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Sexual and Reproductive Health and Rights and Post-2015 Agenda: An Investigation into Development Scenario

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Published Date: May 16, 2016

Sexual and Reproductive Health and Rights and Post-2015 Agenda: An Investigation into Development Scenario

Santosh Kumar Mishra

Population Education Resource Centre (PERC), Department of Continuing and Adult Education and Extension Work, S. N. D. T. Women’s University, Mumbai, Maharashtra

*Corresponding author: Santosh Kumar, Department of Continuing and Adult Education and Extension Work, S. N. D. T. Women’s University, Mumbai, Maharashtra, India, Tel: 922-438-0445; E-mail: drskmishrain@yahoo.com.

Citation: Mishra SK (2016) Sexual and Reproductive Health and Rights and Post-2015 Agenda: An Investigation into Development Scenario. Women Heal Int 2(1): 114. DOI: http://dx.doi.org/10.19104/whi.2016.114      

 

 Abstract

 

About 800 women die every day from preventable causes related to pregnancy and childbirth. Sexual and reproductive health and rights (SRHR) are intrinsic human rights. They encompass the right to sexual and reproductive health, respect for bodily integrity, the right to choose one’s partner and the right to decide on sexual relations and having children, including contraception and abortion. SRHR are directly related to girls’ education, future earnings and economic participation; they are critical for the fulfillment of human rights related to sex, reproduction, family life, and economic and social participation. When women and girls do not have full access to SRHR, their ability to contribute economically, socially and politically to their communities is severely constrained. SRHR should be prioritized and addressed comprehensively in all post - 2015 development framework negotiations, and not be limited to access to family planning. Accelerating progress beyond 2015 will require renewed commitment to investing in women’s sexual and reproductive health and rights, with a focus on universal access to quality, integrated sexual and reproductive health information, education and services throughout the life cycle. The purpose of this paper is to examine the role and importance of SRHR holistically in the development scenario within the context of their linkages to other fundamental human rights as well as with the global poverty and hunger eradication objective; and put forward essential recommendations for them to be given their rightful place in the post-2015 agenda. The paper concludes that if we are truly serious about sustainable development, peace and justice for all, sexual and reproductive health and rights have to be an integral part of all discourse and planning for a better world.

 

 Keywords: Sexual and Reproductive Rights (SRR); Sexual and Reproductive Health and Rights (SRHR); Millennium Development Goals (MDGs); Development Scenario; Networks; Policy-Makers

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 The Context

Sexuality and reproduction lie at the foundation of families and communities. Sexual and reproductive rights (SRR) are intrinsic human rights. They encompass respect for bodily integrity, the right to choose one’s partner and the right to decide on sexual relations and having children, among other things. By eliminating sexual and reproductive rights from the development equation, we are denying the value of our very existence as well as that of future generations. Sexuality is as much a part, if not more, of being fully human and fully alive as needing food and water to live. It is the essence of the joy of being alive and its meaning far broader than biological processes. In the discourse on the setting of the post - 2015 agenda, addressing the gaps, weaknesses and lessons learnt from the current Millennium Development Goals (MDGs) is imperative. One of the glaring gaps in the MDGs pertains to that of human rights, equity, democracy and governance. Sexual and Reproductive Health and Rights (SRHR) fall squarely into this space. SRHR are an often vaguely understood and overlooked component in development; yet their role is fundamental to achieving “sustainable well-being for all” in “the world we want”: two popular catchphrases in the post - 2015 debate. Although SRHR proponents have been advocating for the full recognition of these rights for years, they have yet to be given their proper place in the development agenda for the future we want [1].

In 2000, the millennium development goals committed: “every country around the world to take action”. The world agreed: “we all want to live in a world without poverty, where people can achieve their potential and where good health and education are guaranteed”. Sexual and reproductive health and rights are central to achieving this vision. Such rights concern people’s everyday lives, their livelihoods, their opportunities and their aspirations. They allow individuals to be empowered to exercise choice in their sexual and reproductive lives. However, there are challenges that stand in the way of universal access to sexual and reproductive health and rights being realized. SRHR cut across the three central dimensions of sustainable development: economic, social and environmental. Therefore, ensuring universal access to such rights should be an essential part of the response to the global challenges we face [2].

 

 Objectives and Methodology

 

This paper aims to emphasize why sexual and reproductive health and rights are crucial in the development scenario and how they have been addressed and negotiated in the post - 2015 development framework discussions. It also outlines how a wide range of organizations and networks have campaigned around the issues. Further, the author, in this presentation, put forth policy recommendations to ensure that SRHR are addressed comprehensively by policy makers so that gender justice can be attained. In terms of methodology employed in this presentation, secondary data (which are largely qualitative in nature) has been used and they have been analyzed using descriptive method. Data (collected from books, research reports, government publications, journal articles, and Internet resources) analysis is based on a review of SRHR initiatives undertaken across the regions of the globe over the years.

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SRHR – Conceptual Framework

 

Women’s sexual and reproductive health is related to multiple human rights, including the right to life, the right to be free from torture, the right to health, the right to privacy, the right to education, and the prohibition of discrimination. The Committee on Economic, Social and Cultural Rights and the Committee on the Elimination of Discrimination against Women (CEDAW) have both clearly indicated that women’s right to health includes their sexual and reproductive health. This means that States have obligations to respect, protect and fulfill rights related to women’s sexual and reproductive health [3].

SRHR are interwoven with the right to life, right to health, right to self - determination, right to diverse family, right to livelihood, women’s rights, children’s rights and intergenerational rights, among others. The right to life and health in turn encompass the right to food and nutrition. By the same token, gender justice and social justice cannot be fully served without upholding SRHR. Description of other key terms used in this paper is presented below [4].

Reproductive health

 It implies that people are able to have a responsible, satisfying and safe sex life, and that they have the capacity to reproduce and the freedom to decide if, when and how often to do so. Implicit in this are the right of men and women to be informed of and have access to safe, effective, affordable, and acceptable methods of fertility regulation of their choice, and to appropriate healthcare services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of a healthy infant.

