Sexual and reproductive health beyond 2014: Equality, Quality of care and Accountability position paper To advance the sexual and reproductive health and rights agenda beyond 2014/2015, inequalities must be addressed, quality of care guaranteed and accountability enhanced.
Background and context In 1994, the International Conference on Population and Development (ICPD) endorsed a Programme of Action that set forth an ambitious population and development strategy (1). The ICPD Programme of Action was remarkable in its recognition that gender equality and equity, and the empowerment of women and human rights, are cornerstones of population and development (1, Principles 1, 4 and 8). This led to a paradigm shift from earlier policies targeting population control, to one that places the individual at the centre, and respects choice, rights and empowerment. A total of 179 countries endorsed this programme, and have worked over the last 20 years to meet its objectives. The 20th anniversary of the ICPD Programme of Action is an opportunity for the global community to reflect on progress made in advancing sexual and reproductive health, and address remaining challenges. This paper highlights the main achievements, gaps and remaining challenges in the implementation of the ICPD Programme of Action in key areas related to sexual and reproductive health, and identifies cross-cutting themes impacting service provision. To advance the sexual and reproductive health and rights agenda beyond 2014/2015, inequalities must be addressed, quality of care guaranteed and accountability enhanced.
Key achievements and challenges in the area of sexual and reproductive health Since 1994, countries have devised innovative strategies and programmes to advance the sexual and reproductive health agenda. Whereas this has led to real and substantial accomplishments, significant challenges remain. The United Nations Population Fund (UNFPA)-led Global Survey report points out that progress has been made in several areas. These include: reduction in the rates of new infection for HIV in many countries, an overall 50% reduction in maternal mortality, and increases in the use of modern contraception (2, p.93). Despite these promising advances, significant gaps in ensuring universal access to reproductive health remain. Sexual and reproductive health problems represent one third of
the total global burden of disease for women between the ages of 15 and 44 years, and violence against women and girls remains the most frequent human rights abuse worldwide (3). The inequalities between and within countries, and persistent disparities between women and men, and between social and ethnic groups, have inhibited progress (1).
Sexual and reproductive health of adolescents An estimated 16 million births occur to young women aged 15–19 years, representing 11% of all births (4). About 12% of adolescent girls in low- and middle-income countries are married by the age of 15 years, and as many as 30% are married by the age of 18 years, enhancing their risk for adverse health consequences of early pregnancy (5). Of the estimated
22 million unsafe abortions that occur every year, 15% occur in young women aged 15–19 years and 26% occur in those aged 20–24 years (6). In Africa alone, an estimated 3 million girls are at risk of undergoing female genital mutilation every year (7). Young people aged 15-24 years are at the forefront of the HIV epidemic with 41% of all new HIV infections among adults in 2009 (8).
contraceptive methods is restricted to married women, and where the incidence of non-consensual sexual intercourse is high. For example, in Africa, young women below the age of 25 years account for nearly two thirds of all unsafe abortions (13).
Sexually transmitted infections In 2008, globally an estimated 500 million new (incident) cases of curable STIs (gonorrhoea, chlamydia, syphilis and trichomoniasis) occurred (14). In addition, 536 million people are estimated to be living with incurable herpes simplex virus type 2 (HSV-2) infection. Approximately 291 million women have an HPV infection at any given point in time, and it is likely that the numbers of HPV-infected men are similar. Further, STIs result in a large global burden of sexual, reproductive, and maternal–child health consequences. For instance, syphilis in pregnancy leads to 305 000 fetal and neonatal deaths, and leaves 215 000 infants each year at increased risk of dying from prematurity, low birth weight or congenital disease (15). Human papillomavirus infection causes an estimated 530 000 cases of cervical cancer and 275 000 cervical cancer deaths each year (15). Also, STIs such as gonorrhoea and chlamydia are important causes of infertility. In sub-Saharan Africa, untreated genital infection may be the cause of up to 85% of infertility among women seeking infertility care. In addition, gonorrhoea and chlamydia are major causes of pelvic inflammatory disease and adverse pregnancy outcomes (16).
