International Development CommitteeWritten evidence submitted by the UK Network on Sexual and Reproductive Health and Rights

Background

1. The UK Network on Sexual and Reproductive Health and Rights (the Network) is a coalition of over 70 UK based agencies and individual experts. The Network exists to promote, protect and improve access to sexual and reproductive health and rights (SRHR) for all people, particularly women and young people, and those affected by conflict and disaster. The Network focuses on the implementation of the International Conference for Population and Development (ICPD) Programme of Action.

2. We welcome the opportunity to contribute to this inquiry on the post 2015 Development Goals. This submission has been developed by the Network’s Steering Committee, comprised of the International Community of Women Living with HIV/AIDS, Interact Worldwide, International HIV/AIDS Alliance, International Planned Parenthood Federation, the Commonwealth Medical Trust, Institute of Development Studies, Marie Stopes International, Population and Sustainability Network, and Women and Children First. Given the mandate of the Network this submission focuses specifically on issues of SRHR, building on the broader inputs of the Beyond 2015 Campaign of which many Network members are involved.

3. Our overall recommendation is that any new global framework should include explicit reference to sexual and reproductive health and rights. Current global architecture has not delivered well for women and any new framework should galvanise leadership, resources and attention to meet the specific needs of women, particularly on reproductive health. We urge the International Development Select Committee to be bold in their recommendations and to push for a clear, accessible and accountable framework that will unite and deliver change for the next generation. For too long women have been let down by their governments and we need innovation, pragmatism and ambition in a framework that supports the principles of flexibility and country led ownership, and maximises the active contribution of civil society and the private sector.

Lessons Learnt From the Millennium Development Goals

It is clear why reproductive and maternal health is the most off-track of all the MDGs. The international community has failed to assist millions of women by ignoring the complexities of why many women in the world’s poorest countries die during pregnancy and childbirth each year. For too long we’ve been trying to tackle the issue with one hand tied behind our backs.
Rt Hon Andrew Mitchell MP, June 2010

4. The realisation that the Millennium Development Goals (MDGs) would not be reached without universal access to reproductive health led to the late addition of target 5B (achieving universal access to reproductive health) in 2007. However this target remains the most off-track.1 If prevailing trends persist the target will only be met in Eastern Asia by 2015 and not in Africa, Latin America and the Caribbean, the Caucasus, Central Asia or Southern, Western and South Eastern Asia. It is essential that any new framework does not make the same mistake and includes specific sexual and reproductive health targets from the outset.

5. Key issues of concern in achieving MDG 5B include:

Deep inequalities in access to services and awareness of rights between, and within countries.

Inadequate funding and priority given to family planning.

Progress in increasing and expanding access to contraceptives has slowed—use of contraception is lowest amongst poorer women.

Progress has stalled in reducing the number of teenage pregnancies. Poverty and lack of education perpetuate high adolescent birth rates. Although there has been some limited progress in reducing adolescent pregnancies among richer, urban and secondary educated adolescents, this has not been matched among poorer, rural, and less educated adolescents. As a result disparity has increased rather than decreased over time.2 Complications in pregnancy and childbirth are the leading cause of death amongst adolescent girls in the majority of developing countries.

Only one in three rural women in developing countries receives the recommended care during pregnancy.

6. The MDGs are not grounded in a rights based approach. They have failed to adequately address inequalities that are often masked by a focus on national aggregate targets. Poor women and couples receive less family planning and reproductive healthcare for a variety of reasons, including economic barriers, lack of knowledge and lack of access to services. In an unequal society, universal benefits and services can unintentionally discriminate. Many people from marginalised and discriminated groups are particularly affected by a lack of access to SRHR—for example young and older women, disabled women, Dalit women, women living with HIV, women migrants, minority and indigenous women and sex workers. The hostility that some pregnant HIV-positive women have experienced from doctors in relation to their pregnancies has been well-documented. Any new framework needs to focus on interventions that will have the greatest impact on improving the lives of the poorest and most marginalised people. To ensure this, goals and indicators need to be targeted to meeting the needs and rights of the most excluded and underserved.

7. A key principle of target 5B is one of universal access to rights and health care. However SRHR services are often forgotten or seen as irrelevant in humanitarian emergencies, leaving refugees, internally displaced people and other disaster affected groups without access. The need to control one’s own fertility does not diminish in emergencies. Indeed, maternal and neonatal mortality and levels of sexual violence are often higher in fragile states and emergency settings.

The Coverage of Future Goals

8. Traditional definitions and distinctions between developing and developed countries are increasingly problematic given the acute inequality within many countries, current economic crises and the context of emerging economies, such as Brazil, Russia, India, China and South Africa.

Progress in securing SRHR has been slow, patchy and in some places is reversing (eg Central America). Given the lack of progress in achieving universal access to SRHR in some middle income and even some higher income countries, and the importance of leaving no one behind, the Network recommends that any future framework should be global, covering all countries to ensure an overarching and comprehensive plan of action.

The process: are the right voices being heard? What are the opportunities for and constraints to global consensus?

9. We agree with the Beyond 2015 Campaign that the next global development framework should be the result of a process based on participatory dialogue with those directly affected by poverty, inequality and injustice. We strongly recommend that women’s organisations, NGOs and SRHR experts are fully consulted within these processes.

Targets: was the MDG “target-based” approach a success? Should it be retained? How should progress be measured?

10. Many targets are interrelated and can only be supported through cross sectoral action and a holistic approach. SRHR is integral to many aspects of development such as gender equality, environmental sustainability and economic growth, yet few actors include explicit reference to SRHR in strategies to meet MDG3 or MDG7. Any new framework needs to ensure a comprehensive, cross-sector approach to SRHR. Current goals and their corresponding targets do not focus or incentivise prioritising harder to reach groups. Higher number targets incentivise interventions with communities and citizens that are easiest to reach. Therefore poorer and more marginalised people can be excluded because of a lack of political will or resources to reach them.