Reproductive rights

 It embraces certain human rights that are already recognized in national laws, international human rights documents, and other consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing, and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents.

Sexual health

 It implies a positive approach to human sexuality and the purpose of sexual healthcare is the enhancement of life and personal relations as well as counseling and care related to reproduction and sexually transmitted diseases.

Sexual rights

 It embraces human rights that are already recognized in national laws, international human rights documents and other consensus documents. These include the right of all persons, free of coercion, discrimination and violence, to the highest attainable standard of health in relation to sexuality, including access to

  1. sexual and reproductive healthcare services
  2. seek, receive, and impart information in relation to sexuality
  3. sexuality education
  4. respect for bodily integrity
  5. choice of partner
  6. decision to be sexually active or not
  7. consensual sexual relations
  8. consensual marriage
  9. decide whether or not, and when to have children
  10. Pursue a satisfying, safe and pleasurable sexual life.

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Recognition of SRHR – Challenges

 

Sexual and reproductive health and rights is a key development issue, yet it is an uphill battle to get the recognition and attention it deserves and to mainstream it into the core development agenda. One challenge in advancing SRHR is that they are considered fairly new, unfamiliar or secondary compared to seemingly more pressing (and familiar) issues. Many governmental and non-governmental sectors alike do not know where to place SRHR, or how to connect them in meaningful ways with poverty alleviation, food sovereignty, human rights, social justice or even climate change.

There are vague notions that SRHR have something to do with gender and therefore would fall under the purview of the gender justice advocates, but even many women’s rights groups are not familiar enough with the topic to put it forward strongly and clearly enough to get it the recognition it deserves. In addition, sexual and reproductive rights violations are not just suffered by women, but also by people of diverse sexual orientation and gender identities and expression. A common oversight is recognizing that the suppression of SRHR is directly linked with serious societal problems, such as

  1. poverty
  2. hunger
  3. malnutrition
  4. HIV and AIDS
  5. teenage pregnancies.

Policy-makers can feel pressured to uphold yet another set of rights when they are already struggling to fulfill basic rights like the right to food. Governments of developing and least developed countries especially may understandably feel overburdened and inadequate in meeting yet more obligations. Ironically, what they fail to see is that fulfilling these rights will help them meet the very objectives they are struggling to achieve more effectively, like alleviating hunger and poverty. For instance, access to comprehensive sexuality education and contraception will help address issues like the rise in the number of teenage pregnancies, abandoned babies, population growth rates, and public healthcare costs, related to sexually transmitted infections, among other things.

SRHR constitute a fundamental aspect of development which has remained invisible and unarticulated for too long. Unless and until they become recognized as a critical component which will enable and support the realization of other rights, however, development efforts will fail to serve the needs and rights of humanity adequately or fairly. Making the right intersections across the various components of the development agenda is crucial to its success.

Another reason holding back the progress of SRHR is the fact that the issue sits uncomfortably with many sectors. For example, in many countries and cultures, especially in the Global South, talking openly about sex is still taboo and patriarchy is still predominant. Customary norms that oppress girls and women continue to be widely practiced and “sexually different” people are socially ostracized in most local cultures. The SRHR issue is also fraught with sensitivity in cases where religious or customary rules and even government policies conflict with certain tenets of SRHR. SRHR is, thus, a difficult subject to introduce, explain and talk openly about, let alone advocate for. This is the social reality that presents obstacles to the full and proper discourse, expression and realization of these critical rights.

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MDGs and Health: Gains and Gaps

 

When the world leaders adopted the United Nations Millennium Declaration and set the eight Millennium Development Goals (MDGs) in 2000, they acknowledged that development had a long way to go in the face of growing global hunger, poverty, conflict, disease, and inequities, among other things.

Health is a critical component of sustainable development. The Global Thematic Consultation on Health Report (GTCHR) describes health as: “a beneficiary of development, a contributor to development, and a key indicator of what people-centered, rights-based, inclusive, and equitable development seeks to achieve”. Health is important as an end in itself and as an integral part of human well-being, which includes material, psychological, social, cultural, educational, work, environmental, political, and security dimensions. These dimensions of well-being are interrelated and interdependent.

There are hits and misses discussed in the GTCHR. On the plus side, the health sector has been key in the development success of the MDG era; the health MDGs have raised the issue of global health to the highest political level, mobilized civil society, increased development assistance for health, and contributed to considerable improvements in health outcomes in low- and middle-income countries.

On the downside, the MDGs do not fully address the broader concept of development enshrined in the Millennium Declaration, which includes human rights, equity, democracy, and governance. They have in fact contributed to fragmented approaches between the different health MDGs; between the health MDGs and other MDGs, such as gender equality; and between the MDGs and priorities omitted from the MDG agenda. A further shortcoming of the MDGs is that their focus on specific health outcomes has overshadowed the root causes of poor health and health inequity. While they did place strong emphasis on poverty reduction, other structural factors that impact health have been neglected. According to the GTCHR, these include

  1. absence of punitive legal environments
  2. inadequate social protection measures
  3. insufficient investment in health
  4. gender inequality
  5. social injustice
  6. stigmatization and discrimination of marginalized groups
  7. unfavorable terms for trade and international debt.

Olivier de Schutter, UN Special Rapporteur on the Right to Food, opined that one important shortcoming in the formulation of MDG1 was that it was largely gender-blind and that gender considerations had been only partially mainstreamed throughout the eight MDGs [5]. Moreover, the original MDG framework did not contain indicators on SRHR. It took five years of advocacy to get “Universal Access to Reproductive Health” included as MDG 5b: universal access to reproductive health: which is essential for the reduction of maternal mortality is seriously undermined by the large unmet need for family planning, especially in Sub Saharan Africa, where one in four married women and countless adolescents do not have access to contraceptives [6].

