The FCDO’s approach to sexual and reproductive health

1 The FCDO’s work on sexual and reproductive health

1. Sexual and reproductive health (SRH) plays a vital component in several of the United Nation’s Sustainable Development Goals (SDGs).¹ SDG 3 aims to “ensure healthy lives and promote well-being for all at all ages” and includes commitments on reducing maternal mortality, ending preventable deaths of newborns and children under 5 years of age, ending the AIDS epidemic and ensuring “universal access to sexual and reproductive health-care services”.² SDG 5 aims to “achieve gender equality and empower all women and girls”³ and includes commitments to end harmful practices, such as female genital mutilation, and to “ensure universal access to sexual and reproductive health and reproductive rights”.⁴ The Committee has explored the FCDO’s work on SRH in the context of the SDGs, examining its strategy, commitments, and aid programming and spending.

UK aid spending on sexual and reproductive health

2. From 2020, the UK’s aid budget has faced numerous pressures, resulting in a reduction in the UK’s total Official Development Assistance (ODA). The FCDO’s own ODA spend dropped from £11,785 million in 2019 to £7,635 million in 2022.⁵ This reduction has had a substantial impact on the work of the FCDO on sexual and reproductive health. By 2021, the most recent estimates available, the FCDO had reduced its spending on Sexual and Reproductive Health and Rights (SRHR) by a third, halved its spending on Family Planning and cut spending on Reproductive, Maternal, Newborn and Child Health (RMNCH) by 37% since 2019.⁶

Table 1: <UK Official Development Assistance spending on sexual and reproductive health and rights, family planning and reproductive, maternal, newborn and child health 2019–2021 (US Dollars $)>

	2019	2020	2021
UK ODA spending on Sexual and Reproductive Health and Rights ($ million)	1,021	941	684
Percentage change in ODA spending on Sexual and Reproductive Health and Rights since 2019 (%)		-8	-33
UK ODA spending on Family Planning ($ million)	440	295	225
Percentage change in ODA spending on Family Planning since 2019 (%)		-33	-49
UK ODA spending on Reproductive, Maternal, Newborn and Child Health ($ million)	1,675	1,412	1,050
Percentage change in ODA spending on Reproductive, Maternal, Newborn and Child Health since 2019 (%)		-16	-37

Source: <DSW, Donors Delivering for SRHR: Report 2023, 29 June 2023⁷>

3. The FCDO’s spending on different aspects of SRHR is delivered through both bilateral and multilateral Official Development Assistance (ODA) spending.⁸ In bilateral aid on SRHR, the UK spent £546 million in 2019, £401 million in 2020, and £256 million in 2021.⁹ Comparable data for aid spending on SRHR is not available for before 2019.¹⁰ Changes to bilateral aid spending for programmes working solely on population policies/programmes and reproductive health (PPRH) are shown in the graph below.¹¹ Between 2009 and 2014, the percentage of the ODA budget spent on PPRH broadly remained between 6.3% and 7.7%. The proportion of UK ODA spent on this work dipped to around 4% in 2016, remaining broadly static until 2020. From 2020, in addition to reductions to absolute spending on PPRH programmes (as a result of broader cuts to the UK aid budget), spending in this area also decreased in percentage terms, declining to 2.3% of total spend by 2022.¹²

Source: <Foreign, Commonwealth & Development Office, Statistics on international development: final UK aid spend 2022, 14 September 2023, updated 20 September 2023>

