Linking Sexual and Reproductive Health to HIV and Environment

Linking Sexual and Reproductive Health to HIV and Environment Presenter: Benson Singa CCR Seminar 19th Sept. 2012

Overview • SRH & MDGs • Maternal Health • Demographic and Environmental interplay • Family Planning • Misses opportunities • Conclusion

SRH and MDGs 1. Eradicate extreme poverty and hunger 2. Achieve universal primary education 3. Promote gender equality and empower women 4. Reduce child mortality 5. Improve maternal health 6. Combat HIV/AIDS, malaria and other diseases 7. Ensure environmental sustainability 8. Develop a global partnership for development

5. Improve maternal health • Target 5a: Reduce by three-quarters the maternal mortality ratio Indicators: • 5.1 Maternal mortality ratio • 5.2 Proportion of births attended by skilled health personnel • Target 5b: Achieve universal access to reproductive health Indicators: • 5.3 Contraceptive prevalence rate • 5.4 Adolescent birthrate • 5.5 Antenatal care coverage • 5.6 Unmet need for family planning

SRH & MDGs • SRH underpins nearly all MDGs, either directly or indirectly. Specifically, • it supports Goal 1 because smaller families and wider birth intervals allow families to invest more in each child’s nutrition and health, and can reduce poverty and malnutrition for all members of a household. • It also contributes to improving educational prospects for children, especially by closing the gender gap in education (Goal 2); empowering women (Goal 3); reducing child mortality (Goal 4); and curbing the AIDS pandemic (Goal 6). • In developing countries, slower population growth can reduce pressure on environmental resources (Goal 7). • Achieving Goal 5 would require improved cooperation between global, national and local actors (Goal 8).

National Adaptation Programs of Action (NAPA) • Analysis of the reports shows that: • in addition to concerns regarding the impact of changing weather conditions on factors such as vulnerability to flood, drought and decreased crop yield, 37 of the reports (93%) were found to cite “rapid population growth” as a factor that compounds these problems.

Demographic and climatic interplay • Given the speed of demographic change in many least-developed countries, population growth is identified as problematic in strategies concerned with natural resource depletion. (NAPA reports)

Key themes in the NAPA reports • (i) reducing supply – rapid population growth and climate change act cumulatively to degrade the source of key natural resources, for example through soil erosion and deforestation; • (ii) increasing demand – rapid population growth is projected to escalate the demand for resources that are diminished by climate change, including fresh water and food; and • (iii) vulnerability to natural disaster – rapid population growth heightens human vulnerability to natural disasters caused by climate change, such as by forcing more people to migrate and settle in areas at risk of floods, storms, drought and infectious disease.

Issues cited as linked to Population growth by 37 of 40 NAPA reports • Soil degradation/erosion -21 • Fresh water scarcity -18 • Migration -18 • Deforestation -17 • Inadequate farm land per capita -14 • Loss of biodiversity -11 • Disease and health system constraints -8 • Loss of natural habitat -8 • Diminishing fish stocks -7 • Desertification -5

Guttmacher Institute Adding It Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health (2008)

Benefits of investing in the health of women and their newborns • Fewer unintended pregnancies; • fewer maternal and newborn deaths; healthier mothers and children; • greater family savings and productivity; and • better prospects for educating children, strengthening economies and reducing the pressure on natural resources in developing countries.

GI & IPPF; estimates for 2008 • 215 million women who want to avoid a pregnancy are not using an effective method of contraception, despite increases in use in recent years; • only about one-half of the 123 million women who give birth each year receive antenatal, delivery and newborn care (including routine care and care for complications), and many who get care do not receive all the components of care they need; and • about 20 million women have unsafe abortions each year, and three million of the estimated 8.5 million who need care for subsequent health complications do not receive it.

meeting the need for family planning and maternal and newborn health • Unintended pregnancies would drop by more than two-thirds, from 75 million in 2008 to 22 million per year. • 70% of maternal deaths would be averted—a decline from 550,000 to 160,000. • Forty-four percent of newborn deaths would be averted—a decline from 3.5 million to 1.9 million. • Unsafe abortions would decline by 73%, from 20 million to 5.5 million (assuming no change in abortion laws), • The number of women needing medical care for complications of unsafe procedures would decline from 8.5 million to 2 million. • The healthy years of life lost due to disability and premature death among women and their newborns would be reduced by more than 60%.

