannot treat the poor when it is grossly under-resourced and under-staffed and is not free. • Privatization in health care is a major deterrent to universal access to health care services, including SRH services. (RHM Nov 2010) • There is poor access for rural and vulnerable groups; shortage of equipment and providers; and inadequate services for adolescents. (WHO 2010)

23. Global health initiatives • GHIs (partnerships, usually of World Bank, multilateral agencies, donor governments, large international NGOs & private foundations) have hugely increased development assistance for specific diseases. * $2.5 billion in 1990 to $14 billion in 2005 • GHIs are also reinforcing and strengthening vertical programmes, contributing to increasing health inequalities. • Sexual and reproductive health problems other than HIV/AIDS are largely absent in GHIs.

24. Political determinants of health • A top-heavy global elite has formed. • The agendas of rich governments, donors and NGOs, dominated from the global North, are controlling the agenda instead of evidence-based policies, programmes and practices. • The demand for business plans and measurables are distorting the agenda. • Change will only happen at national level – with political will and a critical mass of support.

25. Rise of religious fundamentalism and cultural relativism • SRHR is seen as a part of a secular agenda and opposition to it is rising in a world increasingly threatened by religious fundamentalism. • Principles established in international human rights law and international consensus documents like ICPD are being challenged in every international forum, including in Europe.

26. Civil society becoming timid • NGOs working on SRHR issues are choosing not to propose initiatives going beyond Cairo, Beijing and other international agreements for fear of a backlash.

27. Progressive SRHR agenda • We need a collective discussion about where the SRHR field should be heading. • The SRHR agenda needs to be re-asserted, in the face of an increasingly unfavourable political environment. • We need to design, advocate and implement integrated, comprehensive SRH interventions.

28. Right to sexual and reproductive health • We need a global convention on the right to health and universal access to health care. (see: Joint Action and Learning Initiative on National and Global Responsibilities for Health, WHO Bulletin 2010) • Within that, we need to demand the right to sexual and reproductive health, and our reproductive and sexual rights.

29. Thanks to: • TK Sundari Ravindran • Sylvia Estrada-Claudio • Wanda Nowicka • Hossam Baghat • Jeffrey O’Malley • Berit Austveg from the conference: Repoliticising Sexual and Reproductive Health and Rights, Langkawi, August 2010.

30. Thank you very much!