4. The Committee received extensive evidence on the impact of the UK aid cuts on bilateral UK aid programmes on SRHR, noting that the FCDO had reduced budgets of bilateral aid programmes, often midway through implementation, and cancelled others. The UK’s flagship Women’s Integrated Sexual Health (WISH) programme initially operated in 27 countries, but activities reduced to 17 countries due to “budgetary re-prioritisation and contextual changes”.¹³ Numerous organisations involved in this project detailed the impact of the aid cuts on WISH.¹⁴ For example, MSI Reproductive Choices stated that their component of WISH faced a 79% cut from 2019/20 to 2023/24. This reduced the reach of their programme from an estimated 2 million to 224,000 clients.¹⁵ International Planned Parenthood Federation stated that they received a sub award for WISH2ACTION (WISH Lot 2) under the WISH programme that had a funding cut of 38% over 2.5 years, which reduced the project’s reach from 15 to 9 countries. Where programmes continued, it was only at 30% of possible capacity. WISH Lot 1 sub awarded £8 million to IPPF for 3 years in 3 countries. This also received a 38% cut over 2.5 years, resulting in a 40% reduction of the programme’s global footprint.¹⁶ While the FCDO extended the WISH project for another year, the Committee heard that this extension received a further 50% cut.¹⁷

5. The FCDO also cut its bilateral funding to the United Nations Population Fund (UNFPA), the UN’s sexual and reproductive health agency. The FCDO committed £425 million to the UNFPA’s Supplies Partnership between 2020 and 2025 as part of its Reproductive Health Supplies programme.¹⁸ While a payment of £65 million was disbursed for 2020, the FCDO only gave the UNFPA £19.8 million for 2021.¹⁹ In response to a Written Parliamentary Question, the FCDO stated that the ODA committed to the UNFPA had been reduced from £425 million to £264 million in 2021, a £161 million cut.²⁰ The FCDO cut several other existing UNFPA bilateral funding agreements in 2021, totalling $42 million.²¹ Affected country programmes included Afghanistan, Malawi, Nigeria and Pakistan.²²

6. CBM UK, an organisation working on disability, told us that “[e]very single FCDO-funded project that CBM was running was cut in the aid cuts, apart from the aid match.”²³ CBM UK stated that the FCDO cut a direct aid grant in Ghana by 25%. The project was providing safe birth, child health and psychoeducation for pregnant women and mothers through building new maternal health self-help groups and outreach clinics. A health project for the most marginalised communities in Bangladesh underwent a £1.1 million cut to a £2 million project, two years into a three-year project.²⁴

7. The FCDO spends ODA on SRHR through core multilateral funds.²⁵ While the UK has less control over ODA classed as core multilateral ODA, core funding to multilateral organisations allows them to act flexibly to respond to changing contexts and need, as it is not designated for a specific purpose. Multilateral organisations may also be best placed to act due to pooled funds leveraging further funding and increasing purchasing power.²⁶

8. As part of cuts to the aid budget, the UK cut core funding to multilaterals working on sexual and reproductive health, including:

• The UNFPA. The UK contributed £20 million to the UNFPA annually from 2010 to 2020, but this reduced to £8 million in 2021.²⁷
• The Global Fund.²⁸ In November 2022, the UK Government announced a pledge of £1 billion to the Global Fund.²⁹ This was an almost 30% cut from its 2019 pledge; the US, Japan, Canada, Germany, the EU and other Global Fund grant implementing countries met the Global Fund’s request for a 30% increase.³⁰
• UNAIDS.³¹ In 2021, the UK cut 80% of its funding to UNAIDS, reducing its contribution from £15 million to £2.5 million.³² In December 2022, the UK Government announced that it would provide £8 million annually to UNAIDS, just under half the UK’s prior commitment.³³
• Unitaid.³⁴ The UK made a 20-year funding commitment of £789 million to Unitaid in 2006 for 2007–26.³⁵ In 2021, funding from the UK was cut from an expected £77 million in 2021 to £6 million. This included a deferred contribution of £33 million from 2020.³⁶

The abrupt nature of the cuts

9. The abrupt nature of the cuts was challenging for organisations implementing UK aid programmes on SRHR. Matt Jackson, then Chief of the London Representation Office for the UNFPA, told the Committee that the UNFPA were given notice of “a few days but less than a week” for an 85% cut to the UNFPA Supplies Programme.³⁷ The CBM UK told the Committee that their project in Bangladesh was cut “with no notice”.³⁸ Alessandra Aresu, Director of Global Inclusive Health at Humanity & Inclusion, stated that as a partner of the WISH programme, they had two months’ notice to end inclusive SRH activities 12 months before the planned date.³⁹ She explained that the sudden end of their programme “did not allow for a proper transition and exit strategy to be put in place.”⁴⁰

