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Sexual and reproductive health and rights an essential component of the

priority health agenda for 2015-2030

Ipas
December 2012


Paper submitted for Health priorities for the post-2015: What is the priority health agenda
for the 15 years after 2015?

Abstract
While the proposed post-2015 development framework will be broader in scope than the
Millennium Development Goals (MDGs), it should give priority to including those focus areas
that received the least attention in implementation of the MDG framework. Within an
overarching health goal, sub-goals and targets related to sexual and reproductive health and
rights should be incorporated so that governments and other stakeholders continue
addressing the most neglected MDGs, including those related to maternal, newborn and
child/adolescent health, as well as gender equality, gender equity and womens
empowerment as core foundations of human development. The principles of the human
rights-based approach should underlie all goals, targets and indicators formulated within the
post-2015 development agenda: accountability, participation, transparency, empowerment,
sustainability, non-discrimination and international cooperation. Any targets or indicators
proposed under an overarching health goal should include measures of access to all
essential reproductive health services including: comprehensive sexuality education; non-
coercive sexual and reproductive health counseling; a wide range of short- and longer-term
modern contraceptives that are available without requirements for spousal or parental
consent; assisted conception measures; prevention of sexually transmitted infections and
diseases that can affect healthy pregnancies (e.g., malaria); adequate and accessible
antenatal, delivery and post-natal care; and prevention and management of unwanted
pregnancies through easily accessible and legal emergency contraception and safe abortion
care. In addition, targets and indicators should be formulated regarding the implementation
of laws and policies and fulfillment of obligations assumed with the ratification of
international treaties that promote access to all evidence-based reproductive health
services.

Introduction
The post-2015 development framework will provide an opportunity at the international,
regional and national levels to continue addressing issues covered by the Millennium
Development Goals (MDGs). While the proposed post-2015 framework will be broader in
scope than the MDGs, it should give priority to including those focus areas that have
received the least attention in implementation of the MDG framework.


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For example, in 2012, only four countries were on track to meet the targets established for
MDG 5 on improving maternal health: China, Egypt, Morocco, and Peru.
1
The Independent
Expert Review Group (iERG) for the UN Secretary Generals Strategy on Womens and
Childrens Health noted:

Among women, to achieve MDG-5, the annual rate of maternal mortality
decline must be 5.5%. But worldwide, the decline has been only 1.9% since
1990. The predicament for adolescent girls is especially acute: one in 8 births
in low-income settings is in girls aged 15-19 years old; in sub-Saharan Africa,
girls aged 15-19 years account for a quarter of unsafe abortions.
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One lesson that can be drawn from implementation of the MDGs is that the post-2015
development framework must address the high incidence of unsafe abortions as a leading
cause of maternal mortality and morbidity that affects vulnerable women in developing
countries. Governments should decriminalize abortion and implement policies and programs
to ensure that women, especially adolescents and young women, have access to safe and
legal abortions without mandatory waiting periods or requirements for parental and spousal
notification and/or consent based on the womans age, as well as adequate, pre- and post-
abortion services including contraceptive counseling and information on HIV and sexually
transmitted infections (STIs).

Sexual and reproductive health and rights are an essential health priority
Sexual and reproductive health and rights comprise an area of governmental policy that
facilitate addressing the neglected and unfulfilled needs of societys most vulnerable and
neglected groups, as well as bolstering efforts to tackle other social welfare issues including
poverty alleviation, promotion of gender-equitable access to education and employment
and agricultural development.

For sustainable development to occur, societies must enable and empower all social groups
to participate fully (taking into account that all individuals belong to multiple social groups
and have varying identities, roles and responsibilities). Promotion of sexual and reproductive
health rights necessarily encompasses promotion of gender equality and equity and
measures to combat gender-based violence and violence against women, which assists in
facilitating the social inclusion of vulnerable groups in development efforts. When laws and
policies are in place to further gender equality, including regulations to ensure that girls are
not forced into early marriages and that women and girls can inherit and own land and
property, provide food for their families by growing and selling food, attend educational
institutions of their choice, and control their own fertility, their participation in social
development is enhanced.

