9. Global Dimensions of Sexual and Reproductive Health

Question 1

Overview Summary

Answer 1

Welcome to the session on global dimensions of sexual and reproductive health. In earlier sessions, you will have learned more about the globalising factors that are changing the ways we define and think about health and specific health issues.

Question 2

Overview Aims

Answer 2

The aim of this session is to consider how global factors affect sexual and reproductive health (SRH) and to understand the actors and global health policies that collectively strengthen the SRH response.

Question 3

Overview Learning outcomes

Answer 3

By the end of this session, you should be able to: Demonstrate how global factors influence sexual and reproductive health (SRH) determinants and outcomes; Critically analyse policy responses and actors concerned with global responses to SRH issues; and Examine global challenges in strengthening SRH service provision and prevention efforts.

Question 4

Key terms Family planning

Answer 4

Family planning allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility (WHO, 2008), (Institute of Medicine, 2009).

Question 5

Key terms Maternal mortality ratio

Answer 5

The number of women dying during pregnancy, childbirth, and the six-week postpartum period due to pregnancy-related causes, per 100,000 live births (Adapted from (WHO, 2021a))

Question 6

Key terms Reproductive health

Answer 6

A state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, addressing the reproductive processes, functions and system at all stages of life. This implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so (UN, 1994).

Question 7

Key terms Reproductive Rights

Answer 7

The human rights of all couples and individuals to decide freely and responsibly the number, spacing, and timing of their children, to have the information and means to do so, and the right to attaining the highest standard of reproductive health (UN, 1994).

Question 8

Key terms Sexual health

Answer 8

A state of physical, emotional, mental and social wellbeing in relation to sexuality, requiring a positive and respectful approach to sexuality and sexual relationships, and the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence (WHO, 2006).

Question 9

Key terms Sexuality

Answer 9

A central aspect of being human throughout life that encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction (WHO, 2006).

Question 10

Key terms Sexual Rights

Answer 10

The application of existing human rights to sexuality and sexual health constitutes sexual rights. Sexual rights protect all people’s rights to fulfil and express their sexuality and enjoy sexual health, with due regard for the rights of others and within a framework of protection against discrimination (WHO, 2010b).

Question 11

Key terms Sex workers

Answer 11

Women, men and transgendered people who receive money or goods in exchange for sexual services, and who consciously define those activities as income generating even if they do not consider sex work as their occupation (Overs, 2002).

Question 12

Key terms

Answer 12

For more details on the sexual and reproductive health and rights key terms, please see panel 2 of the Guttmacher-Lancet Commission report (first essential reading (Starrs et al., 2018)). A comprehensive glossary of various SRH-related terms can be found on the Planned Parenthood website (Planned Parenthood, 2021). Please be aware that preferred terminologies change over time, as can be seen for example in the case of HIV terminology (Dancy-Scott et al., 2018). UNAIDS provides guidance on preferred (non-stigmatizing) language that is reviewed on a regular basis (UNAIDS, 2015).

Question 13

1. Defining sexual and reproductive health and rights

Answer 13

While the key terms included above appear similar, they have different policy implications. The inclusion of the concepts of sexuality, pleasure, and freedom from violence requires implicit acceptance of a rights-based approach to public health. This was a significant departure from the health-based approach normal in public health. You will learn more about the political processes that have led to conceptual shifts and the adoption of these definitions in later sections and your essential readings.

Question 14

1. Defining sexual and reproductive health and rights

Answer 14

The 2018 Guttmacher–Lancet Commission report (Starrs et al., 2018), one of the essential readings for this session, proposes a new, comprehensive definition of sexual and reproductive health and rights (SRHR) and an associated essential package of health services. Panel 1 of the report mentions two principles of human rights, namely “freedoms” and “entitlements”, and applies these to sexual and reproductive health (SRH). Panel 2 expands on the four SRHR components, listed under the key terms above (reproductive health, sexual health, reproductive rights and sexual rights). Panel 3, provides an integrated definition of SRHR that refers to SRH specific human rights and essential services. With these concepts in mind, please complete the first activity of this session:

Question 15

Activity 1 Choose an SRH component or issue and think about whether it relates to the “reproductive health” and/or the “sexual health” domain. Next, think about how it links to the human rights principles of “freedoms” and “entitlements”. Do you think it would fit into a single cell of the table below? If so, which one? If not, please discuss why.

Answer 15

Any of the following or similar SRH components or issues could have been chosen for the activity: Abortion, Contraception, Child marriage, Cervical or other reproductive cancers, Gender-based violence, HIV/AIDS or other sexually transmitted infections (STIs), Maternal and newborn health, Menstrual health, Infertility. Initially, you might have considered placing an SRH issue into a single cell of the table, but you also might find that it fits into more than one cell or interlinks with issues that fit into other cells. For example, infertility could be first placed into the “reproductive health/ entitlement” cell. However, infertility can be caused by certain STIs, such as Chlamydia, so that prevention of infertility interlinks with the prevention of STIs, which are within the domain of “Sexual health”.

Question 16

Activity 1 Choose an SRH component or issue and think about whether it relates to the “reproductive health” and/or the “sexual health” domain. Next, think about how it links to the human rights principles of “freedoms” and “entitlements”. Do you think it would fit into a single cell of the table below? If so, which one? If not, please discuss why.

Answer 16

SH: Freedoms [Prevention of infertility (People should be free from coercion, including forced unprotected sexual intercourse, which can lead to STIs and, if untreated, may lead to infertility)]. SH: Entitlements [Prevention of infertility (People should have the right to access essential services for the prevention and treatment of STIs, which if untreated, can lead to infertility)]. RH: Entitlements [Infertility
(People should have the right to essential reproductive health services, including for the prevention, management and treatment of infertility.)]

Question 17

Activity 1 Choose an SRH component or issue and think about whether it relates to the “reproductive health” and/or the “sexual health” domain. Next, think about how it links to the human rights principles of “freedoms” and “entitlements”. Do you think it would fit into a single cell of the table below? If so, which one? If not, please discuss why.

Answer 17

Another example, where one topic fits into more than one cell is menstruation, which relates to reproductive health and different types of human rights violations, including freedoms (e.g. if in some cultures menstruating women are stigmatised, regarded as ‘dirty’ or ‘impure’ and not allowed to enter places of worship or participate in other activities) and entitlements (e.g. the right to accurate and timely information, if young girls are not educated about menstruation in time and are distressed at their menarche/ start of menstruation and if girls or women are not given practical information and access to resources and infrastructure, including water and sanitation, to manage menstruation in a hygienic and private way.)

Question 18

Activity 1 Choose an SRH component or issue and think about whether it relates to the “reproductive health” and/or the “sexual health” domain. Next, think about how it links to the human rights principles of “freedoms” and “entitlements”. Do you think it would fit into a single cell of the table below? If so, which one? If not, please discuss why.

Answer 18

RH: Freedoms [Menstruation (People should be free to participate in all spheres of life, and be free from menstrual-related exclusion, restriction, discrimination, coercion, and/or violence.)] RH: Entitlements [Menstruation (People should have the right to essential reproductive health services, including services relating to the management of menstrual disorders, such as dysmenorrhea/ menstrual pain and menorrhagia/heavy menstrual bleeding and relating iron-deficiency anaemia; people should also be able to receive accurate, age-appropriate information about the reproductive system, including menarche/onset of menstrual bleeding, irregular bleeding and menopause, and should be able to manage menstruation in a hygienic way, in privacy and with dignity.)]

Question 19

Activity 1

Answer 19

Because of the interlinkage of the different SRHR components, an integrated response has been propagated by the Guttmacher-Lancet Commission and others. This response also needs to be multi-sectoral to address the wider social and economic determinants of SRHR and needs to happen on global, national and local levels, as you will learn during this session.

Question 20

2 Global factors and determinants of sexual and reproductive health

Answer 20

This section introduces you to global factors associated with sexual and reproductive health (SRH) determinants and outcomes. You will become familiar with the global dimensions and main domains of SRH. You will come to understand how societal regulation of sexual behaviour, gender inequality and poverty influences SRH outcomes and determinants. You will consider population growth, demographic changes, and sustainable management and the role of family planning approaches. You will look at how social and structural drivers can undermine the effectiveness of proven HIV interventions, and how global health governance has affected SRH.

Question 21

2.1 Global dimensions of SRH

Answer 21

Before we move on, let us take a moment to consider what the global dimensions of sexual and reproductive health are. Lee defines global dimensions of health as “plural processes that are multiple yet intimately interrelated (Lee, 2003)”. As you will have noted in other sessions, global dimensions of health can be economic, political, sociocultural, technological, and environmental, and all of these can affect SRH. Table 1 below presents some examples of how these dimensions affect SRH. As you read through it, try to think of other examples related to your own country or region.