10. The lack of a proper transition had a knock-on effect through the aid delivery channel. The abrupt cuts impacted the relationship between implementing partners and aid recipients and between implementing organisations working together, particularly bigger organisations working with local and smaller partners. Kirsty Smith from CBM UK, a charity working on disability, stated that this “destroyed the relationships … with our local partners, many of whom … are often very small, extremely grassroots and do not have very much experience.”⁴¹ In turn, this impacted the UK’s relationship with implementing partners and its reputation. MSI Reproductive Choices told us

Whilst we know the UK’s ODA budget is currently under huge pressure and understand that hard choices need to be made, the abrupt and seemingly arbitrary nature of some of the cuts have harmed the UK’s reputation as a serious, reliable, and credible global player and interlocutor with both international and national stakeholders.⁴²

11. Evidence to the Committee underlined that achieving sexual and reproductive health and rights requires a longer-term approach, as does reaching marginalised groups. For example, the IPPF underlined that building public sector sexual and reproductive health capacity takes time.⁴³ Humanity & Inclusion told the Committee that “it takes time to succeed and therefore needs to be adequately and sustainably resourced.”⁴⁴ Saskia Perriard-Abdoh from the Kaleidoscope Trust, a UK-based charity focused on fighting for the human rights of LGBT+ across the Commonwealth,⁴⁵ agreed that

… engaging marginalised communities requires a long-term commitment. By that, I mean that, as well as adequate levels of funding, you also need multi-year funding that is stable and secure and builds trust within communities that something that has been given will not be inadvertently taken away the next day.⁴⁶

The impact on the most marginalised

12. Evidence said that the aid cuts impacted the most marginalised people the most, an assessment backed up by the FCDO’s own Equalities Impact Assessments (EIAs). The FCDO produced a “broad-brush” impact assessment on the impact of the aid cuts on equalities for 2021–22 for internal use.⁴⁷ It stated that the “proposed scale of reductions to specific gender interventions, including… Sexual and Reproductive Health and Rights (SRHR) will impact girls’ education and wider efforts to advance gender equality” including “likely reductions of… 70% for SRHR bilateral, and 80% SRHR central programming.”⁴⁸ A further EIA, used to inform ODA allocations in 2022–23, noted that reductions to aid spending would “inevitably impact on equalities and inclusion objectives.”⁴⁹ However, it also outlined potential mitigations:

Reductions in the core contributions to organisations (e.g., UN Women, UNICEF) focused on women and girls and the most marginalised are likely to have a significant equalities impact. This includes support to organisations that work in supporting health systems, sexual and reproductive health and rights (SRHR) and therefore mothers and children. The purpose of such reductions is to increase bilateral programming in these areas, particularly policy advice to governments, which has the potential to impact positively on these groups and will be monitored to maximise the FCDO’s impact.⁵⁰

13. FCDO Ministers received an EIA to inform the 2023–24 ODA allocations. It indicated that the potential impact and reach of SRHR programmes would likely be reduced due to the anticipated ODA reductions, stating

Pan Africa: Spend reductions on the Women’s Integrated Sexual Health Programme (WISH) will mean that the programme’s results for women and girls would be reduced by approximately 60 per cent. The number of couple years of protection (CYPs) provided will drop from nearly 3 million to around 1.1 million; the number of unsafe abortions averted from nearly 300,000 to approximately 115,000; the number of maternal deaths averted will drop from 2,531 to just over 1,000.

Yemen: Half a million women and children in Yemen will not receive healthcare and fewer preventable deaths will be avoided. It may cause lasting damage to health systems in Yemen, if other donors are unable to fund.⁵¹

The FCDO told us that, having considered this assessment, “FCDO Ministers made adjustments, including those targeted at helping the most vulnerable and those with a relevant characteristic.”⁵² The FCDO increased allocations to Afghanistan, Yemen, Syria, and Somalia primarily to respond to humanitarian need. It is not known how much of these increased allocations, if any, will be spent on SRHR programmes. Another uplift of £12m to central humanitarian and health programmes is explicitly stated to include SRHR programmes (including FGM) among others, although the proportion of this allocation going to SRHR programmes is unknown.⁵³

A renewed commitment to sexual and reproductive health and rights?