Women and girls must be enabled to take voluntary, autonomous decisions about whether
and when to have children so that they can take full advantage of educational and
employment opportunities and be able to participate in community and civic decision-
making and activities. The Guttmacher Institute has reported, for example, that ensuring
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access to contraceptives for all women who need them would prevent an additional 54
million unintended pregnancies, 26 million abortions (of which 16 million would be unsafe)
and 7 million miscarriages, as well as 79,000 maternal deaths and 1.1 million infant deaths.
2
Measures must also be taken to prevent and treat pregnancy-related injuries and illnesses
that interfere with womens and girls life plans and which can lead to social exclusion due to
stigma, such as fistulas
3
and unsafe abortions, which lead one in four women who suffer
complications to develop temporary or lifelong disabilities requiring medical care and which
cost individuals and societies US$ 930 million annually in lost income.
4


Essential sexual and reproductive health services include: comprehensive sexuality
education; non-coercive sexual and reproductive health counseling; a wide range of short-
and longer-term modern contraceptives that are available without requirements for spousal
or parental consent; assisted conception measures; prevention of STIs and diseases that can
affect healthy pregnancies (e.g., malaria); adequate and accessible antenatal, delivery and
post-natal care; and prevention and management of unwanted pregnancies through easily
accessible and legal emergency contraception and safe abortion care.

Underlying principles for addressing sexual and reproductive health
The human rights-based approach to addressing maternal mortality and morbidity, endorsed
by the Human Rights Council in several resolutions,
5-8
provides a set of principles that should
underlie all goals, targets and indicators formulated within the post-2015 development
agenda: accountability, participation, transparency, empowerment, sustainability, non-
discrimination and international cooperation. The Office of the High Commissioner on
Human Rights (OHCHR) has issued guidance for UN Member States and other stakeholders
on application of this approach to maternal mortality and morbidity which can easily be
applied to all areas of sexual and reproductive health.
9


Accountability implies that essential interventions and services must be defined in
accordance with a governments core obligations under international law and that they
must be consistent with the best available public health research evidence, as reiterated by
the African Unions Commission on Maternal, Newborn and Child Health.
10
States should
protect against interference with sexual and reproductive health rights by third parties (e.g.,
attempts to prevent women from accessing legal abortions
11
) by adopting and enforcing
appropriate laws, policies, regulations and guidelines,
12
and by rescinding laws and policies
that criminalize sexual and reproductive health prevention and treatment measures, as
recommended by the UN Special Rapporteur on the right to health.
13-14


Participation implies that people must be active agents who are entitled to participate in
decisions that affect their lives, including their sexual and reproductive health. For example,
WHO recommends that adolescents be approached as full partners in the design,
implementation and monitoring of programs for contraceptive information and service
provision,
15
experience that can stand them in good stead for engagement in other
community development efforts.

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Transparency implies that government spending on specific sectors and programs should be
clearly identifiable in overall budgets and be made available in a format readily accessible to
the general public. This facilitates budgetary monitoring by civil society and other groups
and can help identify where changes in health systems are needed. For example, WHO
points out that the costs to health systems of managing the complications of unsafe
abortions are high (US$ 114 per case for Africa and US$ 130 per case for Latin America);
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if
safe abortion were available, these expenditures could go to covering other health or social
needs.