Question 22

2.1 Global dimensions of SRH Economic

Answer 22

Global effect on health: Inequality in financial resources affect availability, accessibility, and quality of health care. Global effect on SRH: Unequal access to safe abortion, where rich only can overcome social barriers to access; Rural/ urban inequity in skilled birth attendance

Question 23

2.1 Global dimensions of SRH Political

Answer 23

Global effect on health: Change from ‘health-based’ to ‘right-based’ approach to health. Global effect on SRH: Persistent resistance to providing sexual health services and education to young people

Question 24

2.1 Global dimensions of SRH Sociocultural

Answer 24

Global effect on health: Change of cultural values in relation to health. Global effect on SRH: Female genital mutilations from cultural tradition to a form of gender-based violence

Question 25

2.1 Global dimensions of SRH Technological

Answer 25

Global effect on health: Internet as a growing source of (dis-) information for health. Global effect on SRH: Proliferation of sexist and stereotyped images/ messages that reinforce negative gender stereotypes or posts from anti-vax movements that discourage Human Papilloma Virus vaccine uptake; Conversely, for informed users, the internet as a valuable and empowering source of information and a means to access SRHR-related support and care where traditional services are not accessible.

Question 26

2.1 Global dimensions of SRH Environmental

Answer 26

Global effect on health: Increased droughts and floods heighten malnutrition. Global effect on SRH: Food insecurity as barrier to HIV treatment adherence; increased poverty affecting all SRH outcomes

Question 27

2.2 Determinants of sexual and reproductive health

Answer 27

While holistic, the broad definitions of SRH may be difficult to operationalise, so it is useful to look at the different domains of SRH concerns (Figure 1).

Question 28

2.2 Determinants of sexual and reproductive health

Answer 28

A safe and pleasurable sexual life includes the freedom from violence related to gender and sexuality; healthy sexual function; freedom from harmful sexual practices. Healthy childbearing includes good pregnancy outcomes and safe motherhood but also concerns around infertility. If someone wants to avoid unintended pregnancy and childbearing, we can think of different options that they can consider including contraception and induced abortion. A fourth important domain is the maintenance of a healthy reproductive system, which deals with STIs/RTIs, HIV and reproductive cancers. Sexual behaviour underlies these four interrelated domains, and they are all embedded in a sociocultural context with social norms and other structural influences located in economic and political systems, well beyond the health sector. While SRH concerns are rooted in a biomedical dimension, their origins lie in human behaviour. Both sexual and health-seeking behaviour are strongly constrained by a range of structural factors affecting SRH.

Question 29

2.2 Determinants of sexual and reproductive health

Answer 29

Let’s look at some differentials in SRH outcomes. Low-and middle-income countries (LMIC) accounted for 94% of all maternal deaths in 2017. A woman’s lifetime risk of dying from preventable or treatable complications of pregnancy and childbirth is 1 in 37 in Sub-Saharan Africa, compared to 1 in 4800 in Europe and Northern America and 1 in 7800 in Australia and New Zealand (WHO, 2019).

Question 30

2.2 Determinants of sexual and reproductive health

Answer 30

Two thirds (67%) of all people living with HIV live in Sub-Saharan Africa, where adolescent girls and young women (aged 15 to 24 years) account for about one in four HIV infections, despite comprising only 10% of the population (UNAIDS, 2020, 2021). Globally, the risk of acquiring HIV is on average 26 times higher for sex workers, 25 times higher among men who have sex with men (MSM) and 34 times higher for transgender women (UNAIDS, 2021) - a transgender person does not identify with the gender assigned at birth and it is estimated that between 0.1% and 1.1% of reproductive age adults are transgender. (UNAIDS, 2014).

Question 31

2.2 Determinants of sexual and reproductive health

Answer 31

The global lifetime prevalence of intimate partner violence among ever-partnered women is 30.0% (WHO, 2013). Population-based surveys conducted in 46 LMIC between 2014 and 2018 revealed that about one in five women experienced intimate partner violence in the past year (UNAIDS, 2020). We will now be exploring why we are getting such stark differentials.

Question 32

2.2 Determinants of sexual and reproductive health

Answer 32

Although human sexual capacity is universal, its expression is defined, regulated, and given meaning by cultural norms. Societies differ in the restrictions they put on anything beyond these circles, including sex before and outside of marriage, homosexuality, selling and buying sex, sex at younger and older ages. These socio-cultural norms are embedded in social institutions and legal frameworks. While most countries have laws, which criminalise sexual activity that is violent or causes harm, some also criminalise consensual sexual activity, such as same-sex sexual activity, buying and selling sex, or adultery. Laws that focus on enforcing moral codes on sexuality tend to create barriers to access to health care as they stigmatise behaviour.

Question 33

2.2 Determinants of sexual and reproductive health The effect of gender on SRH

Answer 33

Gender norms influence both men and women’s vulnerability and risk. Given men’s power and privilege in patriarchy, the ways in which gender norms shape men’s HIV risk is not commonly conceptualised as vulnerability (Dworkin, 2005; Higgins, Hoffman, & Dworkin, 2010). However, gender practice impacts men’s lives through the socially dominant notions of masculinity. In many societies, being powerful and in control, earning money, not showing weakness and being sexually virile are ways of being masculine which are particularly valued and in addition, justify the collective power of men over women in society. However, the social nature of masculine identity means it is open to challenge and therefore has to be continually ‘proved’ or performed. With increasing levels of poverty, disenfranchised men may not succeed in their role of family provider. Men respond to this in different ways, but one response might involve focusing instead upon risk taking, violence or sexual prowess in order to re-establish power and authority. Many behaviours and traits considered to be ‘masculine’ have a detrimental effect upon men’s own health and that of their partners. This may include drinking alcohol, having many sexual partners, demonstrating strength by concealing difficulties, not asking for help and not sharing worries with others.

Question 34

2.2 Determinants of sexual and reproductive health The effect of gender on SRH

Answer 34

Research into determinants of SRH, especially HIV, has brought global attention to the importance and magnitude of gender-based sexual violence. Over 1 in 3 women worldwide has been beaten, abused, or coerced into sexual intercourse in her lifetime (UNFPA, 2010). Sexual violence and coercion can have severe, long-term, sometimes fatal, mental and physical health consequences, particularly related to SRH. These can be divided in direct and indirect outcomes. Direct outcomes include unwanted pregnancy, unsafe abortion, STIs (including HIV), and gynaecological disorders. Indirect outcomes can include disempowerment and fear, making it more difficult to negotiate future sex and contraceptive use. There is evidence linking experiences of sexual abuse in childhood or adolescence with high-risk behaviours in adolescence and patterns of victimization during adulthood (WHO, 2010c).

Question 35

2.2 Determinants of sexual and reproductive health The effect of gender on SRH

Answer 35

While women and girls experience over two-thirds of the burden of injury and disease due to sexual violence, boys and men are also affected. The most common forms of sexual coercion of public health concern are sexual coercion against women at sexual debut, in childhood, within intimate partnerships. Due to high sexual violence in conflicts a resolution was passed by the UN Security Council (SRC1820) in 2008 recognising rape during war as a crime against humanity (Garcia-Moreno & Stockl, 2009; UN, 2008).

Question 36

2.2 Determinants of sexual and reproductive health The effect of gender on SRH

Answer 36

Discrimination and violence against gay men and other MSM, including rape based on sexual orientation and gender identity are widely reported (Beyrer et al., 2011). Structures of gender inequality are typically reproduced in relation to transgender, who in many instances experience socially condoned sexual violence (Corrêa, Petchesky, & Parker, 2008). Gender norms are relational, and they are bound in hierarchies of power and social stratification, through social class, ethnicity and age.

Question 37

2.2 Determinants of sexual and reproductive health The effect of poverty on SRH

Answer 37

Poverty is associated with many adverse SRH outcomes and intersects with other social factors to create contexts of risk. In most countries, there are huge inequities between women from lowest versus highest wealth deciles in terms of coverage with reproductive, maternal, and neonatal health interventions. (Barros et al., 2020). In 2019, in low-income countries, only 41% of women in the lowest-income quintile delivered their baby in a health facility compared to 85% in the highest income-quintile, mostly due to financial and geographical barriers to access (Sully et al., 2017). Socioeconomic status is also clearly linked to teenage pregnancy and early sexual debut. Early first intercourse is less likely to be consensual and more likely to be unprotected and regretted (Wellings et al., 2001). In the UK, first sex before age 16 was more common among those from low-income households and those without qualifications. Analysis from the longitudinal British Cohort Study 1970, has shown that women whose mother had no qualifications are about twice as likely as others to have a baby in their teenage years (Ermisch & Pevalin, 2003). Early childbearing, unplanned pregnancy and intimate partner violence are barriers to employment and income generation and risk factors for homelessness, independent decision making, poor self-esteem and low aspirations (Vyas & Watts, 2009) (Nanchahal et al., 2005), so the cycle of deprivation perpetuates.