Perspectives in Family Planning • Health perspective: • reduces maternal mortality. (MM is estimated at 1.8 times higher without contraceptive use; additional 272,000 deaths) • It is estimated that contraceptive use has reduced maternal deaths by 44 percent by reducing the number of unintended pregnancies. • If all women requiring FP had access to services MM would be reduced by a further 30%

Perspectives in FP • Environmental impact perspective: • Reduced population growth rate could reduce future CO2 emissions. • Rapid urbanization could increase CO2 emissions. • on balance, slowing population growth through increased voluntary contraceptive use would have profound climate-related benefits.

MDGs perspective • Perspective on effects of family planning on poverty, hunger, primary education, and promotion of gender equality • These issues relate to Millennium Development Goals 1, 2, and 3, and studies have shown the enormous benefits of spacing births on a woman’s improved income and nutrition, increased opportunities to work in the formal labor force, as well as improved nutrition and education of her children. • The economic benefits can be seen at both the household level and the country level.

Human rights perspective • Human rights can shape policies and programs to increase access to contraceptives. • From this perspective, civil societies and other stakeholders can hold governments and all providers accountable for the quality of services offered.

GARY DARMSTADT • “Regardless of which perspective rings most true for you, the evidence confirms that providing a woman with the right to decide when and how many children to have is beneficial in many different ways for her, her family, her nation and the world”.

Missed opportunities • Aid for family planning as a proportion of total health aid to developing countries fell from 8.2% in 2000 to 2.6% in 2009, whereas • funding for HIV rose from 3% to 26%. • In the massive scale-up of HIV services the opportunity to deal with family planning at the same time was missed.

Cost effectiveness of integration • A 2009 systematic review of 58 studies found that linking HIV and reproductive health services could • enhance program efficiency and effectiveness and • increase uptake of services, coverage of underserved populations, and use of effective contraceptive methods. • However, important questions remain about when, where, and how best to integrate, as well as the cost effectiveness of integration.

FP and HIV services • Have multiple overlapping objectives, which may not be fully achieved through separate, vertical programs. • Linking these services makes intuitive sense, as the same behaviors that result in pregnancy also put people at risk for HIV

Evidence for Integrated services • Evidence demonstrates that integrated services can: • have a positive impact on client satisfaction, • improve access to component services, and • reduce clinic-based HIV-related stigma, and that • They are cost-effective. • Evidence of FP services reaching men and adolescents and of their impact on health outcomes is inconclusive. • Several studies found that providers frequently miss opportunities to integrate care and that the capacity to maintain the quality of care is also influenced by many programmatic challenges.

U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in 2004 • Resulted in an exponential expansion in U.S. HIV support to Kenya, which increased from $34 million in 2003 to $534 million in 2009. • Dramatically shifted the focus of U.S. assistance, with investments in HIV dwarfing other programming. • In 2008, $534 million was targeted to HIV, $3.4 million to material and child health (MCH), and $13 million to family planning (which increased to $17 million in 2009).

CSIS Commission on Smart Global Health Policy – Aug 2009 • Governance issues pose among the most challenging obstacles to mounting an effective national response. • Health planning and expenditures, systems of procurement and oversight, • political spillover into the health sector, and anemic country ownership of health programs all underscore the uncertainty around sustainability of current U.S. investments. • Of particular concern in sustainability of investments is the growing “HIV mortgage” that increasing demand, access, and cost of HIV first- and second-line antiretroviral (ARV) therapy will entail. • Currently the donor community shoulders 98 percent of this burden. • The Kenyan government faces multiple human security challenges that affect health outcomes, including severe food insecurity, chronic water scarcity in parts of the country, spillover from regional conflicts, and a growing humanitarian crisis among refugees.

The Case for AMPATH • Provides an alternative model for integrating programs, • provides clinical care, training, research, and capacity building within neighboring communities. • Originally established to prevent and treat HIV/AIDS, the partnership, with significant external funding, • now works to address associated challenges of disease, hunger, and poverty through agriculture and rural development projects, supplemental feeding, and economic development training.

Conclusion • Investments in the health sector will have diminishing marginal returns if other critical sectors are not adequately addressed

LEST WE FORGET “I will not let my HIV status stand in the way." (Decisions on motherhood among women on ART in a slum in Kenya- a qualitative study)

COMMENTS Thank You

Linking Sexual and Reproductive Health to HIV and Environment