While progress on some sexual and reproductive health (SRH) indicators can be seen from 2000, for example, reduced maternal deaths in all sub-regions, the SRHR agenda remains largely unachieved. Universal access to SRH services has been defined by WHO as follows [7]

“The equal ability of all persons according to their need to receive appropriate information, screening, treatment and care in a timely manner, across the reproductive life course, that will ensure their capacity, regardless of age, sex, social class, place of living or ethnicity to:

  • decide freely whether and when to have children and how many children to have and to delay and prevent pregnancy
  • conceive, deliver safely, and raise healthy children and manage problems of infertility
  • prevent, treat and manage major reproductive tract infections and sexually transmitted infections including HIV/AIDS, and other reproductive tract morbidities such as cancer
  • enjoy a healthy, safe and satisfying sexual relationship which contributes to the enhancement of life and personal relations

Current national aggregate data on key SRHR indicators reported for MDG purposes hides disparities within countries. This is validated by available national demographic and health surveys. The Asian - Pacific Resource & Research Centre for Women (ARROW) ICPD + 15 monitoring study in 12 Asian countries in 2009 concluded that no one country had made progress on every single indicator of reproductive health and reproductive rights [4]. This remained true in 2013 as indicated in ARROW’s monitoring report on the status of SRHR in 21 countries in the Asia - Pacific region [8]. The same 2013 report concluded that in spite of some progress in the recognition of universal health rights in South East Asia, universal access to SRH services was generally difficult to achieve. This was true even in countries where there were efforts to promote universal health coverage with barriers in both the supply and demand sides, including cultural factors and gender power relations. Its findings coincided with those of the GTCHR in that socio - economic inequalities played a determining role in access to contraception, maternal health services and other SRH services.

In light of the achievements and shortcomings of the MDGs thus far, the debate on what should go into the post - 2015 agenda rages on. The GTCHR made several recommendations, including

  1. further reducing child and maternal deaths
  2. controlling HIV
  3. advancing SRHR, with a particular focus on youth.

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Post – ICPD Developments

 

Critical to the assertion of SRHR is the International Conference on Population and Development (ICPD, Cairo, 1994), which came up with a Program of Action (PoA) stipulating several objectives and actions related to SRHR. In 2010, the UN General Assembly mandated a comprehensive review of progress towards meeting the Cairo commitments. The year 2014 was the target year for reviewing the commitments stipulated in the ICPD PoA. So this is a crucial time to address the gaps in the assertion of SRHR.

ARROW has consistently monitored the ICPD PoA for the Global South since 1994 with a focus on the Asia-Pacific region. In its latest review of 21 countries in the Asia-Pacific region, key findings are reported against a set of indicators. The review found that the difference between wanted fertility rates (WFR) and total fertility rates (TFR) were highest in Nepal, India, Bangladesh and Kiribati where women were having more children than they desired to have. Secondly, women continued to shoulder the burden of contraception while male involvement, as equal partners in decision-making on reproduction, as stipulated in the ICPD PoA, was limited at best in all 21 countries over the past 15 years. Unmet needs for contraception were highest in South Asia (15.6%), followed by South East Asia (13.4%).

Thirdly, adolescent births continued to be a challenge in the region, except for East Asia. In South Asia, early marriage, early childbearing and insufficient access to health services are the main causes of relatively high mortality among adolescent and young women. Fourthly, unsafe abortions remained a major contributing factor in the occurrence of maternal deaths in the region.

Mortality due to unsafe abortions for South East Asia and South Asia was estimated at 14 percent and 13 percent of all maternal deaths, respectively. About 2.3 million women in the region were hospitalized annually for treatment of complications from unsafe abortions. While the number of women dying of pregnancy and childbirth - related complications was nearly halved (47%) from 543,000 in 1990 to 287,000 in 2010, it should be noted that South Asia had the largest number of maternal deaths outside of Sub-Saharan Africa. Only 8 of the 16 countries studied had 80 percent or more deliveries with skilled birth attendance and in eight countries; more than 50 percent of the women delivered with no skilled help. The highest incidence of cervical cancer was in

  1. India
  2. China
  3. Bangladesh
  4. Indonesia
  5. Pakistan.

Cervical cancer was found to be the most frequent cancer among women in Bhutan, Cambodia, India, Lao PDR, Nepal, and Papua New Guinea. Governments in the region were seen to be not at all able to adequately provide the necessary screening, preventive measures, treatment, and care services for reproductive cancers.

As for HIV and AIDS, women (15+) living with HIV constituted the highest percentages in the Oceania region (56%), followed by South Asia (37%) and East Asia (28%). HIV-related stigma and discrimination remained constant barriers to universal access to HIV prevention treatment, care and support in the region. Lastly, in terms of laws to protect the bodily integrity and autonomy of women, all except three of 21 countries in the region had laws against rape, and in most cases, considered it as a crime. Provisions on anti-sexual harassment in the workplace existed in 11 countries. It should be noted, however, that the existence of a law is no guarantee of implementation or any redressal mechanism.

Persons of diverse sexualities and gender identities and expressions still face stigma and discrimination with respect to SRH services. Half of the world’s youth reside in the Asia-Pacific region, but there are few if any “youth - friendly health services” that assure confidentiality and which are non-judgmental and non-discriminatory to help young people make informed choices. The monitoring study found that government uptake of ICPD guidelines in the region had been inconsistent; a shortcoming which must be rectified in the post - 2015 agenda.

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Non - Realization of SRR – Understanding Causes

 

The non-realization and violation of SRR, just like with other basic human rights, is largely rooted in the drivers of poverty. Poverty is caused by complex social, economic and political factors, and it should be measured using the Multidimensional Poverty Index (MPI), which includes aspects of:

  1. health,
  2. education
  3. living standards

As per the 2013 Human Development Report, 1.56 billion people (in the 104 countries covered) live in “multi-dimensional poverty” while the 2013 MDG progress report for Asia and the Pacific states that over 740 million people in the region live in “abject poverty” [9]. The MPI measure of poverty shows that women and marginalized sectors represent the majority of the poor [UN Economic and Social Commission for Asia and the Pacific [10].