Question 38

2.2 Determinants of sexual and reproductive health The effect of poverty on SRH

Answer 38

The association between poverty and SRH also works in the other direction with poor SRH impacting not only the household but also the community and beyond: different levels intersect and effects are not independent. So when HIV affects a family, they suffer loss of income and are burdened with the cost of caring for a sick family member, including the opportunity cost of caring time lost to paid work. The cost at family level, when they can no longer pay for the basic commodities needed for survival, will also be shared by the wider community which provides support to affected households and care for orphaned children. Social and human capital at household and community levels are also damaged: for example, children may miss school to care for family members or households may not be able to afford school fees. This loss of educational opportunity has a long-term impact on their life chances and income. The aggregated impact of HIV/AIDS on households and communities is therefore likely to increase poverty locally and nationally in countries with high HIV prevalence (Bell, Devarajan, & Gersbach, 2004)

Question 39

2.2 Determinants of sexual and reproductive health The effect of poverty on SRH

Answer 39

Global factors affect nations, communities and households, and ultimately individual’s risk and risk reduction behaviour. Factors include levels of population growth and structure, socio-economic and demographic trends such as urbanization and migration, national and global economy, levels of development, political organization and systems of governance and transitions associated with political change and conflict in a region. Again, the effects are not independent; for example, migration-related vulnerability can be magnified through economic reforms like structural adjustment programme introduced by the World Bank and International Monetary Fund. The effects are mediated by under-investment in social goods, such as public education and health care; disruption of social cohesion and the erosion of social capital (Corrêa et al., 2008). In the next section, we will consider important global issues impacting SRH: population growth, the HIV pandemic and the effects of global economic systems on SRH health systems.

Question 40

Activity 2 The importance of gender norms and relations on health outcomes has long been recognized, and the burden of the HIV epidemic brought gender into even sharper focus. In South Africa where the majority of HIV infections occur through unprotected heterosexual sex, HIV prevalence is three times higher among young women than among young men aged 15-24. For this activity, research how biological as well as social and structural factors may contribute to this statistic.

Answer 40

Your findings may have shown some of the following: Biological susceptibility:Women are at higher biological risk of HIV infection because male-to-female transmissibility is thought to be about twice that of female-to-male transmission(Higgins et al., 2010). HIV is more likely to enter a woman’s blood stream because of her more extended contact with semen and the more extensive mucosal surface of the vagina. In addition, STIs are more commonly asymptomatic in women and untreated STIs increase the risk of HIV transmission.

Question 41

Activity 2 The importance of gender norms and relations on health outcomes has long been recognized, and the burden of the HIV epidemic brought gender into even sharper focus. In South Africa where the majority of HIV infections occur through unprotected heterosexual sex, HIV prevalence is three times higher among young women than among young men aged 15-24. For this activity, research how biological as well as social and structural factors may contribute to this statistic.

Answer 41

Social and structural vulnerability for women: Epidemiological profiles of HIV have shown that women are more likely to be infected not through their own risk behaviour but through that of their partner (Higgins et al., 2010). Gender dynamics increase women’s likelihood of being exposed to HIV in several ways. While it is well known that condom use is one of the best ways of preventing STIs and HIV, it is very difficult for many women to insist on or even suggest using condoms,especially where there is a threat of violence from an intimate partner on whom they are financially dependent. Women’s economic dependency may confine her at the point of securing partnerships, as she needs to portray desirable characteristics including appearing sexually inexperienced and unaware when it comes to sex. The premium placed upon virginity in some cultures leads to older men having first choice of virgin girls and hence increasing these women’s risk of being exposed to STIs and HIV at a younger age. Women may fear getting tested for HIV and disclosing a positive HIV result, and their ability to leave partners may again be limited by their financial and emotional dependence. In order to make a living, some women may resort to selling sex while others are in transactional relationships. Finally, in many societies, women need the consent of their husband in order to access resources such as medical treatment. This lack of autonomy combined with lack of confidentiality at health services further hinders women’s ability to seek help and information in relation to their sexual health.

Question 42

2.3 Global factors associated with SRH Population growth and demographic change

Answer 42

Before 1700, human population grew at an imperceptibly slow pace. Early increase in population growth started in Europe in the 18th century when mortality decreased as a result of a combination of rising living standards, the mechanisation of agriculture and thus improved nutrition, and better control of infectious diseases. These developments were not distributed evenly globally. Therefore, globally life expectancy and population growth remained low until the second half of the 20th century (Cleland, 2013). The pace of population growth change increased dramatically from 1950s after mass application of modern preventive health measures in parts of Asia, Latin America and Africa resulted in large falls in death rates, particularly among infants and children. By 1960, world fertility remained largely unchanged, and the rate of population growth peaked in the 1960s at 2% per year, causing international concern and adoption of population control measures (Edouard, 2009). Growth rates dropped to 1.2% in the decade 2000–2010. Increased contraceptive use has been the main direct determinant of the fertility declines, though abortion (both legal and illegal) and rising age at marriage have also contributed (Cleland, 2013).

Question 43

2.3 Global factors associated with SRH Population growth and demographic change

Answer 43

More recent data from 2010 to 2017 showed negative population growth rates for 33 countries, most of which are located in Europe (Figure 3). Positive growth rates of more than 2% were recorded in 33 of 46 countries in Sub-Saharan Africa. Here, improvements in life expectancy halted between 1980 and 2000 because of HIV/AIDS and deteriorating economies. In the past decade, AIDS deaths have fallen, though life expectancy remains much lower than in other regions. The regional total fertility rate (estimated average number of children a woman would bear if she survived through the end of the reproductive age span and experienced at each age a particular set of age-specific fertility rates) remains high at about 4.6 in Sub-Saharan Africa compared to 1.6 in Western Europe (GBD 2017 Collaborators, 2018).

Question 44

2.3 Global factors associated with SRH Population growth and demographic change

Answer 44

A key policy question is the extent to which state promotion of family planning can accelerate reproductive change in countries in Africa with high population growth and the remaining high fertility areas of Asia. In many countries steep fertility decline happened without strong programmes, e.g., in Europe in the 1930s and more recently in Brazil and Burma (Myanmar). Investments in child survival, education, women’s empowerment and poverty-reduction are all conducive to fertility decline. Unwanted child bearing is higher among low-income households and illiterate individuals so education is a powerful mediator in this context (Cleland, 2013). The likelihood of having an abortion is roughly similar for women in high- versus low- and middle-income countries, but women from resource-poor countries are more likely to have unsafe abortions, causing about 8-11% of maternal mortality (Starrs et al., 2018).

Question 45

2.3 Global factors associated with SRH Population growth and demographic change

Answer 45

Government family programmes can accelerate fertility decline and a failure to promote contraception with high level political support explains the current high growth rates in sub-Saharan Africa. Prior to the International Conference on Population and Development (ICPD) held in Cairo in 1994 family planning has been a well-funded international development priority. By 1994, however, population growth no longer seemed an important or emotive issue for participants. Rapid fertility declines had occurred in many LMIC, while fertility had dropped below replacement levels in many high-income countries (HIC). In the meantime, the women’s movement had gained strength and successfully transformed the agenda of the family planning movement to one for reproductive health and rights, explicitly rejecting demographic targets to focus on improving individual rights and health while respecting individual reproductive freedom (Sinding, 2007).

Question 46

2.3 Global factors associated with SRH Population growth and demographic change

Answer 46

This paradigm shift occurred largely due to a lack of macro-level urgency and presence of strong focused micro-level advocacy. At the same time international funding and government priorities within African countries shifted to the control of HIV (Cleland, 2013). However, since ICPD global attention has shifted from both population growth and reproductive health. The Millennium Development Goals (MDGs), agreed by almost all nations in 2000, did not include a specific goal for reproductive health. From 2001-2009 and 2017-2021, the US government joined the Vatican to oppose abortion, thus increasing controversy and reducing available funding for RH globally (BBC, 2021; Blystad, Haukanes, Tadele, & Moland, 2020; Sinding, 2007). As we will see later on the Sustainable Development Goals (SDGs) included relevant goals for SRH.

Question 47

2.3 Global factors associated with SRH Population growth and demographic change

Answer 47

At the 2012 London Summit, international donors and low-income country leaders pledged to re-invigorate family planning programmes (Cleland, 2013). This was made evident by support for ‘Family Planning 2020’ (FP2020), an international initiative that aimed to enable 120 million more women and girls to use contraceptives by 2020 in countries with highest fertility. Much progress has been made since then, especially among African countries. Nevertheless, FP2020 fell short of its original goal (reaching 60 million rather than 120 million more women and girls), and has been extended to FP2030 (FP2020, 2020). We will come back to how the SDGs attempt to address this issue in a later section.

Question 48

2.3 Global factors associated with SRH Demographic trends

Answer 48

Demographic profiles are changing everywhere - in Sub-Saharan Africa we still see predominantly young age structures, in most of Asia and in Latin America there are now large cohorts of young people moving into the reproductive ages and despite lower fertility rates, the total numbers of births will continue to increase, which is referred to as population momentum (Greer, 2009; WHO, 2010c). In contrast, HIC are characterised by low birth rates, increased life expectancy, and an ageing population that depends on a small working age population. Some European governments have responded by reversing birth control with pro-natal policies, often incorporated with policies addressing equality. Examples include subsidised childcare, paternity/maternity leave, and the right to return to employment without discrimination. Attracting migrants could be another solution. However, immigration is an emotive subject in many HIC. For example, the UK government is hesitant, and even restricts immigration, having exited from the European Union in 2021 following a very politically sensitive and divisive process known as Brexit, where unrestricted immigration from the EU was a core issue.