Contraceptive information and services Worldwide, 222 million women are estimated to have an unmet need for modern contraception and the need is greatest where the risks of maternal mortality are highest; in the least developed countries, six out of ten women who do not want to get pregnant, or who want to delay their next pregnancy, are not using any modern method of contraception (9). Women with unintended pregnancies that are continued to term are more likely to receive inadequate or delayed prenatal care and to have poorer health outcomes, such as infants with low birth weight, infant mortality, and maternal mortality and morbidity (10). According to 2012 estimates, providing access to contraception to all women in low- and middle-income countries who currently have an unmet need for modern methods of contraception would prevent 54 million unintended pregnancies, 26 million abortions and 7 million miscarriages; this would also prevent 79 000 maternal deaths and 1.1 million infant deaths (9).
Prevention of unsafe abortion In 2008, 22 million unsafe abortions were estimated to have occurred, accounting for half of all induced abortions in that year) (11). Approximately 47 000 pregnancy-related deaths (13%) were attributable to complications of unsafe abortion; moreover, a recent study estimates that every year in low- and middleincome countries, 5 million women are admitted to hospital as a result of unsafe abortion (11). Nearly all unsafe abortions (98%) occur in low- and middle-income countries (11). The rate of induced abortion has declined from 35 per 1000 women aged 15–44 years in 1995 to 26 per 1000 in 2008. Though this trend appears promising, the decrease is largely attributed to the decline in the rate of safe abortion, while the rate of unsafe abortion has remained relatively constant since 2000, at around 14 per 1000 women aged 15–44 years (12). Young women are especially vulnerable where access to effective
Maternal mortality and morbidity Between 1990 and 2010, maternal mortality worldwide dropped by almost 50% (17). However, every day, approximately 800 women die from preventable causes related to pregnancy and childbirth; 99% of these deaths occur in low- or middle-income countries. Maternal mortality is higher in women living in rural areas and among poorer communities. Young adolescents face a higher risk of complications and death as a result of pregnancy than older women. Skilled care before, during and after childbirth can save the lives of women and newborn babies.
Violence against women and girls One in three women aged 15–49 years are estimated to have experienced physical and/or sexual violence by an intimate partner, or non-partner sexual violence (3). Thirty per cent of all women aged 15–49 years who have been in a relationship have experienced physical and/or sexual violence by an intimate partner in their lifetime (3). Twenty-nine per cent of adolescent girls aged 15–19 years who have been in a relationship are estimated to have experienced physical and/or sexual violence by an intimate partner in their lifetime (3). The prevalence of intimate partner violence varies by geographic region, ranging from 24.6% in the World Health Organization (WHO) Western Pacific Region, up to 37.7% in the WHO South-East Asia Region. The prevalence among high-income countries is 23.2%.
Often, many of these inequalities overlap, and some individuals or groups of individuals face a multitude of barriers to sexual and reproductive health services; for example, women belonging to an ethnic or religious indigenous group, sex workers, or transgender individuals face multiple and unique obstacles to services. Such multiple and intersecting inequalities have a unique and specific impact on individuals’ realization of their sexual and reproductive health. However, many countries fail to recognize the existence and impact of intersecting inequalities. As a result, the experiences and needs of individuals with multiple disadvantages are not integrated into national strategies to combat gender inequality and racial discrimination, further entrenching the discrimination and disadvantage they face (20,21).
Emerging priorities for sexual and reproductive health: ICPD beyond 2014 Three cross-cutting themes have emerged from ongoing ICPD evaluation processes as key areas of focus to advance sexual and reproductive health and development: large inequalities both between and within countries, the absence of quality in service provision, and the need for accountability (18). Moving the sexual and reproductive health and rights agenda beyond 2014/2015 must address inequalities, guarantee quality of care, and enhance accountability in relation to sexual and reproductive health.