Poverty is the cause as well as the consequence of poor health and well-being. The “poor are more likely to fall ill, but less able to find prompt and appropriate medical help, care and support to deal with their ill-health because of the systems put in place to deal with illness” [11]. Poverty compromises the potential of people to fully realize their SRR throughout their lives in many ways, such as:

  • inadequate food
  • under-nutrition
  • anemia
  • disease
  • low educational attainment
  • poor quality shelter
  • sexual abuse
  • intimate partner violence
  • poor access to SRH services.

As for food security, a poor individual is less likely to have access to adequate and nutritious food. The four pillars of food security are

  1. availability
  2. access
  3. utilization
  4. stability

This means that all people at all times must have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active healthy life [12]. The reality is that the actual number of people suffering from hunger and food insecurity has decreased only marginally since 1990. An estimated 870 million people presently suffer from hunger and chronic undernourishment, 563 million of whom live in Asia [13]. In terms of the original MDG target of halving the percentage of people suffering from hunger by 2015; progress has been very inconsistent across the different continents and within countries. The UN Special Rapporteur on the Right to Food, Olivier de Schutter declared in 2013 that the new global target set at the 1996 World Food Summit to halve the absolute number of hungry people by 2015 (rather than the percentage) is “today out of reach by far”. One in three people in the world suffer from malnutrition which is also called “hidden hunger”, and women and children from the low-income sectors of society in developing countries are the most adversely affected.

Malnutrition results in poor growth and development. For girls, this often results in complicated labour and having low birth-weight babies. Chronic under-nutrition can lead to infertility. It is estimated that half of all pregnant women worldwide suffer from iron deficiency anemia and this is made worse with repeated pregnancies, which deplete whatever little body reserves are available [14].

Postpartum hemorrhage is the commonest cause of maternal death in developing countries [15]. In general, poor nutrition and malnutrition affect sexual health through adverse effects like sexual dysfunction in men and women, tiredness, illness, lack of desire, and painful intercourse, among others [16]. Good nutrition is particularly critical to people living with HIV and AIDS who have to deal with a compromised immune system [17].

Realization of the sustainable development goals is closely connected with the realization of basic human rights based on the principles of equality and nondiscrimination. de Schutter cites the finding of the Global Thematic Consultation on Addressing Inequalities that situations of deprivation are often associated with discrimination based on factors such as:

  1. gender
  2. age
  3. caste
  4. race
  5. ethnic and indigenous identity
  6. minority status
  7. (dis)ability
  8. place of residence
  9. marital and family status
  10. HIV status
  11. sexual orientation.

Amongst the multiple forms of discrimination, gender-based discrimination was found to remain “the single most widespread driver of inequalities in today’s world” [18]. Women and girls are subject to discriminatory laws or social or cultural norms which come from certain stereotypes about gender roles, a major contributing factor in the feminization of poverty. Women make up about 70 percent of the worlds poor and the number of rural women living in poverty has doubled in the last 20 years [19].

Poor women generally have unequal access to land and other productive resources, and to educational and economic opportunities, such as decent wage employment. They also have unequal bargaining power within the household and are burdened with gendered labour resulting in drudgery and time - poverty. Furthermore, they are usually marginalized from decision - making at all levels. Cross-country comparisons show that in all regions, women perform the bulk of unpaid work in what is referred to as the “care economy”: the minding and education of children, fetching water and fuel - wood for the household, purchasing and preparing the food, cleaning, or caring for the sick and the elderly, among others [20].

Data from demographic and health surveys for selected countries of the Asia - Pacific region have established that women from the lowest wealth quintile suffer a considerably poorer SRH status as compared to their better-off counterparts [21]. The former are more likely to live in poor quality shelters, work in unsafe and unhealthy conditions, and suffer violence at the hands of intimate partners and others, causing them poor health, injury, disease, and even death. For example, in the places where poor women live, there is lack of good sanitation facilities, making it difficult for the management of menstruation, often resulting in urinary tract and reproductive tract infections. The lack of clean water also affects the use of barrier methods of contraception such as female condoms and diaphragms.

Uneducated poor women, especially those living in remote places, have been found to have less access to modern contraception and other SRH services. The burden of contraception still lies heavily on women and poor women are more likely to experience unwanted and multiple pregnancies. This, in turn, leads them to seek unsafe abortions, which in many cases results in their death or lifelong disability. The incidence of these is especially high among unmarried adolescents [22]. Early and child marriages, a platform for the erosion of SRR of girls and women, are another consequence of poverty [23]. Poor families, especially in South Asia, marry their daughters off at an early age because they are seen as a financial burden. Early and child marriages feed the vicious cycle of persistent poverty. Such marriages and the resultant adolescent pregnancies deprive young girls of education and employment opportunities, leaving them in poor bargaining positions and excluding them from critical decision-making. They rob them of their childhood, impose on them the burden of household responsibilities at a tender age, and expose them to the risk of marital violence, with little or no power to negotiate on sexual and reproductive matters. These conditions increase their chances of a risky pregnancy and childbirth and with these, infant and maternal morbidity and mortality. In agriculture, where women farmers and farm workers form a large part of the informal and thereby, ‘invisible’ sector, women are particularly vulnerable to oppression and abuse. In particular, women are more susceptible to the effect of hazardous chemical pesticides. Women may absorb pesticides through the skin more readily than men and they have a higher proportion of body fat which becomes a reservoir for fat-loving pesticides [24]. Exposure to pesticides increases the risks of miscarriages, infertility, cancers, and bearing children with deformities [25]. Taking just one case in point, a number of studies have linked breast cancer in women with their exposure to pesticides.

The state of affairs where the rich grow richer and the poor grow poorer is largely due to the dominant economic system that runs the modern world, which perpetuates hunger, poverty and inequity. For instance, in agriculture, the agrochemical and seed industry has driven the current toxic model of food production, which has resulted in widespread pesticide poisonings, farmer impoverishment and environmental damage, among other things.

Another example is the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), which has increased the cost of drugs creating further financial barriers to access healthcare. Women have been more negatively impacted by trade liberalization than men. On average, women are reported to incur higher pocket expenditure than men; it’s because of their greater need for healthcare related problems like reproduction and chronic diseases. Women spending money for gynecological problems are costs more than a household’s average monthly income for people living in below the poverty line.