Question 49

2.3 Global factors associated with SRH Demographic trends

Answer 49

Although global population projections differ depending on the statistical models used (UN, 2017; Vollset et al., 2020), it is likely that even with rapid fertility decline the world’s population will grow by another 2 billion with inevitable implications for human welfare and the environment. At current levels of economic development, the African region will have little effect on CO2 emissions despite relatively high population growth rates. While economic growth may reduce poverty and hasten the fertility decline, development and urbanisation bring inevitable costs for the environment. High- and upper-middle-income countries contribute most to climate change, and the post-2015 sustainable development agenda for the first time requires urgent action on planetary sustainability from wealthier countries.

Question 50

2.3 Global factors associated with SRH Influence of HIV Pandemic

Answer 50

The HIV pandemic has taught us much about the importance of sociocultural, economic, legal and political contexts in shaping individual risk and health outcomes. As the HIV virus spread globally, attention turned to underlying socio-economic factors to explain the high incidence and numbers of people living with HIV (PLHIV) in LMIC, particularly sub-Saharan Africa. Individual’s agency to change is constrained by structural factors that need to be addressed. The HIV pandemic also showed us that advancing SRH is impossible without the promotion of human rights. Legal environments which protect human rights greatly facilitate effective responses to HIV. Conversely, punitive laws criminalising HIV transmission, sex work and same-sex partnerships impede prevention and treatment efforts by reinforcing stigma. Repressive laws encourage harassment by police with confiscation of condoms taken as proof of illegal practices. In such climates, educational health promotion materials cannot contain the explicit information needed on safer sex practices. Fear of arrest makes outreach more difficult and frustrates attempts for people in need to come forward and seek and access health services (Beyrer et al., 2011; Cáceres, Mario Pecheny, Tim Frasca, Roger Raupp Rios, & Fernando Pocahy, 2009).

Question 51

2.3 Global factors associated with SRH Influence of HIV Pandemic

Answer 51

Biomedicine and epidemiology, which have dominated the HIV field, have often focused on scientific evidence alone, and tried to promote beneficial interventions, such as harm reduction and treatment for prevention as value-neutral. However, it is not clinical efficacy alone, but various hidden values (relating to costs, rights, equality, or other social goals) that drive health policy and planning. To avoid trade-offs between deeply held values in the name of disease prevention, these values need to be made explicit for value-based decisions to be made in an open and transparent way. Given the contested nature of sexuality, explicit normative valuation needs to guide HIV prevention strategies, to help introduce beneficial interventions and structural changes, but prevent others, such as punitive and repressive laws that would restrict other important social values in the name of HIV prevention. Forces outside the health sector affect public health and these forces are global in nature. Shaping social environments to reduce risk and vulnerability involves changes in social, economic and political sectors with implications beyond health alone (Parkhurst, 2010). Trade-offs between population health and other important policy goals (in terms of trade, finance, agriculture, among others) are undeniable and global governance for health needs to take account of these competing interests (Gopinathan et al., 2014).

Question 52

3.1 Policy actors and responses: Global Governance of Health Influence of HIV Pandemic

Answer 52

While the ICPD called for implementation of a comprehensive package of sexual and reproductive health services, decision making on resource allocation at state level was steered by MDGs (Berer, 2011; Fonn & Ravindran, 2011) and most recently, the SDGs have helped guide the work on SRH. You will hear about the SDGs and how they differ from the MDGs in section 3.3 below.

Question 53

3.1 Policy actors and responses: Global Governance of Health Influence of HIV Pandemic

Answer 53

The World Bank and IMF are very influential actors in global governance creating environments where the fight for comprehensive sexual health care gets easily side-lined by following a neo-liberal agenda (Fonn & Ravindran, 2011). The free market ideology changed the financing of health services globally, with funding policies pushing for the expansion of private sector provision and states consequently withdrawing responsibility for universal access to health care services (Fonn & Ravindran, 2011). This started after the oil crisis in the late 1970 when several LMIC became heavily indebted to the International Monetary Fund who imposed conditions of “structural adjustments” on governments who needed access to loans. The priority of debt repayment has typically limited governments’ ability to spend on health and social services. Tools for prioritising health services have been based on burden of disease estimates and cost-effectiveness studies – typically underemphasizing the preventive services like contraception and abortion and leading to selective, single disease vertical programming, preferred by donors and foundations. Vertical programmes can impede governments from building strong health systems and there is evidence that weak health systems in turn undermine achievements of the vertical programmes (you will learn more about this in a later session of this module.)

Question 54

3.1 Policy actors and responses: Global Governance of Health Influence of HIV Pandemic

Answer 54

A shift in international discourse based on principles of equity and social justice was needed. The capabilities approach to human and social development (as initially developed by Amartya Sen) proposed to provide stronger philosophical and theoretical foundations for evaluating global governance by assessing the impacts of various sectors on health. This approach values policy choices resulting in social arrangements that optimize people’s capabilities, or a range of freedoms people value, including civil freedoms, social and economic opportunities, security as well as freedom from harm (Gopinathan et al., 2014). Such a framework promotes a more comprehensive, systematic approach to ensure action across sectors for health equity and social justice.

Question 55

3.2 SRH Actors in Global Health Policy

Answer 55

A broad range of actors are important in global SRH action, some of which have already been mentioned in earlier sessions. The main institutional actors are within the United Nations (UN) system. The WHO, the World Health Organisation, is largely dominated by medical professionals and despite its commitment and understanding of social determinants of health, has historically prioritised disease, the determinants of disease, and disease-driven services rather than health and well-being (Horton, 2014).

Question 56

3.2 SRH Actors in Global Health Policy

Answer 56

UNFPA, the United Nations Population Fund is the specialised agency of the UN charged with monitoring reproductive rights and drafting guidance on their implementation. The aim of UNAIDS, the Joint UN Programme on HIV/AIDS is to help mount and support an expanded response to HIV/AIDS, engaging the efforts of many partner institutions, governments and civil society. UNDP, The United Nations Development Programme, is the UN’s global development network, and works with partners to address interactions between governance, human rights and health responses. UN Women is theUN’sentity dedicated to gender equality and the empowerment of women. UNICEF, the United Nations Children’s Fund, advocates a rights based approach to improving the health of mothers and babies, through enhancing healthcare provision, addressing gender discrimination and societal inequities (UNICEF, 2008; WHO, 2010a). The United Nations Human Rights Council (UNHRC) is the inter-governmental body overseeing a whole range of human rights issues and they work with treaty bodies and special rapporteurs. These have a mandate to monitor and publicly report on human rights problems which includes assessing and verifying complaints regarding alleged human rights violations, including those related to SRH.

Question 57

3.2 SRH Actors in Global Health Policy

Answer 57

In practice, funding defines which SRH programmes are implemented, giving donors tremendous influence over the global SRH agenda. Multilateral organisations use pooled funds from member contributions (mainly governments), the main ones being the World Bank, the EU and various UN agencies. Some are specifically designed to address HIV, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and UNITAID, set up in 2006 as the International Drug Purchasing Facility. Large bilateral donors for SRH are the US and the UK, with China becoming more important (Bosmans, Nasser, Khammash, Claeys, & Temmerman, 2008; Pitt, Greco, Powell-Jackson, & Mills, 2010). Bilateral agencies such as the US Agency for International Development (USAID) have had significant influence on reproductive health globally, changing their positions over time and influenced heavily by political debates. For example, the ‘Mexico City Policy’ (also known as the ‘Global Gag Rule’), originally introduced by Republican President Reagan in 1985, and since then regularly rescinded by Democratic administrations and reinstated by Republican US administrations has blocked U.S. funding for organisations involved in abortion services; this led to a major reduction in access to safe abortion services and family planning globally (Blystad et al., 2020). In 2003, President Bush initiated PEPFAR (The U.S. President’s Emergency Plan for AIDS Relief), the largest health initiative ever initiated by one country to provide antiretroviral treatment in resource-limited settings. The private sector includes philanthropic foundations, charities and corporations. The Bill and Melinda Gates Foundation is the largest private grant-making foundation in the world (McCoy, Kembhavi, Patel, & Luintel) and its influence on global health programmes and initiatives is profound.

Question 58

3.2 SRH Actors in Global Health Policy

Answer 58

Religious political influence has been particularly important in the history of SRH, as the issues often provoke emotional and moral responses with far-reaching consequences. Emotive, values-driven issues such as contraception, abortion, sex work, sexuality, and women’s rights have affected funding flows for SRH. The Holy See (the Vatican) has Non-member Permanent Observer status to the United Nations. It engages actively in negotiations at international conferences and has the same powers as member states to negotiate, sign and ratify UN-sponsored international law making treaties (Coates, Hill, Rushton, & Balen, 2014).

Question 59

3.2 SRH Actors in Global Health Policy

Answer 59

Civil Society actors involved in SRH take varied positions but some of them have been instrumental in advocating for better SRH services and ensuring broad-based mobilisation that creates bottom-up demand (Haslegrave, 2013). For example, the International Women’s Health Coalition (IWHC) and those representing marginalised and vulnerable groups: Global Network of Sex Work Projects (NSWP), Global Forum on MSM & HIV (MSMGF) and Global Network of People Living with HIV/AIDS (GNP+) have been working relentlessly on advocacy. They also serve as critical watchdog on the implementation of development commitments and holding governments and organisations to account. More recent grassroot movements facilitated by social media include the #MeToo movement and SheDecides (O’Neil, Sojo, Fileborn, Scovelle, & Milner, 2018; Zuccala & Horton, 2018).