14. The FCDO has published strategy and approach papers which articulate the direction of its aid work, including on SRHR:

• Ending preventable deaths of mothers, babies and children by 2030 approach paper in December 2021⁵⁴
• Health systems strengthening for global health security and universal health coverage (HSS) approach paper in December 2021⁵⁵
• FCDO disability inclusion and rights strategy 2022 in February 2022⁵⁶
• The international development strategy in May 2022⁵⁷
• The international women and girls strategy in March 2023⁵⁸
• The White Paper on international development in November 2023⁵⁹

The Minister for Development has reiterated his support for women and girls and SRHR.⁶⁰ In its White Paper, published in November 2023, the FCDO stated that it would “deploy policy and investment to defend strongly and to advance sexual and reproductive health and rights, including safe abortion.”⁶¹ These approach papers and strategies from the FCDO indicate a renewed commitment from the FCDO to women and girls and SRHR. However, the timing of these papers has been accompanied by a continued reduction in UK aid spending, which has led to cuts to bilateral SRHR programmes and funding to multilaterals working on SRHR, with funding levels running contrary to the FCDO’s policy aspirations.

15. The cuts to bilateral and multilateral Official Development Assistance on sexual and reproductive health and rights (SRHR) since 2020 have had a considerably negative impact upon the aid recipients of SRHR programmes, particularly on women and girls and those belonging to marginalised groups. The abrupt nature of the aid cuts damaged the UK’s relationships with aid partners and its reputation as an aid delivery partner.

16. The Committee welcomes the FCDO’s recent policy statements which have renewed the FCDO’s commitment to SRHR. To turn words into action, this should be backed up by consistent and long-term funding.

17. In order to meet previously set targets in this area, the FCDO should calculate a minimum percentage of bilateral Official Development Assistance to be spent on sexual and reproductive health and rights (SRHR). It should explain to the Committee why it has chosen this target and ensure adequate commitment of funding. This should not be lower than spending levels before the covid-19 pandemic. The proportion of bilateral spending on population programmes/policies and reproductive health should also not be any lower than before the covid-19 pandemic at 4% of bilateral ODA spending per annum. To ensure reliability and predictability of funding, the FCDO should ensure that programme funding is given on a multiyear basis. Programmes should run for a minimum of 5 years where possible.

18. Multilateral organisations are sometimes best placed to act and implement aid programming on sexual and reproductive health. The UK has historically been a key donor to multilateral organisations working on sexual and reproductive health. Evidence to the Committee has shown the benefits of both bilateral and multilateral funding. The FCDO should continue to support key multilateral organisations such as the UNFPA, the Global Fund, Unitaid and UNAIDS that are uniquely placed to work with national governments, and with civil society and communities, on certain aspects of SRHR. As a minimum, it should meet its prior commitments to these organisations. It should also restore discretionary funding to at least the same levels as before the covid-19 pandemic.

2 Family planning

19. Family planning is a vital component of SRHR. It consists of “the information, means and methods that allow individuals to decide if and when to have children”, including the availability of contraceptives and information on how to become pregnant when desirable, as well as treatment of infertility.⁶² Although approximations vary, an estimated 874 million women use a modern contraceptive method and 92 million women use a traditional contraceptive method.⁶³ There are an estimated 164 million women who want to delay or avoid pregnancy but are not using any contraceptive method, and thus are considered to have an unmet need for family planning.⁶⁴ Family planning is linked to positive development outcomes.⁶⁵ The UNFPA state that family planning is a ‘best buy’ as “every $1 invested in contraception delivers returns of over $8 by averting unintended pregnancies and reducing the demand for, and the cost of, maternal and other health services.”⁶⁶