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 Results and Discussion

 

From the foregoing discussions, critical considerations for the post-2015 agenda become clear. On 2nd June 2014, the Open Working Group (OWG) on Sustainable Development Goals (SDGs) released a zero draft of the first list of proposed sustainable development goals to be attained by 2030. The non-negotiable for sustainable and equitable development must be equality and non-discrimination which encompass the protection of women’s rights and women’s empowerment. Within these, SRHR must be articulated, recognized and asserted.

SRR violations not only affect individuals, but the well-being of their families and communities as well. The suppression and violations of these rights have intergenerational consequences on health, perpetuate poverty, keep the victims from participating fully in public life, and prevent them from making informed SRH decisions [26].

Any attempt to make progress towards universal access to SRH services will have to take into account the social determinants of health: poverty, hunger and malnutrition, social and economic inequities, unemployment, poor living and working conditions, and the disadvantages that women face as a result of ingrained gender-power inequalities [27].

Another cross - cutting issue that needs to be addressed in such an objective is the fragmentation of the ICPD’s comprehensive SRH agenda into narrow silos of “maternal health”, “HIV and AIDS”, and other “sexual and reproductive health needs”, which have so far received far too feeble investment or political commitment. As long as this fragmentation continues, there can be little hope of achieving universal access to SRH services and with that, little hope of effectively achieving well-being for all. There is a need not only to revive the ICPD agenda, but to expand it to include the needs of population groups which have been overlooked and neglected within this agenda, such as:

  1. people of diverse sexualities
  2. those with disabilities and the aged.

Universal access to healthcare services, which invariably include SRH services, would bring many benefits. For one thing, a healthier population would, in the long run, reduce public expenditure on health and loss of work days due to sickness. Greater population well-being will contribute to higher productivity, economic growth, and poverty reduction. Universal access to SRH services will help reduce:

  1. unwanted pregnancies
  2. maternal deaths
  3. sexually transmitted infections and diseases.
Path Forward

 

The way forward requires political will and public commitment to stopping the present cycle of impoverishment, inequity and rights violations along with ineffectual strategies that have failed to stem these. Several considerations and recommendations for policymakers and civil society organizations in asserting and advancing the SRR of each and every human being are discussed below. These incorporate some of the key calls by the UN Special Rapporteur on the Right to Food in his paper on Advancing Women’s Rights in Post - 2015 Development Agenda and Goals on Food and Nutrition Security. There are many issues raised by civil society in response to the new SDGs in the zero draft. Some of these concerns and recommendations, along with those put forward by the Post - 2015 Women’s Coalition in its “Feminist Response and Recommendations (to the) Proposed Goals and Targets on Sustainable Development for the post-2015 Development Agenda”, are also included in the recommendations strategic measures put forth below:

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For policy - makers

 

11.1.1 Addressing hunger and poverty: Any poverty goal must uphold our moral obligation to ensure every human being an existence of dignity. In particular, they must address the feminization of poverty. Poverty eradication strategies must tackle the intersecting and structural drivers of inequities and the various forms of discrimination based on:

  • gender
  • age, class
  • caste
  • race
  • ethnicity
  • sexual orientation
  • gender identity
  • geographical location
  • disability.

As SRR are embedded in the human rights agenda, eradicating hunger and poverty is key to the advancement of such rights. For one thing, small-scale agro-ecology is a proven pathway for reducing poverty and hunger (including hidden hunger) in poor countries. This was one of the key findings of the International Assessment of Agricultural Knowledge, Science and Technology for Development (IAASTD) in 2008 on the state of food and agriculture in the world. The report further declared that “business as usual is not an option” referring to the current corporate toxic model of agriculture which began with the Green Revolution in the 1960s.

The validation of agro-ecology was reiterated in a report written in 2012 by the Overseas Development Institute (ODI) under the commission of the Hunger Alliance [28]. The report’s core recommendations for smallholder agriculture to have a stronger impact on nutrition were to:

  • empower women farmers
  • promote home gardens and small-scale livestock and fish rearing
  • complement agricultural programs with education and nutrition communication, health services, clean water and sanitation.

In order to make these recommendations work, the report made four main calls to policy-makers (excerpted below):

  • (a) Encourage smallholder agricultural development by making sure that the rural investment climate is conducive to investment and innovation. (b) Provide rural public goods, roads and other physical infrastructure. (c) Improve access to inputs, insurance and finance for smallholders. (d) Develop and promote innovations for marginal farms. (e) Recognize and protect the rights of small farmers to their land.
  • Patterns of agricultural development need to be steered towards more diversified food production: (a) Promote home gardens, with small-scale livestock and fish rearing. (b) Complement this with communication on nutrition, health and child care.
  • Back up smallholder agricultural programs with primary healthcare, clean water and sanitation, other direct interventions for nutrition, and female empowerment: (a) Address female disadvantages in farming through recognizing and strengthening women’s rights to fields and common property resources; directing attention to women’s needs in farming and finding ways to support them; and in general, developing innovations both on field and in domestic tasks, such as water supply and fuel collection, that are appropriate for women and will save them time. (b) Make sure that girls living in rural areas are educated right through to the completion of secondary school.
  • (a) Provide greater political support for improving food security and nutrition. (b) Regular national surveys of nutrition and food security should be conducted, at least once every five years, preferably every three years.

All of the above must be grounded on the principles of food sovereignty which encompass the people’s rights to decide what to grow and how to grow it; to a safe environment; to access to land, seeds and other productive resources; and to gender justice. In particular, access to productive resources must cover not just access, but also ensure ownership and fair distribution of such resources. All these rights should be legally enforced and protected in a non-discriminatory manner.

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Women’s empowerment

 

Women empowerment is more than just enabling girls and women to go to schools and universities, to get jobs or run for public office; it is about confronting and dismantling existing inequitable power structures. Enhancing the leadership and participation of women in rural institutions is crucial in the empowerment process. Women must be given a far greater role in decision-making from household and community to governmental level.