Question 60

3.2 SRH Actors in Global Health Policy

Answer 60

Global movements and campaigns that mobilize and work with various SRH actors include the ‘FP2030’ (mentioned above), ‘Education for all’, and ‘Every Woman Every Child’ movements and the ‘Men Care’ campaign (EWEC, 2015; FP2020, 2020; GCE, 2019; MenCare, 2021).

Question 61

3.3 SRH Relevant forums, consensus documents and monitoring frameworks

Answer 61

Various UN platforms and consensus documents deal with a range of agendas concerning SRH (Coates et al., 2014). Thematic groupings include population and development, the advancement of women, social development and poverty eradication, sustainable development, and human rights and security. Historically the most important declarations are those set at the ICPD, held in Cairo in 1994 and the 1995 Beijing Declaration and Platform for Action, focused on gender equality and universal access to quality reproductive healthcare. The UN Millennium Declaration in 2000 aimed to end extreme poverty via eight time-bound goals and targets by 2015. Although debated, SRH was not set as a specific goal, and spread mainly across MDG 4, 5 and 6, respectively to improve child health, maternal health, and combat HIV/AIDS, malaria and other diseases. In 2006 however, it was included as one of the targets of MDG 5, with indicators including antenatal care coverage, contraceptive prevalence rate, adolescent birth rate, and unmet need for family planning (Edouard, 2009).

Question 62

3.3 SRH Relevant forums, consensus documents and monitoring frameworks

Answer 62

At the Rio+20 Summit governments reaffirmed the need to achieve sustainable development. The post-2015 development agenda (2030 Agenda for Sustainable Development) thus expands on the MDGs’ emphasis on social development by also focusing on environmental and economic pillars of sustainable development. This makes the SDGs equally relevant to HIC (Lu, Zhang, Bundhun, & Chen, 2021). The creation of the SDGs (other than the MDGs) also involved global stakeholder consultations and civil society advocacy and has been lauded for covering a wider range of SRHR-related issues; nevertheless, the process has been critiqued for excluding persons with limited literacy or internet access from global polls and surveys and for failing to agree on the inclusion of some important SRHR dimensions and aspects (Logie, 2021).

Question 63

3.3 SRH Relevant forums, consensus documents and monitoring frameworks

Answer 63

Reducing maternal mortality and ensuring universal access to sexual and reproductive health-care services are targets under the health goal ‘ensuring healthy lives’ (SDG 3). The empowerment of women and gender equality (SDG 5) includes eliminating violence against women, ending all discrimination and harmful practices. Equitable education for boys and girls comes under SDG 4. SDG 5 mentions reproductive rights but not sexual rights (Open Working Group, 2014). This is a crucial omission as the main barriers to universal access to SRH, for example legislation against consensual same-sex activity, spousal and parental consent laws, conscientious objection and mandatory waiting periods will remain in place without reforms in laws and policies. The same is true for legal restrictions on access to safe abortion services, something crucial to the goal of reducing maternal mortality. (Halford & Prasad, 2014).

Question 64

3.3 SRH Relevant forums, consensus documents and monitoring frameworks

Answer 64

With the transition of the MDGs to the SDGs, a number of global initiatives and strategies were launched and/or renewed to help further the SDGs and/or keep track of progress towards SDG and SRHR-relating targets; these include the ‘Countdown to 2030’ initiative, a global collaboration of academics, UN agencies and civil society organizations to track progress of interventions for Reproductive, Maternal, Newborn, Child and Adolescent Health and Nutrition (CD2030, 2021); the ‘Global Strategy for Women’s, Children’s and Adolescents’ Health(2016-2030)’, launched by (former) UN Secretary-General Ban Ki-moon (EWEC, 2015); the ‘Every Newborn Action Plan’ (WHO, 2014); ‘Ending Preventable Maternal Mortality’ (WHO, 2015b); the UN Global Programme to Accelerate Action to End Child Marriage (UNICEF, 2021); and ‘FP2030’ (FP2020, 2020);

Question 65

3.3 SRH Relevant forums, consensus documents and monitoring frameworks

Answer 65

These initiatives and strategies provide various indicators and monitoring frameworks that include and/or complement those developed under the ‘2030 Agenda for Sustainable Development’ and those developed by the WHO for monitoring progress toward ‘Universal Health Coverage’ (WHO, 2021c). The indicators cover many SRHR components, including sexual and reproductive health care for adolescents; contraceptive services; detection of intimate partner violence; prevention, detection, and management of HIV and other STIs; maternal and newborn care. However, they fall short in terms of targets that are related to safe abortion, infertility, reproductive cancers other than cervical cancer, men’s SRHR and the needs of people of diverse sexual orientations and gender identities and expression (Starrs et al., 2018).

Question 66

3.3 SRH Relevant forums, consensus documents and monitoring frameworks

Answer 66

Please see table 1 and Appendix table 2 in the 2018 Guttmacher-Lancet Commission report (first essential reading) for an overview of linkages between key areas of SRHS and the SDGs and for a list of indicators for measuring progress on SRHR under the global frameworks and agreements cited above (Starrs et al., 2018). You may also browse the WHO SRHR Policy portal (WHO, 2021b) for data in specific areas you are interested in (https://www.who.int/data/sexual-and-reproductive-health-and-rights).

Question 67

3.3 SRH Relevant forums, consensus documents and monitoring frameworks

Answer 67

In 2014, The Global Investment Framework for Women’s and Children’s Health set up by a WHO study group estimated that increasing health expenditure by just $5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits (Stenberg et al., 2014). More recently, the Lancet-Guttmacher Commission reported estimates for various SRHR-related costs. For example, they estimated average costs for meeting all women’s needs for contraceptive, maternal and newborn care at US$9 per capita annually in economically developing regions with enormous returns and multigenerational benefits. Due to its interconnectedness, investment in SRH would also accelerate progress towards the other SDGs (Starrs et al., 2018).

Question 68

3.3 SRH Relevant forums, consensus documents and monitoring frameworks

Answer 68

The SDGs largely guide development aid and domestic funding priorities. The MDGs with narrow targets led to “development silos”, with reducing educational gender disparities framed as women’s empowerment ignoring multiple interdependent and indivisible human rights of women: sexual, reproductive, economic, political, and legal (Sen & Mukherjee, 2014). This is a real danger and has to be monitored. Equitable human development cannot be achieved without a human-rights approach and may thus not be achieved under this framework. We will now discuss how social movements and human rights groups can influence the standard-setting for sexual health policy and practice by using human rights frameworks beyond the SDGs.

Question 69

3.4 International Legal Frameworks

Answer 69

Setting human rights standards is an iterative and evolving process involving law-making bodies in the United Nations system. Since policies and programmes need to be based on principles of social justice and governments need to be held accountable for implementation of human rights standards, nongovernmental organisations (NGOs), and politically conscious social movements have an important role to play in this ‘norm-building’ process (Miller & Roseman, 2011).

Question 70

3.4 International Legal Frameworks

Answer 70

Treaties are agreements under international law between sovereign states and international organizations. As legal instruments treaties are legally binding on all States who ratify them. There are various treaties that relate to SRH. The first treaty is the Universal Declaration of Human Rights 1948 and there are various others including the Convention on the Elimination of All Forms of Discrimination Against Women 1979 and the 1989 Convention on the Rights of the Child.

Question 71

3.4 International Legal Frameworks

Answer 71

The first specific international health and human rights provision was the ‘right to health’, laid down in the WHO Constitution in 1946. It denotes the ‘right to the highest attainable standard of physical and mental health’, not the right to be healthy. Regardless of a country’s income level, governments have the obligation to put in place policies and action plans which will lead to available and accessible health care for all. These obligations are not limited to health services but also to underlying structures that determine health: water, sanitation, housing, adequate nutrition, healthy occupational and environmental conditions, education and information about health, including sexual and reproductive health.

Question 72

3.5 Sexual Rights

Answer 72

Open debates about sexual rights and bodily integrity rights surfaced in UN forums only in the 1990s and were introduced largely through the political ideas the transnational feminist movements developed during the 70s and 80s. The Cairo Programme for Action agreed at the ICPD in 1994, states that “Everyone has the right to the enjoyment of the highest attainable standard of physical and mental health. States should take all appropriate measures to ensure, on a basis of equality of men and women, universal access to health-care services, including those related to reproductive health care, which includes family planning and sexual health. Reproductive health care programmes should provide the widest range of services without any form of coercion. All couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children and to have the information, education, and means to do so.” (Programme of Action, Chapter II, Principle 8, 1994)

Question 73

3.5 Sexual Rights

Answer 73

This document was adopted by 184 countries, providing governments with guidance for addressing the sexual and reproductive health of their populations in a more comprehensive and integrated manner. The women’s movement had focussed on issues of sexual freedom, safety and bodily integrity of women and girls, using principles (like the right to life, gender equality, right to health, security of the person and freedom from torture) enshrined in the major human rights covenants and treaties. Because of vigorous opposition by the Holy See, its Christian right-wing and Islamist allies, ‘sexual rights’ and ‘sexual orientation’ were erased from the final declaration. As the focus had been exclusively on women and concerns related to violence and reproductive freedom, the context was implicitly heteronormative. Yet the feminist movement can be credited with getting the word ‘sexual’ into the UN language and opening the space for further advocacy and debate (Corrêa et al., 2008).