When rights-holders (e.g., women, youth, disabled persons, health-care providers, etc.) and
their entitlements are specifically identified in policies along with governmental obligations
to fulfill these, steps are taken towards empowerment. The iERG has commented that a
post-2015 framework must place women and children in a central position, for example, by
addressing issues such as womens empowerment, girls education, and reproductive health
as vital elements of development.
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Sustainability requires governments to balance expenditures and income in a way that
avoids making cuts to programs and services designed to meet the needs of vulnerable
population groups. The resolution adopted by UN Member States at the 2012 Commission
on Population and Development (CPD) urged governments and development partners to
improve maternal health, reduce maternal and child morbidity and mortality, and prevent
and respond to HIV and AIDS by, inter alia, strengthening health systems and ensuring that
they prioritize universal access to sexual and reproductive information and health-care
services, including family planning, antenatal care, safe delivery and postnatal care,
especially breastfeeding and infant and womens health care, emergency obstetric care,
prevention and appropriate treatment of infertility, quality services for the management of
abortion complications, training and equipping health-service providers and taking other
measures to ensure that legal abortion is safe and accessible, especially taking into account
the particular needs of persons in vulnerable situations. The resolution further called upon
governments to make every effort to mobilize the required resources to ensure that the
health, development and human rights-related objectives of the ICPD Programme of Action
are met.
16


Non-discrimination must ensure that all people, regardless of their social identities based on
race, gender identity, sex, sexual orientation, age, ethnicity, residence, etc., have access to
needed to social and health services. The 2012 CPD resolution agreed, for example, that
governments should meet the reproductive health-service, information and educational
needs of young people, including evidence-based comprehensive education on human
sexuality, sexual and reproductive health, human rights and gender equality, with full
respect for their privacy and confidentiality and free of discrimination.
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Finally, international cooperation requires States to seek outside resources when they have
demonstrated an inability to cover basic population needs, while donors must commit to
providing resources in a way that strengthens governmental and community structures. The
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Center for Strategic and International Studies recently recommended, for example, that the
US government focus on providing recipient countries with support to improve maternal
health-related data collection at individual health facilities and in communities.
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Targets and indicators
Targets and indicators for a sub-goal on sexual and reproductive health and rights under an
overarching health goal should include measures of access to all reproductive health
services included in The Partnership for Maternal, Newborn and Child Healths guidance on
Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn
and Child Health.
18
As noted in this reference document, When linked together and
included as integrated programmes, these interventions can lower costs, promote greater
efficiencies and reduce duplication of resources, which can allow governments to devote
more resources to other areas.

A particular concrete focus can be placed on indicators to monitor improvements achieved
in data collection systems regarding access to reproductive health services, such as
contraceptive use, skilled birth attendance, postabortion care and safe abortion,
disaggregated by age, residence and socioeconomic status. Guidance issued by OHCHR on
the use of human rights indicators provides concrete examples of such indicators.
19


Another focus should be on the implementation of laws and policies and fulfillment of
obligations assumed with the ratification of international treaties that promote access to all
evidence-based reproductive health services. This would include revision of laws that
criminalize or impede access to comprehensive sexuality education, modern contraceptives
including emergency contraception, and safe abortion care. In this context, attention should
also be given to monitoring mechanisms at the community level,
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as well as the
implementation of national human rights bodies, such as human rights commissions and
ombudspersons, and redress mechanisms for persons denied sexual and reproductive
rights.

Concluding remarks
The post-2015 development framework provides an opportunity to ensure that sexual and
reproductive health, based on principles of gender equity and human rights, are addressed
as a health priority. During formulation of the MDGs, this was not adequately incorporated
until a target on achieving universal access to reproductive health was added in 2007.
However, the indicators did not address reproductive rights, which can be rectified in the
post-2015 agenda by including sexual and reproductive health and rights as a sub-goal of the
overarching goal on health.

WHO has proposed that an overarching health goal could possibly focus on universal health
coverage and/or healthy life expectancy.
21
Within such an overarching health goal, sub-goals
and targets related to sexual and reproductive health and rights should be incorporated so
that governments and other stakeholders continue addressing the most neglected MDGs,
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including maternal, newborn and child/adolescent health, as well as gender equality, gender
equity and womens empowerment as core foundations of human development.

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