Removing the obstacles for women and girls, and empowering them is fundamental to the eradication of hunger. One cannot conclude that power has shifted in any meaningful way until we can provide equal opportunity, equal access, equal power and equal citizenship to women [29]. This requires reforming discriminatory legal provisions as well as challenging the gendered division of roles that the social and cultural norms impose on them. Discussed below are elements deemed as critical in freeing women from the social, economic, cultural and psychological bondages that keep them downtrodden and which will enable them to realize their rights including their SRR.

Access to education and employment: Access to education and employment can enable women to earn adequate incomes and this is essential in ensuring their independence and well-being. However, access to education in itself, will not ensure access to employment for women unless it is accompanied by efforts to break down gender stereotypes in terms of the types of employment that can be performed by women, as well as the roles of women and men in carrying out family responsibilities.

The gender divide in educational enrolment and completion has to be first acknowledged and addressed, such as ensuring gender-sensitive and non-discriminatory learning environments. Against this backdrop, better comprehensive education for girls and women, including sexuality education, can and will result in more economic opportunities for the latter on and off farm leading to greater economic independence and a stronger bargaining position within households and communities. This will lead to improved nutrition and welfare of households. Such provision of education will also contribute to:

  • better self-esteem
  • rights assertion
  • informed decision-making on sexuality-related issues
  • Self-protection against harassment and violence.

In addition, States must ensure that women get fair and equitable employment terms such as equal compensation and opportunities, reasonable work hours in formal and non-formal workplaces, hygienic and safe work environments for women workers, supportive legislation for pregnant women and working mothers, and workplace protection from sexual harassment and abuse. For men and women workers, their families and communities, healthy workplace initiatives that take into account sex and gender differences can lead to better health and well-being. They can also lead to empowerment through the equitable and meaningful participation of workers in programs that encourage communication and action and foster support [30].

Right to nutrition: The brain development of children and their physical size have been found to depend on the quality of their nutrition during their first 1,000 days of life. The effects of malnutrition are inter-generational; a girl malnourished as an infant will in all likelihood have a baby with a low birth weight. This underscores why adequate nutrition for pregnant and lactating women must be treated as a priority in all food and nutrition security programs. It has been long established that breastfeeding, especially in the first two years of a baby’s life, is the best way to feed infants. Governments should ensure that information about the benefits of breastfeeding is widely disseminated and that employment practices enable working women to continue breastfeeding after resuming work.

Women and girls comprise an estimated 60 percent of the world’s undernourished [31]. To turn this figure around, improved diets need to be ensured along with universal access to education (including comprehensive sexuality education), health services (including sexual and reproductive health), water and sanitation.

Relief from drudgery and time poverty: Time poverty is one of the major obstacles to women’s empowerment and their access to education and employment. It has been estimated that reducing the time spent by the women in the Indian State of Gujarat to fetch water by just one hour a day would allow them to increase their incomes by 100 USD per year. In developing countries and especially in rural communities, women are underserved by public services [32]. Governments should provide public services in a way that recognizes the importance of relieving women and girls from mindless drudgery and time poverty. These include the establishment and/or expansion of childcare services and public transportation systems and the improvement of access to cleaner energy sources for household needs.

Food sovereignty and gender justice for women in agriculture: It is difficult for women to be economically independent and achieve food sovereignty when, in many countries, they have little rights to property ownership. For rural women to thrive as food producers, gender-sensitive agricultural policies are required. These should abide by the FAO Voluntary Guidelines for the progressive realization of the right to adequate food in the context of national food security (Guideline 8.6) through women’s full and equal participation in the economy and the right of women to inherit and possess land and other property, and their access to productive resources, including credit, land, water and appropriate technologies. Priority should be given to gender-responsive taxation and subsidies that support the infrastructure needed to enable women to:

  • engage in sustainable production
  • transport their produce
  • access warehousing and other storage facilities
  • receive a fair price for their products.
Equality and non - discrimination

 

The population-weighted mean Gini coefficient (a common measure of inequality) for the Asia - Pacific region rose from 33.5 to 37.5 from the 1990s to 2013. World leaders have agreed that new development goals and targets must be rooted in upholding universal human rights, including women’s rights, and the principles of equality and non-discrimination.

The Global Thematic Consultation on Health Report (GTCHR) makes special mention of the rights and inclusion of marginalized, disadvantaged, and stigmatized groups. These are generally:

  • people with disabilities
  • migrants
  • ethnic minorities
  • sex workers
  • people using drugs
  • transgender and homosexual people
  • poor female youth.

Many of above named people belong to key HIV affected population groups. The GTCHR categorically states that further progress in improving health and wellbeing can only be made by reducing inequities (especially gender inequalities), all forms of discrimination and human rights violations.

Policy-makers should, thus, institute the collection of data which will capture situations of discrimination and marginalization and other causes of lack of access to basic rights and services. Furthermore, the post - 2015 development agenda must create an “enabling environment for transformative social schemes that break the cycle of discrimination and fight hunger by empowering women”. States must dare to go beyond piecemeal actions and act to holistically and systematically pursue transformative food security strategies which challenge and change cultural constraints and redistribute roles equitably between women and men. In particular, SRH programs need to be based on a human rights framework, including the right to be free from discrimination, coercion and violence as well on the principles of bodily integrity, dignity, equality and respect for diversity as part of affirmative sexuality.

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Education

 

Education is a fundamental component in achieving equity and equality. Efforts to improve access to education must prioritize and address the difficulties faced by marginalized groups in enrolling and completing education.Furthermore, education should be provided through the human rights perspective and promote principles like gender equality, non-discrimination, tolerance, and non-violence. This aspect remains largely absent in the current education agenda which typically focuses on indicators like school completion and literacy rates. Another important component of education which has also been on the back-burner is universal access to evidence-based, comprehensive sexuality education that is “high quality; non-judgmental; incorporates elements of human rights, tolerance, gender equality, and non-violence; and is available in various formal, informal, and non-formal settings”. Comprehensive sexuality education is the best way to achieve universal access to SRHR in the future by providing the youth with life-saving information and skills and enabling them to apply the concepts of human rights and non-discrimination in their decisions and interactions in building a better world.