Question 74

3.5 Sexual Rights

Answer 74

While a WHO definition of sexual rights has been documented in reports by panels of experts, there is no globally recognised articulation of sexual and reproductive health rights (Coates et al., 2014), mainly due to competing ideologies of key stakeholders engaged in the global public policy process. Yet much of the substantive content is already in binding obligations of international human rights law. To advance SR rights, accountability frameworks need to draw on reviews of ICPD Programme of Action (UN, 1994), and the Beijing Platform of Action (UN, 1995). While these documents are not legally binding, and remain contested, they do contribute to creating a framework within which human rights activists can work to promote and protect human rights. As Correa et al (2012) put it “A human rights framework provides both the norms upon which movements can base social justice claims and systems of public regulations and accountability they can use as forums to publicize those claims and shame corporate and government violators – even when in practice enforcement is weak” (p153)(Corrêa et al., 2008)

Question 75

3.6 The challenge of including sexual and reproductive rights into treaty-based human rights law

Answer 75

Getting sexual and reproductive rights into treaty-based human rights law, is an ongoing battle and since legal texts need interpretation the focus is on getting new issues “interpreted into” the treaties (Miller & Roseman, 2011). For example, public health professionals may agree based on an extensive evidence base that young people have a human right to comprehensive sexuality education especially in the context of HIV/AIDS pandemic. Yet, in the early 2000s, under PEPFAR at least 33% of HIV prevention budget needed to be spent on abstinence-until-marriage programmes, promoting the so-called ABC approach. Researchers from Human Rights Watch found that the US-funded programmes in Uganda systematically censored and distorted information in sex education materials and thus withheld life-saving information from children. Human Rights Watch then used existing laws on non-discrimination and the right to information to appeal against the abstinence-only sexuality education policies in Uganda (Miller & Schleifer, 2008). Using the obligations of states to guarantee the rights contained in different treaties they have signed (the 1966 International Covenant on Civil and Political Rights; the 1966 International Covenant on Economic, Social, and Cultural Rights; and the 1989 Convention on the Rights of the Child), they developed the claim that young people have the right to protect against HIV (Miller & Schleifer, 2008).

Question 76

3.6 The challenge of including sexual and reproductive rights into treaty-based human rights law

Answer 76

Claims like this are then publicly debated in an official dialogue between State Parties and the UN treaty body of independent experts, who have the mandate to formulate authoritative interpretations. When the State reviews policies in line with expert guidance, it legitimates the new application of existing laws to specific sexual rights, expanding the scope of the human rights treaties (Miller & Schleifer, 2008) (Miller & Roseman, 2011). In this example, the claims strengthened the transnational coalition promoting accountability of U.S. global AIDS policies to health and human rights.

Question 77

3.6 The challenge of including sexual and reproductive rights into treaty-based human rights law

Answer 77

The victories on sexual rights have been mixed. The internet brought an explosion of information exchange, greatly helping civil society groups and human rights advocates to extend support to local pressure groups advocating human and sexual rights causes across border and cultures. The same information revolution has been used by religious and politically organised groups that hold the opposing view to organise and call for the recreation of ‘traditional cultural and family values’, often inciting homophobia and reinforcing patriarchal views (Corrêa et al., 2008). Yet, a sophisticated and broadly representative coalition of civil society groups has tirelessly debated sexual rights issues in the UN human rights treaty bodies, with the Yogyakarta Principles on the Application of International Human Rights Law in relation to Sexual Orientation and Gender Identity, launched in 2007, and later on the Yogyakarta Principles plus 10, adopted in 2017, which supplemented the original Principles to include new areas of gender expression and sex characteristics, achieving major visibility (Beyrer et al., 2011) though they have not yet been adopted at the UN-level.

Question 78

3.6 The challenge of including sexual and reproductive rights into treaty-based human rights law

Answer 78

Likewise, progress on reproductive rights, and in particular on abortion, has been disappointing. Arguments for women’s rights to decision-making in regard to abortion have been based on health, rather than on equality, non-discrimination, dignity (Miller & Roseman, 2011). This brings back the seduction of medicalizing reproduction, with conservative forces in the global debate trying to counter any changes in gender relations and pushing them back to ‘nature’, even reverting to the biological differences between men and women (Corrêa et al., 2008). The Holy See strategically pits the right to abortion against the right to life as set out in the Universal Declaration of Human Rights, adding their own doctrine that life begins at the moment of conception. In the Security Councils, the Holy See frequently objected to victims of rape in conflict being given access to emergency contraception and services to terminate pregnancy. Direct reference to abortion was taken out of a final resolution (Coates et al., 2014).

Question 79

3.6 The challenge of including sexual and reproductive rights into treaty-based human rights law

Answer 79

The global debate on emotive SRHR issues, such as abortion, access to modern contraceptives and comprehensive sexuality education, continues to be highly politized and volatile. A recent policy analysis noted the disappearance of the language on abortion from outcome documents of the Commission on the Status of Women (a subsidiary body of the UN Economic and Social Council) since 2017. The authors have also criticized changes to previously agreed SRHR language in other UN documents and linked these to the reinstatement of the ‘Mexico City Policy’ by US President Trump in 2017 and lobbying tactics of anti-choice groups (Gilby, Koivusalo, & Atkins, 2021).

Question 80

4 Global challenges in SRH provision

Answer 80

Discussion of global determinants and outcomes, legal frameworks, and institutional actors brings us to global challenges in SRH service provision. This final portion of the session considers challenges in SRH service provision at a global level, by considering maternal and access issues for young people, sex workers, MSM and transgender, and finally, violence prevention.

Question 81

4.1 Maternal health

Answer 81

Maternal health is still a global issue. In 2017, 295,000 women died worldwide from complications during pregnancy and childbirth (WHO, 2019). It is the world’s largest health inequity with a large gap between high and low-income countries. Maternal mortality is higher in rural areas, among poorer and less educated communities. Most deaths can be prevented by skilled attendance at birth and access to emergency obstetric care, but there is a global shortage of qualified health workers. Every year, unsafe abortions result in the death of an estimated 47000 women and more than 5 million complications (WHO, 2015a).

Question 82

4.1 Maternal health

Answer 82

Maternal health remains high on the global health agenda, partly because of the insufficient progress made against the MDGs 5 goal. Reducing maternal mortality is the first target within the overarching SDG on health. Structural barriers have not changed, including underlying socio-economic factors like poverty, gender inequity, and education. If all women with an unmet need for family planning would use contraception, maternal mortality would fall by 30% (Cleland, Conde-Agudelo, Peterson, Ross, & Tsui, 2012). More work will be needed on the removal of legal and regulatory barriers in particular abortion law that limits access to a safe abortion (Glasier, Gulmezoglu, Schmid, Moreno, & Van Look, 2006; WHO, 2010c). An even bigger job might be the change in social norms. Conscientious objection is used by an increasing number of providers to refuse both abortion and contraception services to clients on religious or personal grounds (Cottingham, Germain, & Hunt, 2012).

Question 83

4.2 Young people’s SRH

Answer 83

Half the world’s population is currently under age 25 with large cohorts of young people in LMIC. More young people become sexually active before marriage as the age at marriage and levels of education increase (Bearinger, Sieving, Ferguson, & Sharma, 2007). In LMIC, 218 million women have an unmet need for modern contraception. Among these, the unmet need is much higher among adolescents than among all women of reproductive age (43% versus 24%). Adolescents in LMIC account for more than 20 million annual pregnancies, half of which are unintended. Complications of pregnancy (including unsafe abortion) or childbirth resulted in an estimated 27,000 deaths among adolescent women in LMIC in 2019 (Sully et al., 2020). Every year, 3 million girls aged 15–19 undergo unsafe abortions (Yarrow, Anderson, Apland, & Watson, 2014) and 2.1 million adolescents live with HIV; infection with other STIs is high too. When considering young people’s access to health care we need to reiterate that determinants of their health lie largely outside of the health-service sector. Foremost, there are structural factors like national wealth, income inequality, and access to education (Viner et al., 2014). Effective action therefore needs intersectoral engagement (Patton et al., 2014) (Patton et al.) to increase access to education and employment.

Question 84

4.2 Young people’s SRH

Answer 84

An important barrier to access in most countries is that SRH services are mainly delivered through maternal and child health delivery system, and this excludes unmarried women, and childless married ones, and of course men (Sadik, 2013). The absence of comprehensive sexuality education still deprives too many young people from knowledge about risks and healthy lifestyles and life skills to negotiate consensual safe sex (Bearinger et al., 2007; WHO, 2010c). When seeking modern contraceptives or STI screening, young people often face barriers, including lack of knowledge, family opposition, or provider discouragement. Parental consent laws and age-of-consent laws all impede access. Many young people are in fact sexually active before they are legally recognised as able to consent to sex. Any laws that prevent young people’s independent and confidential access to SRH services creates barriers to their willingness and ability to access any service at all (Yarrow et al., 2014).