The role of the private sector and other non-state organisations

11. The ICPD Programme of Action highlights the need for effective partnership between government and NGOs, recognising the strong role that NGOs play in both service delivery and advocacy. However in many countries, NGOs remain on the fringes of the public health system with limited opportunities for co-ordination with government services. In the UK, expert non-state service providers make a significant contribution to health care, not only providing a significant proportion of national health care services but innovation and advancement of medical techniques and practices. This contribution is enabled by government subsidies for the full integration of selected NGO service providers into the National Health Service. Any future framework should actively promote and support the integration of expert NGO and community-based service providers into public health systems to strengthen health systems.

Communities’ role in health systems should be acknowledged and valued. In addition to being an alternative channel for support, civil society should be recognised as a key avenue to reach people excluded or underserved by government services. In the implementation of any future framework the Network would support a greater role for civil society in demand creation, community mobilisation and training of health personnel. Use of umbrella networks to channel funds can offset the transaction costs of working with more stakeholders, whilst ensuring the involvement of smaller grassroots organisations.

The content of future goals: what would be a good set of global goals? What continuity should there be with the MDGs, and how should the unfulfilled MDGs be taken forward?

12. It is essential that discussions on any future framework do not detract or undermine momentum to achieve the existing MDGs. To ensure credibility of both the current and future framework it is vital that all existing goals are met. Any goals not met by 2015 should be given an extended deadline (eg 2020) with clear action plans and resources allocated to meet each target. These goals and targets should be brought together within the new framework to ensure continuity and priority to all unmet MDGs.

13. To ensure that any future framework realises and supports SRHR the Network recommends:

Explicit reference to universal access to SRHR.

Three specific themes/goals on 1) health, 2) women’s empowerment and 3) youth—all including reference to SRHR and the synergies across all goals.

Inclusion of explicit indicators with clear accompanying targets to achieve each. In practice, this could look like:

Goal	Indicator Theme
Health	—	Maternal mortality.
	—	Contraceptive prevalence rate (with sub-indicator on % of women who can access their first choice of contraceptive).
	—	Post abortion family planning.
	—	Number of unsafe abortions.
Women’s Empowerment	—	Unmet need for family planning disaggregated by location, age, poverty, education and caste.
	—	Level of gender based violence.
	—	Contraceptive method mix.
	—	Proportion of women who make decisions about their own health care.
	—	Proportion of women who have the final say (or joint say) of whether or not to use contraception.
Youth	—	Age of marriage.
	—	Age of first birth.
	—	Adolescent birth rate.
	—	Sex education on national curriculum.

A goal on health is essential and would benefit from a strong focus on preventative health care which is currently critically underfunded given its potential impact in ensuring healthy populations. This could include family planning, provision of anti-retrovirals, prevention of non-communicable diseases, bed nets for malaria prevention etc.

14. Addressing Maternal Mortality

Between 1990 and 2010, maternal mortality worldwide dropped by almost 50%, illustrating that the elimination of preventable maternal mortality is possible within the next decade. However more than 350,000 women still die annually from complications during pregnancy or childbirth, 99% of these deaths are in low income countries. Simple and low cost solutions to improving maternal and neonatal health are well known and any new framework should include clear targets to eliminate preventable maternal mortality.

15. Any framework must recognise the wide-ranging benefits of SRHR and its relevance to other sectors beyond its critical role in tackling maternal mortality. These benefits include:

Women’s empowerment—Family planning initiatives based on informed choice empower women and transform their social and economic position. A lack of access to reproductive services, information and choice undermine women’s educational and economic equality, their ability to provide for their children, their ability to participate in decision making processes and perpetuates violence and discrimination.

Economic benefits -Falling birth rates bring a widely proven long term “demographic dividend”—increasing the ratio of working adults to dependents, creating economic growth, and improving the health, education and welfare of citizens and their children.

Child health—Allowing women to plan their pregnancies leads to healthier outcomes for children. A recent study showed that if all births were spaced by at least two years, the number of deaths among children under five would decline by 13%, by 25% if there were a three year gap.

16. Youth

Half of the 7 billion people alive today are under 25. The unprecedented number of young people entering their reproductive years over the next 15 year period will result in a projected 40% rise in demand for family planning. The social and economic potential of this generation will not be realised unless they can choose their own future through accessing sexual and reproductive health services. Young people face specific barriers to accessing reproductive health including a lack of information, discrimination and social stigma, lack of confidentiality, and policy restrictions. Meeting the rising level of demand for comprehensive SRHR services among young people—and facilitating their meaningful engagement in the process—must be a priority for any new framework.

17. General Recommendations

The impact of population increase, urbanisation, climate change and economic crises were underestimated in the formulation and implementation of the MDGs. A future framework needs to be more flexible and responsive to future shocks and risks.

Any framework should be designed to:

Eliminate the root causes of poverty and inequality.

Promote opportunity and empowerment for women and girls.

Tackle inequality and discrimination to achieve inclusion and respect of diversity.

Promote, protect and respect rights—strengthening existing international conventions and human rights laws.

Suggested principles for implementation:

Results based—delivering measurable impact in reaching the poorest and underserved.

Holistic: addressing socio-economic and cultural barriers.

Backed by adequate resources and finance mechanisms.

Participatory, accountable and transparent—in development and delivery.

Country-owned and implemented in partnership between governments and non-state service providers, with the support of development partners.

October 2012