 

State Accountability

 

Governments are accountable to uphold the United Nations Universal Declaration of Human Rights (UDHR) of 1948. These rights are interrelated, interdependent and indivisible. SRHR were enshrined in the International Conference on Population and Development (ICPD) and its Program of Action (PoA). States party to this are also bound to abide by it.

In view of the fact that food and nutrition security cannot be accomplished in isolation from addressing inequality and discrimination, strong accountability mechanisms must be a part of the post-2015 development framework. This will ensure the monitoring of the situation of women and other disadvantaged groups so as to determine whether development approaches are truly being empowering, enabling and equitable.

Learning from the experience of the MDGs, the post - 2015 agenda must pay due attention to rectifying inequality and discrimination in all its forms, bearing in mind that gender inequality and gender-based discrimination are the main obstacles to inclusive and sustainable development. The post - 2015 framework should not allow the usual targets to overshadow or omit the rights of women and other marginalized groups. New goals and targets must, therefore, be designed to progressively eliminate disparities between the most marginalized sectors and the general population as well as between countries and regions.

In terms of the new SDGs, the Post 2015 - Women’s Coalition calls for “political action…to overturn current discriminatory, oppressive and violent social, political, and economic systems and develop, invest in, and implement those that create an enabling environment for women’s rights, equality, and sustainable peace”. It further states that “goals and targets should reflect international human rights standards and include reference to the rule of law through the principles of non-retrogression, progressive realization, and common but differentiated responsibilities”.

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Universal access to high quality SRH services

 

Universal access to high-quality sexual and reproductive health (SRH) services faces two formidable barriers. The first is legislative restrictions that restrict the access of adolescents and young people to SRH services, and the second is health system blindness to gender-power inequalities in society. The GTCHR made the following recommendations:

  • include specific health-related targets as part of other development sector goals
  • take a holistic, life-course approach to people’s health with an emphasis on health promotion and disease prevention
  • accelerate progress where MDG targets have not been achieved and set more ambitious targets for the period to come
  • address the growing burden of non-communicable diseases (NCDs), mental illness, and other emerging health challenges.

In addition, the report called for efforts to accelerate progress on the MDG health agenda. These should build on national and global efforts that have already resulted in significant progress in reducing child and maternal deaths and controlling HIV, tuberculosis, malaria, and neglected tropical diseases. It says: “The new agenda should be even more ambitious, and reaffirm the targets of ongoing initiatives such as: ending preventable maternal and child deaths; eliminating chronic malnutrition and malaria; providing universal access to sexual and reproductive health services, including family planning; increasing immunization coverage; and realizing the vision of an AIDS- and tuberculosis-free generation.”

In particular, the report emphasized that SRHR must be addressed. It stressed that young people required special attention, including comprehensive sexuality education as well as protection from sexual violence and abuse. Universal access to SRH services needs to be seen within the context and the larger goal of universal access to healthcare. Narrow approaches that focus on one specific area in isolation such as reproductive health or HIV and AIDS can result in inefficient investment of resources in weak healthcare systems that fail to meet their goals. There are various ways to strengthen healthcare systems, some of which are listed below:

  • Reduce the proportion of health expenditure from out of pocket payment and increase the proportion of government spending on SRH services.
  • Implement a system of tax revenue based funding aimed at universal rather than targeted coverage with adequate financial protection for a reasonably wide range of SRH services.
  • Invest substantially in increasing the availability and improving the distribution of SRH services across rural/urban locations within the country.
  • Consult communities about appropriate and acceptable healthcare and services. In many instances, this can resolve cultural and social barriers to access.
  • Address gender based inequalities which deter access to healthcare services through greater health system responsiveness.

For the new SDGs, “universal healthcare for all” should include “women, adolescents and young people, those with diverse sexual orientation and gender identities and other marginalized groups”. Moreover, this should be a time bound target, i.e, by 2030, universal access to quality information, education, services and care at all stages of the human lifecycle, across all levels of healthcare, locations (home, community and health facilities) and times (including conflicts, disasters, migration and displacement) should be achieved.

 

For Civil Society

 

Many civil society groups (CSOs) have emphasized the need for the new SDGs to ensure continued, sustained investments in women’s SRHR by governments and donors in fulfilling their official development assistance (ODA) commitments and reallocations towards the poorest and most vulnerable countries. There are many groups petitioning for the advancement of SRHR along with other human rights. One important platform is the Post - 2015 Women’s Coalition, and its “Feminist Response and Recommendations (to the) Proposed Goals and Targets on Sustainable Development for the Post - 2015 Development Agenda”. Some of their concerns and calls have been incorporated into the recommendations discussed above.

Another recognized collective platform of CSOs is the ASEAN Civil Society Conference/ASEAN Peoples’ Forum (ACSC/APF). In a session on “Building Cross-movement Alliances for Food Sovereignty, Ending Poverty and SRHR in the ASEAN” held in March 2014 in Yangon, Myanmar, the following calls to governments were raised:

  • Given the status of uneven progress on SRHR in the ASEAN, governments must show political commitment and provide sustained financial investments to ensure SRHR for all, including women, young people, people of diverse sexual orientation, gender identities, and gender expression, people with disabilities, migrants, displaced peoples, sex workers, indigenous peoples, and other marginalized groups. These include reviewing, amending and implementing laws and policies to uphold human rights (including sexual and reproductive rights), and ensuring universal access to comprehensive, affordable, quality, gender-sensitive health services at all stages and across all locations, to achieve the highest standard of sexual and reproductive health. Services include:
    • contraception
    • safe abortion services
    • services to ensure maternal health and nutrition
    • diagnostic and treatment services for STIs, HIV and AIDS, infertility and reproductive cancers
    • counseling
    • comprehensive sexuality education.
  • Ensure the right to and access to adequate, culturally appropriate, nutritious and safe food for all. Pursue a common policy of food sovereignty, and increase investment in rural infrastructure, technology, research, education for small-scale farmers, including women. Review and withdraw unjust free trade agreements; put a stop to land grabbing; provide equitable access to and control of water and land; promote sustainable agricultural practices; regulate investments in agriculture; and implement a truly just land reform and administration program to secure land rights and tenure of peasants, fishers and indigenous peoples. Develop cooperation among agriculture producers in the region and consumers; pursue sustainable agriculture to address resource degradation arising from monocropping and the impacts of climate change.
  • Support development of intersectional analyses and research on food sovereignty, poverty and SRHR. Ensure meaningful engagement of civil society in shaping the future of ASEAN, and create platforms for cross-movement alliance building.