Question 85

4.2 Young people’s SRH

Answer 85

Although the ICPD had placed adolescent SRH on the global agenda, progress in Adolescent SRHR (ASRHR) had been slow until 2015. This has changed with the SDGs and with the extension of the ‘Global Strategy for Women’s and Children’s Health ’ to the ‘Global Strategy for Women’s and Children’s and Adolescents’ Health (2016-2030)’ (EWEC, 2015). Since then, great progress has been made at global and regional levels in putting ASRHR higher on the agenda, and some progress at national levels in developing strategies and programs and formulating laws and policies. However, this progress has been uneven across different ASRHR issues and geographical regions, and challenges persist partly due to denial of adolescent sexuality, entrenched gender inequality, insufficient engagement of young people in political and programmatic processes, weak systems with insufficient service integration, lack of multisectoral coordination, changes in population dynamics, family and community structures, and due to humanitarian and climate crises (Irwin, 2019; Moreau et al., 2021). To learn more about these challenges and the political, programmatic and social responses, please have a look at the recommended reading (see reading list below (Chandra-Mouli et al., 2019)) and other recent articles on this topic (Engel et al., 2019; Kabiru, 2019; Saewyc, 2021).

Question 86

4.3 Reaching sex workers

Answer 86

Sex workers have high rates of HIV and their vulnerability is increased by high levels of violence perpetrated against them. This includes gang rape and forced unprotected sex, as documented among female, male and transgender sex workers alike (Deering et al., 2014). All sex workers are affected by deep-rooted social stigma and universal discrimination towards them are serious barriers to prevention and treatment services. There is strong evidence that criminalization of sex work increases vulnerability (World Health Organization, United Nations Population Fund, Joint United Nations Programme on HIV/AIDS, & Projects, 2012) and limits uptake of HIV prevention and treatment, but morality will often favour more punitive approaches. Structural approaches to reduce stigma and discrimination, address violence and decriminalise sex work are needed on top of providing improved access to health services (WHO, 2013). To learn more about this topic, please see the recommended reading by Busza J.R. (2014).

Question 87

4.4 Reaching men who have sex with men and transgender people

Answer 87

Men who have sex with men (MSM) and transgender people also face extreme structural violence based on a stigmatised sexual orientation or gender identity. At least 69 countries have laws that criminalize consensual same-sex relations among adults. These laws undermine basic human rights of lesbians, bisexuals, transgender persons, and MSM, and expose them to hate speech, violence, forced anal examinations and forced heterosexual marriages (UNAIDS, 2020). In several African countries, these legal barriers have been amplified by moral frameworks with fundamentalists manipulating religious beliefs or ethnic, culturally-based identities to incite hatred, leading to widespread homophobia and prosecution not only of MSM but also of outreach workers. Stereotypes of homosexuality as “foreign” need addressing by promoting awareness that local traditions and religions are not homogenous with regard to sexual diversity. Global civil society needs to work with local minorities to organise and network. Financing of HIV services for these minority groups comes nearly exclusively from international donors rather than from national spending (UNAIDS, 2014).

Question 88

4.5 Prevention of violence against women

Answer 88

Throughout this lecture we have seen that gender is a social structure intersecting with other social hierarchies to create contexts of risk for poor SRH. Gender-based violence is a social practice with enormous public health impact and currently a key priority on the policy agenda, and a lot has been learned about effective prevention strategies (Ellsberg et al., 2015). Looking more closely at the 5th SDG on gender equality and empowering all women and girls reveals that it does not include any targets or aspirations regarding men, rendering them invisible (Gruskin, Safreed-Harmon, Moore, Steiner, & Dworkin, 2014). Yet gender norms are relational, and there is growing evidence that interventions need to address both men and women to effectively transform gender-power inequalities. Settings where intimate partner violence is highly prevalent, are often those where men have commonly been victims of violence as children and where interpersonal violence between men is high. As the Jewkes et al (2015) reading shows, gender inequalities in such settings is systemic and violence can be seen as an instrument of this oppressive system (Jewkes, Flood, & Lang, 2015).

Question 89

4.6 (Re-)Emerging infections, conflict and other humanitarian crises

Answer 89

Many SRHR issues, such as gender-based violence (GBV) and poor access to essential SRH services are aggravated during epidemics, pandemics, armed conflict, and other humanitarian crises. This century has witnessed many epidemics, with some crossing national borders and becoming of regional concern, such as the Ebola epidemic in 2014, and others spreading further and developing into global epidemics and pandemics, including H1N1 influenza in 2009, Zika in 2015, and the ongoing Covid-19 pandemic. Often these epidemics and pandemics exacerbate vulnerabilities that are present prior to the outbreak. The international response to the Ebola outbreak in West Africa, for example, has been critiqued for neglecting SRHR issues, which exacerbated health inequities and social injustice that women had already been facing (Chattu & Yaya, 2020). SRH services are too often considered unessential during health emergencies, and poor health outcomes arise from the disruption of life-saving services, including maternal and neonatal care, as well as care for individuals experiencing abortion complications, sexual violence, and other forms of GBV. The risk of GBV increases with higher exposure to perpetrators during economic hardship, lockdowns, quarantines, and school closures. During Ebola outbreaks, non-Ebola related bleeding due to pregnancy complications or rape has also been misinterpreted as Ebola symptoms, reinforcing fear and stigmatisation and delaying access to care. Outbreaks and pandemics can also lead to delayed access to SRH services if people fear getting infected during health facility visits. (Onyango MA, Resnick K, Davis A, & RR, 2019; Tran, Lichtenstein, Black, Rosmini, & Schulte-Hillen, 2021). Disruptions of SRH services and increased violations of SRHR rights have been reported in many parts of the world due to the Covid-19 pandemic, and researchers and advocates have asked policymakers to prioritize SRHR, both during and after the pandemic (Chattu & Yaya, 2020; Endler et al., 2021; Guttmacher Institute, 2021; Hall et al., 2020). For further information about this topic see the recommended reading on the potential of digital health interventions to increase access to SRH and mental health services during and after the pandemic (Chattu, Lopes, Javed, & Yaya, 2021), and the reading on the impact of Covid-19 on SRHR, including in regions of armed conflict (Nesamoney, Darmstadt, & Wise, 2021).

Question 90

4.6 (Re-)Emerging infections, conflict and other humanitarian crises

Answer 90

Not only armed conflict, but also natural disasters and other humanitarian crises exacerbate GBV and other SRHR-related problems, due to various factors, including increased militarization, lack of community and State protections, displacement, scarcity of essential resources, disruption of community services, changing cultural and gender norms, disrupted relationships and weakened infrastructure Yet, humanitarian emergency responses have historically given insufficient attention to SRHR and to protecting women, adolescents and children, who in crises face increased risks of poor physical and mental health outcomes, harassment, assault and rape (Bendavid et al., 2021; EWEC, 2015; IASC, 2015). It has recently been emphasized that all humanitarian personnel should assume that GBV is occurring during crises, without waiting for or seeking data on the true magnitude of GBV, due to safety and ethical challenges in collecting such data. The priority should be to follow the updated guideline issued by the Inter-Agency Standing Committee (IASC) in 2015, which includes practical guidance and tools for humanitarians and communities to coordinate, plan, implement, monitor and evaluate essential actions for the prevention and mitigation of GBV, throughout all stages of the humanitarian response, from preparedness to recovery (IASC, 2015). Field manuals and toolkits have also been developed by the Inter-Agency Working Group on Reproductive Health in Crises (IAWG) with minimum service package resources for SRH care to all members of a crisis-affected population, including internally displaced populations and refugees. Given the huge numbers of people fleeing armed conflict (nearly 36 million children and 16 million women were displaced in 2017) and natural disasters, and an average length of displacement for refugees of 17 years, the provision of SRHR services to these populations will be essential to ensure that SDGs are met and nobody is left behind (Bendavid et al., 2021; IAWG, 2018, 2020, 2021).

Question 91

5 Areas of action to improve SRHR

Answer 91

Great progress in SRHR has been made between 2010 and 2020, notably with the formulation of the SDGs in 2015. As previously mentioned, however, important gaps remain, for example within the areas of fertility, safe abortion, STIs, and reproductive cancers. For a holistic approach, various aspects of the SRH continuum across the life course should be addressed and integrated; the SRH needs of very young adolescents aged 10-14 years (Moreau et al., 2021) and older people ≥50 years (Banke-Thomas, Olorunsaiye, & Yaya, 2020) should be considered, including previously neglected topics, such as menstrual health (Hennegan et al., 2021; Wilson et al., 2021) and menopause (Namazi, Sadeghi, & Behboodi Moghadam, 2019). Further advancing SRHR requires not only improvements in health care, but also changes in the enabling environment and recognition of contextual factors. The Guttmacher-Lancet Commission suggested five areas of action, including legal and policy reforms; addressing social determinants of SRHR; education and communications; health systems, and technology and innovation. The Commission also made various recommendations for the way forward (see section 6 and 7 of the report as recommended reading (Starrs et al., 2018)).