Ensure quality of care Sexual and reproductive health services should be, but often are not, provided at a level of quality that meets human rights standards. In addition to medical ethics and the public health imperative, the right to the highest attainable standard of health obligates governments to ensure that health facilities, goods and services, including sexual and reproductive health services, are of good quality. The persistence of poor sexual and reproductive health outcomes among the poor, particularly in Africa and Southern Asia, underscores the need to strengthen the reach, comprehensiveness and quality of health systems. Despite decades of unprecedented medical advances and innovations in health care, stark inequalities persist in the accessibility and quality of health systems across and within countries (19, Paragraph 87). A recent WHO study showed the significant role of quality of care in improving health outcomes. The study suggests that to achieve a substantial reduction in maternal mortality, a comprehensive approach to emergency care, and overall improvements in the quality of maternal health care, will be needed (22). The right to health obligates governments to identify and eliminate economic, social, systemic and service-related barriers, including by protecting and promoting the right to education and information, so that individuals can enjoy the highest attainable standard of health, including sexual and reproductive health (19, Paragraph 63).
Address inequalities There is clear evidence that inequalities and inequities in the accessibility and quality of health systems across and within countries continue to persist (19, Paragraph 63). Sub-Saharan Africa and Southern Asia continue to have some of the least accessible and most fragile health systems, as measured by indicators such as health-worker density, coverage of critical services, health information systems, commodity stock-outs and quality assurance. Within many middle- and highincome countries, pockets of weak and poor healthsystem coverage or low-quality services abound for certain areas or populations, such as for the poor, older persons, rural residents and residents of urban slums, and for uninsured or undocumented persons (19, Paragraph 87).
It is therefore imperative to give priority to, and fully implement, information and service-delivery standards that respect, protect and fulfil the human rights of their clients (23). Nonetheless, these standards are often not included in sexual and reproductive health policies, or operationalized in the sexual and reproductive health programmes of most countries and their international partners. They are not routinely used in the formulation of training and service-delivery protocols, or the content of sexual and reproductive health information, even though available evidence suggests that achieving quality standards improves the effectiveness and utilization of sexual and reproductive health information and services (24–27). Quality of care should therefore go side by side with the increase of service coverage, since the latter alone does not guarantee the health results (27). Strengthening health networks and referral systems is still an unfinished agenda in many countries. Upgrading of second- and first-level facilities with appropriate infrastructure and equipment, and providing adequate numbers of skilled and motivated human resources are necessary to increase coverage and facilitate access.
There is an urgent need to collect statistics and data, not just on health interventions, but also on other sexual and reproductive health issues, such as: sexual coercion and violence, female genital mutilation/cutting, early and forced marriage, and use of safe and unsafe abortion. This information is crucial if governments are to assess accurately the extent to which rights are being denied, and target interventions accordingly. Disaggregating data by sex, ethnicity, relevant age groups (10–14 years, 15–19 years, 20–24 years), wealth quintiles, and place of residence helps to ensure that discrimination and exclusion are not masked by national averages.
Conclusion The 20-year review of the ICPD Programme of Action has highlighted various areas where it remains an unfinished agenda. As governments meet to assess performance, it is important to be reminded of the comprehensive sexual and reproductive health agenda enshrined in the Programme of Action (1). Systematic consideration of both health and human rights evidence must be incorporated into a measured response to advance the sexual and reproductive health agenda, and fully achieve the objectives of the ICPD Programme of Action. This is essential not only for advancing the ICPD agenda but also for ensuring that the post-2015 agenda and the new international framework speak to the needs and aspirations of people around the world. To achieve this, attention must be paid to addressing inequalities, ensuring quality of care and enhancing accountability.
Enhance accountability Ensuring effective monitoring and accountability is at the core of promotion and protection of sexual and reproductive health. The Commission on Information and Accountability for Women’s and Children’s Health emphasized multiple dimensions of accountability, by adopting a framework built on three pillars: monitoring, review and action (including redress). The independent Expert Review Group, established to monitor and assess progress in implementation of recommendations made by the Commission, has stated that accountability needs to be based on certain core principles: clarity about stakeholder responsibility for action; accurate measurement; independent verification; impartial, transparent, and participatory review; and clear recommendations for future action (28). Accountability is also intrinsic to ensuring that individuals’ agency and choice are respected, protected and fulfilled. Agency and choice are fundamental to enabling individuals to have a voice and to hold governments to account. Governments must ensure accountability and monitor, review and remedy sexual and reproductive health and rights and violations (29).
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