 

Need for Multi - Sectoral Alliance and Collaboration

 

Because SRHR is such a cross-cutting issue, there is a need to bridge the divide across movements through strong alliances. The dangers of addressing global challenges in silos have been elucidated above. Twenty years after governments committed to the ICPD POA and 19 years after they agreed to the MDGs, we find that many countries still fall short of achieving most of the critical development goals. It is time for a new agenda for action towards achieving universal access to SRH services, one that strikes at the root causes of poverty, inequity, hunger, and disease. Therefore movements advocating for SRHR, poverty eradication, food sovereignty, the right to adequate food and nutrition, and other human rights need to forge alliances to counter the powers that promote “corporate-based solutions”. One such platform is the Post-2015 Women’s Coalition. Another collective platform of CSOs is the ASEAN Civil Society Conference/ASEAN Peoples’ Forum (ACSC/APF). It works on issues such as sustainable peace, development, justice and democratization which affect the people in ASEAN countries.

Another platform for cross-movement alliances is the Global Network for the Right to Food and Nutrition. This is an initiative that mobilizes CSOs and international social movements, including peasants, fisher folk, pastoralists, indigenous peoples, and food and agricultural workers to hold states accountable for their obligation to realize the right to food and nutrition. It recognizes the invisible structural violence perpetrated by states and corporations that impedes the realization of women’s and girls’ rights.

The ICPD+20 and MDGs + 15 review processes provide opportunities to revitalize and strengthen the SRHR agenda. It is time to integrally link the SRHR agenda with other socio-political development agendas and work together across social movements to achieve the collective goals of poverty reduction, food sovereignty, and SRHR for all. CSOs would be wise to adopt a broad-based and integrative approach wherever possible in terms of rights advocacy so that solutions will be holistic and successes, multi-tiered. After all, in so many ways, we are all serving the same cause and the same people: the poor, marginalized, oppressed and disadvantaged.

Our wins and losses are intertwined. A better understanding of the complex linkages of the various issues we face today is needed to ensure that the new development agenda is able to adequately address the challenges and the gaps. Towards this end, ARROW launched a multi-year project in June 2012 on “Revitalizing and Strengthening the SRHR Agenda through Inter-Movement Work to Impact the ICPD + 20 and the MDG+15 Processes”.

Achieving social justice for all requires addressing issues of poverty, hunger, landlessness, gender inequality, their root causes, and SRHR, together. Rights to adequate food and nutrition are intrinsically linked to all other human rights, including the rights to:

  • water
  • housing
  • education
  • property
  • decent work
  • livelihood
  • social security
  • social welfare.

Only if individuals are able to enjoy good health and well-being, will they be able to participate effectively in all domains of the society: economically, socially, politically and culturally. Similarly, the rights to adequate food and nutrition cannot be separated from women’s self-determination, autonomy and bodily rights, and the right to health. There is need for ensuring the right to adequate, culturally appropriate and safe food and nutrition for all while giving specific attention to specific groups of women such as the pregnant, the lactating, and those living with HIV and AIDS, who have specific food needs. Further, there is urgency of the implementation of existing instruments and agreements on human rights; the repeal of laws and policies that criminalize and marginalize specific groups in society; monetary, financial and trade reforms; and the creation and implementation of strict, gender-sensitive, and anti-corruption policies. There is urgency for investing in public goods such as agriculture, health (including SRHR), and education which will benefit all especially the poor and marginalized.

Collective platforms/programs like those mentioned above are important and effective avenues to put forward the voice of the people and the calls of civil society. They need to be given due recognition and legitimacy in international arenas to ensure the exercise of democracy, equity, justice, transparency, participation and accountability.

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 Summary

 

Sexuality and reproduction lie at the heart of what it is to be human and alive. Not recognizing this represents a serious failure on the part of society and governing institutions to understand and respect the whole person beyond just the physical. SRR are intrinsic human rights. They encompass respect for bodily integrity, the right to choose one’s partner and the right to decide on sexual relations and having children, among other things. Sexuality is as much a part, if not more, of being fully human and fully alive as needing food and water to live. Gender advocates have battled for years for women’s rights, citing how crucial women are to feeding the world while human rights activists, including those calling for SRHR to be recognized, have put forward compelling arguments, with evidence, to show that upholding these rights is fundamental to the goals of sustainable development, social justice and peace. It is not that the decision-makers do not know what is right; it is simply that they have chosen otherwise and the poor continue to pay the price for this as well as the environment. It is a well-known fact that the current climate crisis is largely due to human activity, mainly, industrialization, modern (corporate) agricultural practices and deforestation. Why do we need to justify the importance and relevance of SRHR as if they were somehow less crucial to the whole objective of creating a better world for all? Are we only comfortable about talking about food and jobs as if these were all a human being needed to be fulfilled or happy? Does talking about sexuality make us uncomfortable? If so, then let us be embarrassed about being human, being passionate, enjoying sensations and feelings, falling in love, getting married, having children, and the very celebration of life. Everyone, yes, even the poor, have a right to all of these. To sum up, to say that it is high time that SRHR took their rightful place in the human rights equation is actually an understatement. It is long overdue and the poor have already suffered, and continue to suffer, for this unconscionable delay. If we are truly serious about sustainable development, peace and justice for all, sexual and reproductive health and rights have to be an integral part of all discourse and planning for a better world.

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Copyright: © 2016 Santhosh Kumar. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.