Question 92

5 Areas of action to improve SRHR

Answer 92

It exceeds the scope of this session to go into detail, but we wish to highlight the importance of an integrative and multi-sectoral approach. Thereby, potential dissonances between different SRH areas, such as HIV and STI or prevention and treatment (Narasimhan et al., 2018; Stewart & Baeten, 2020), and between different sectors, such as population health and environmental preservation have to be surmounted and new partnerships built (Barroso & Sinding, 2019; Mayhew et al., 2020). Opportunities for inter-sectoral co-financing should be sought, as due to the interconnectedness advancement in one SDG can also facilitate progress towards other SDGs (McGuire et al., 2019).

Question 93

5 Areas of action to improve SRHR

Answer 93

It is clear that interventions need to work across all levels of the social ecology: individual, interpersonal, community and societal (Michau, Horn, Bank, Dutt, & Zimmerman, 2014). The diagram below (figure 4) depicts changes needed across the social ecology to transform masculinities and shows the complexity of the task ahead when we aim for transforming strong social structures that impact all aspects of SRH. You can go back to the required reading on social norms for details (Jewkes et al., 2015). This conceptual clarity on how to intervene should give hope for the future. A more transformative development paradigm anchored in human rights and a new global and national economic order would make our work much easier.

Question 94

Integrating activity Question

Answer 94

Please share your responses to the questions below with your fellow students via the discussion board and comment on at least one other post: 1) Choose a SRHR issue, problem or need that is of importance globally and/or nationally in a country of your choice. Justify your choice in a few sentences, e.g. by referring to internationally available data on the topic. 2) What type of collective action problem (if any) does your SHRH issue refer to? (See ‘Types of collective Action Health Problems’ section in introduction session 1 of this module that differentiates between ‘transboundary or cross border problems’, ‘commons problems’, ‘shared problems’, and ‘planetary problems’.) 3) Look at your SHRH issue through a human rights lens. Is it linked to international human rights law or a reproductive health agreement? 4) What action(s) has/have been taken so far globally to address this issue and by which actor(s)? For example, has it been stated in or does it link to any of the SDG targets or indicators? (State no more than a few actions/actors). 5) Do you know of any action(s) taken so far regionally or nationally in your country to address this issue and if so, by which actor(s)? (State no more than a few actions/actors.) 6) Have there been any barriers to global, regional or national action or linked concerns, and if so, how have they been addressed or how could they be addressed in the future? (No more than a few barriers/considerations)

Question 95

Integrating activity Hints

Answer 95

To get inspiration for your choice of SHR components/issues and/or population groups with distinct SHR needs you could have a look at Figure 3 of the Guttmacher-Lancet report (essential reading). For data to justify your choice you may browse the WHO SHRH policy portal (https://www.who.int/data/sexual-and-reproductive-health-and-rights ) or websites of other UN agencies or monitoring frameworks mentioned during this session. To apply the human rights framework, see panel 1-3 of the Guttmacher-Lancet Commission report (essential reading) and the sections on human rights in this session. To check if your issue has been included in the SDGs, you may browse the UN SDG website or have a look at table 1 of the Guttmacher-Lancet Commission report (essential reading) on linkages between key areas of SHRH and the SDGs. For relevant global, regional and national actions and actors, you could also go back to the section on global actors and responses of this session, browse the WHO SHRH policy portal (see link above), or websites from other relevant organizations. Some of the recommended readings also contain country examples – see for example, boxes 3-7 of the adolescent health reading by Chandra-Mouli et al (2019), or examples of three countries in the Blystad et al (2020) reading. You could also search PubMed or other electronic bibliographic databases (https://www.lshtm.ac.uk/research/library-archive-open-research-services/resources/databases )for relevant country case studies, such as the ones by Kangaude et al. (Kangaude, Coast, & Fetters, 2020).

Question 96

Integrating activity Feedback

Answer 96

The below is an example of how a response might look: 1. Chosen SRHR topic and country: Child marriage in Malawi; Importance of the chosen topic: Globally, about one in five women marry before age 18; In Malawi 42% of young women had been married by age 18 and 9% by age 15 in 2015 (UNICEF global database). Child marriage is often associated with the interruption of schooling, vulnerability to HIV and other STIs, domestic violence, forced sexual intercourse and early pregnancy. Early pregnancy and birth at age ≤15 are also associated with increased risk of maternal and neonatal morbidity and mortality. (Reasons for this are complex, and include anatomical, biological and access issues.)

Question 97

Integrating activity Feedback

Answer 97

2. Type of collective action problem: Child marriage is a ‘shared problem’, as it is prevalent in many countries around the globe, especially in South Asia and Sub-Saharan Africa. It may also be a ‘transboundary or cross border problem’ if it involves child trafficking, where children are tricked, forced or persuaded to leave their homes and are moved or transported within a country or to other countries often for forced labour and sexual exploitation. Human trafficking and modern slavery have not been discussed in this session, but are important topics.

Question 98

Integrating activity Feedback

Answer 98

3. Human rights link: Child marriage more or less directly links to a number of sexual and reproductive rights, including ‘freedoms’ (e.g., the right of all individuals to decide whether, when, and whom to marry), and ‘entitlements’ (e.g., the right to services for the prevention, detection, and management of sexual and gender-based violence and coercion). The ‘Convention on the Elimination of All Forms of Discrimination against Women’ (CEDAW) states in article 16: “The betrothal and the marriage of a child shall have no legal effect, and all necessary action, including legislation, shall be taken to specify a minimum age for marriage….” Child marriage is also linked to rights mentioned in ‘The Convention on the Rights of the Child’, the ‘Convention on Consent to Marriage, Minimum Age for Marriage and Registration of Marriages’, the ‘Universal Declaration of Human Rights’, and the ‘International Covenant on Economic, Social and Cultural Rights’. Under certain circumstances, child marriage may also meet the international legal definitions of slavery and slavery-like practices, which is prohibited under international law.

Question 99

Integrating activity Feedback

Answer 99

4. Global actions/actors: Child marriage was recognized as important for public health and human rights in the ICPD, but was omitted from the MDGs. In 2015, however, it was included in SDG target 5.3, “Eliminate all harmful practices, such as child, early and forced marriage and female genital mutilations” and SDG indicator 5.3.1: “Proportion of women aged 20–24 years who were married or in a union before age 15 and before age 18”. In addition, child marriage can link to other SDG goals and targets. For example, in cases where it has a negative effect on schooling, it links to SDG 4, “Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all.” Under certain circumstances it may also link to SDG target 16.2, “End abuse, exploitation, trafficking, and all forms of violence against and torture of children. In 2011 ‘Girls Not Brides’ was founded, a global network of >1,500 civil society organisations from >100 countries committed to ending child marriage and ensuring girls can reach their full potential; in 2016, UNFPA and UNICEF launched the UN Global Programme to Accelerate Action to End Child Marriage.

Question 100

Integrating activity Feedback

Answer 100

5. Regional and/or national actions/actors: The African Union and the Southern African Development Community have condemned child marriage. The ‘Marriage, Divorce and Family Relations Act’ raised the marriage age to 18 in Malawi in 2015. An initial loophole that still allowed children as young as 15 to marry with parental consent was closed a few years later. In 2018, the Government launched the ‘National Strategy on Ending Child Marriage’, and in 2019 the ‘National Children’s Policy’ which prohibits child marriage as a hindrance to the development of children and the country. Relevant actions by the Government in collaboration with partner organizations include the promotion of the ‘Journey of Life’ tool that mobilizes and supports communities and community-based organizations to identify and act on child protection issues; the Social Cash Transfer Programme ‘Mtukula Pakhomo’ tackles poverty, as one of the reasons for girls dropping out of school and getting married early if families need to reduce the household size to be able to feed younger siblings. In 2016, senior female traditional leader Chief Theresa Kachindamoto of Dedza District annulled 850 child marriages and suspended all village heads that refused to ban the practice of child marriage.

Question 101

Integrating activity Feedback

Answer 101

6. Barriers, concerns to address: Despite the new policies and laws, child marriage remains a common problem in Malawi (especially in the poorest and rural areas), largely due to poor resource allocation and poor enforcement of civil laws, as customary laws and practices continue. Sadly, natural disasters, such as the floods in the aftermath of Cyclone Idai, have exacerbated poverty. Most recently, rates of child marriages and teenage pregnancies rose sharply during the Covid-19 pandemic due to reduced family income and school closures. This prompted senior Chief Theresa Kachindamoto to order village chiefs to dissolve all the child marriages that took place during the country’s Covid lockdown so girls could return to classes. Advocacy campaigns and programmes in Malawi need to be tailored depending on cultural backgrounds, e.g., different kinship systems (‘matrilineal’ vs ‘patrilineal’, where kinship follows the mother’s vs father’s line). They also need to consider different forms of marriage, including formal vs informal unions, age disparage unions vs unions between minors of similar age, and whether they have been arranged by adults or have been self-initiated and/or are preceded by premarital conception. Globally, potential unforeseen effects of age restrictions must be carefully considered. For example, the rights of under 18’s to SRH services must not be restricted by establishing 18 as a minimum age for marriage.

Question 102

Summary

Answer 102

Having come to the end of this session you will now have a better understanding of why poor SRH is unevenly distributed across populations. You should be able to demonstrate how global factors influence SRH determinants and outcomes. Secondly, to critically analyse key institutional actors and policy responses concerned with global action addressing SRH issues; and finally, to examine global challenges in strengthening SRH service provision.