Sexual and reproductive health for all: what does it take?

“Development partners must share power”

– Amy Jackson, Options’ Technical Officer, Evidence for Action (E4A) – MamaYe

Over the past few decades, donors have often relied on the same funding modalities, implementing organisations, and approaches to improve the demand for, and access to, sexual and reproductive health services. This has only dragged populations left behind, further behind. To make sexual and reproductive health (SRH) a reality for these populations, we need to change direction and let those who are left behind lead the way.

Sexual Reproductive Health and Rights (SRHR) is an agenda that is pushed by donors and national governments but not by the communities most affected. Instead of providing funding to the same players, donors should focus on supporting small scale innovation through public and private sector partnerships to increase access to sexual and reproductive health for marginalised population groups. Development partners and national implementing partners must share power and funding with grassroots organisations and actively involve these communities to understand the unique barriers they face to accessing SRHR, and co-design interventions that are tailored to their unique needs. This will mean adopting innovative approaches such as human centred design; accepting that progress is incremental; and identifying new allies, including community leaders or traditional health practitioners.

“Increasing public funding for family planning is not enough”

– Lamine Thiam, Options’ Regional National Ownership Lead, Women’s Integrated Sexual Health Programme (WISH)

25 years after the vast majority of the world’s governments committed to making sexual and reproductive health and rights (SRHR) a reality for their citizens, the needs of many women and girls in Sub-Saharan Africa are still unmet, and government health spending remains critically low, at an average of just 0 to 5 %.

Governments must mobilise innovative financing – for example through private sector engagement – to reduce their overreliance on donor funding, so that the achievements of family planning programmes can be sustained. The governments of Burkina Faso and the Democratic Republic of Congo are taking steps in the right direction as they are set to host their first national conference and dialogue on family planning to mobilise domestic funding this year.

But increasing public funding for family planning is not enough to finally provide and protect girls’ and women’s universal access to SRHR. We need to form a broad coalition of the private sector, media, civil society, faith and community-based organisations, that advocates for governments to create an enabling domestic environment for legal reform – like in Chad, where the SRHR civil society organisation ‘Coalition Pour le Plaidoyer de la SR’ is calling on the Head of State to ratify an SRHR law (which was passed by the National Assembly seven years ago) – and implement task shifting policies that decentralise access to SRHR services at the community-level.

We also need to identify new national champions among religious and traditional leaders to help overcome the socio-cultural barriers that prevent girls and women from accessing SRHR services, especially in Muslim-dominated communities where family planning is a taboo.

Governments must also develop more comprehensive behaviour change communication that not only narrowly focuses on norms and predisposing (social-cultural barriers) factors, but also on reinforcing (peer pressure, including from religious and traditional leaders who are against SRHR) and enabling factors (availability, access, and quality of SRHR in primary health care facilities) that affect the uptake of services among girls and women.

Enabling factors are also linked to the smart integration of SRHR services into other maternal, new-born and child health services and to expanding access to community-based SRHR initiatives by allowing lower-level medical staff or trained non-medical agents to provide contraceptives, such as the contraceptive injection. This would lower discontinuation rates and unplanned pregnancies, and remove any financial and logistical burden to accessing SRHR services women may face.

“Identifying the right investment priorities is key”

– Leyla Hussein, Options’ Global Ambassador, The Girl Generation (TGG)

Governments need to make the girl child a priority and place her firmly at the top of their national development agenda. The fact that the conference explicitly lists ‘ending gender-based violence and harmful practices’ as one of its five themes shows that we’re talking girls’ needs, but we need outcomes. So, what comes after the conference and whether promises will be turned into actions is what matters. To do this, identifying the right investment priorities is key.

But even as we’re nearing 2020, 200 million girls in the world are subjected to female genital mutilation while more than 33,000 girls are forced into child marriage every day and face serious risks during childbirth. All of these harmful practices deny them the chance to pursue their own path in life. But first of all, the international development community needs to recognise that we cannot talk about improving women’s reproductive health if they continue to be unable to access critical information and services. To provide girls with a future and to enable them to be in charge of their life choices, governments must to invest in their education, (reproductive) health and basic needs so that a girl knows that she is powerful, has access to quality education and any job she desires and is not at risk of being physically or emotionally harmed.

However, to achieve real change for girls and women, donors and national governments also need to focus on creating economic opportunities more broadly for those left behind. As an FGM survivor, psychotherapist and activist, I have seen time and time again that if we want to stop putting girls at risk, we need to ensure that the basic needs of their families are met. When a girl’s parents have jobs and can afford to send her to school, they are more likely to take her on a different path in life than to marry her off because they have the resources to provide for her.

“We must commit to broadening young people’s reproductive health choices if we are serious about achieving SRHR for those left behind”

– Geoffrey Okumu, Options’ Sustainability Lead, Women’s Integrated Sexual Health Programme (WISH)

25 years ago, at the International Conference on Population Development (ICPD), the global community gathered in Cairo and committed to advancing individual rights and freedom by making their citizens’ reproductive choices a fundamental human right. Fast forward to 2013, when 20 countries from sub-Saharan Africa convened in Johannesburg and committed to implementing Comprehensive Sexuality Education (CSE) and Sexual Reproductive Health for adolescents and young people.

But despite these commitments, adolescent girls in sub-Saharan Africa continue to bear the greatest burden of HIV infections and experience the highest unmet need for family planning, which causes high teenage pregnancy rates. The policy environment in most of these countries has not improved enough to facilitate access to sexual and reproductive health services for young people, which has been further compounded by governments’ inadequate budgetary allocation towards sexual reproductive health, particularly to family planning.

The Nairobi Summit provides an opportunity to advocate for the sexual reproductive health of young people and their participation in the process. As they have risen to say ‘nothing for us without us’, we must commit to broadening their reproductive health choices if we are serious about achieving sexual and reproductive health and rights for those left behind.

“Unless the underlying issue of gender inequality is addressed, we risk spending the next 25 years skirting around the elephant in the room”

– Jessica Hopf, Options’ Senior Programme Manager, Supporting Access for Adolescents to Integrated Sexual and Reproductive Health Services (Safire) Programme

Sexual and reproductive health is not a standalone issue that can be resolved by providing contraceptives and medical interventions. Unless the underlying issues of gender inequality is addressed and girls and women finally have the right to take control and ownership over their own bodies and future, we risk spending the next 25 years skirting around the elephant in the room and making very little progress beyond the commitments that were made at conferences like ICPD.

If we really are to make sexual and reproductive health a reality for all, we need to first address the power dynamics around gender equality – starting at the global level where the issue is still not prioritised by the majority of world leaders – down to the community level where social norms and power structures are enforced on a day-to-day basis. At the country level, national governments must take ownership and share power by introducing gender ratios in their parliaments. This would also involve engaging community leaders and village elders to promote sexual and reproductive health and change social norms on gender that prevent girls and women from progressing.