20. The Committee recognises and is proud that the FCDO has long been a proponent of family planning. At the 2012 London Summit on Family Planning, the UK committed £516 million (US $800 million) over eight years towards “enabling an additional 120 million women and girls in the world’s poorest countries to use modern methods of family planning by 2020.”⁶⁷ This commitment was part of the UK’s broader commitment to double efforts on family planning, increasing investments from £90 million per year to £180 million per year from 2012–13 to 2019–20.⁶⁸ The 2012 summit led to the formation of an international network known as Family Planning 2020 (FP2020).⁶⁹ The UK gave £15.8 million to FP2020 between 2013 and 2022 to support evidence and advocacy.⁷⁰

21. In 2017, the UK co-hosted another international summit on family planning and committed to spending at least an average of £225 million on family planning in total every year for the next five years.⁷¹ The Government stated in December 2022 that it had exceeded this commitment, spending approximately £246 million each year between April 2017 and March 2022.⁷² After the original commitment period, FP2020 was renewed to FP2030 in January 2021.⁷³ While the Government has stated that UK funding has been allocated to the Global Family Planning Partnership FP2030,⁷⁴ the UK does not seem to have made a long-term financial commitment on SRHR funding to FP2030.⁷⁵ The recent White Paper on International Development also confirms a commitment to family planning, stating

All people, including women and girls, should have control over their own bodies. This means universal access to comprehensive sexual and reproductive health and rights, including modern methods of contraception, maternal health services, and abortion. Everyone should be able to avoid unwanted sexual contact, and decide if, and when, to have children.⁷⁶

22. However, the UK’s cuts to SRHR aid programming have impacted its work on family planning. The FCDO’s flagship Reproductive Health Supplies programme (2019–2025) aims to build sustainable markets for reproductive health commodities. The budget for this programme was originally £600 million, with £425 million allocated to the UNFPA Supplies Partnership. The FCDO cut the allocation to UNFPA Supplies Partnership for 2021 by almost 85%.⁷⁷ The UNFPA had to cut the commodities that it provides by 30%.⁷⁸ The UNFPA “is the largest provider of free voluntary modern contraceptives worldwide.”⁷⁹ Over 40% of the global market of these contraceptives comes from or through the UNFPA. The cut put “immense pressure” on global supply chains for contraceptives.⁸⁰ The total budget for the programme is now £295 million.⁸¹ The FCDO also cut the UNFPA’s core funding by 60%. The Coalition of Health Professional Bodies and Royal Colleges for SRHR told that Committee that “the latest cuts of 60% to the UNFPA budget means they will no longer be able to supply contraceptives to about a third of all users in some of the world’s poorest countries.”⁸²

23. However, the IPPF told the Committee that there should be “analysis of the effectiveness of the UNFPA system including looking at the direct and indirect cost of managing the supply chain, cost if other alternatives were to be used” and raised concerns about delays and bureaucracy within the UNFPA.⁸³ However, it acknowledged that “FCDO support to the global FP commodity supply chain through UNFPA has been a critical contribution to ensuring delivery of services in several countries.”⁸⁴

Safe abortion

24. According to the World Health Organization, around 73 million induced abortions take place worldwide each year, equating to 61% of all unintended pregnancies and 29% of all pregnancies. Abortion can be performed safely through medication or a surgical procedure by a range of healthcare workers. However, the WHO estimates that around 45% of all abortions are unsafe and 97% of unsafe abortions take place in lower-income countries.⁸⁵ The FCDO has stated that each year there are 35 million unsafe abortions, resulting in life-changing injuries and the deaths of at least 23,000 women each year.⁸⁶

25. In its international women and girls strategy, the FCDO committed to “prioritise the often-neglected issues of safe abortion”.⁸⁷ Its work on SRHR includes safe abortion and it has stated that it also works with grassroots organisations on safe abortion, including in crisis settings,⁸⁸ and funds safe abortion through the Safe Abortion Action Fund.⁸⁹

26. The Coalition of Health Professional Bodies and Royal Colleges for SRHR, including the Royal College of Obstetricians and Gynaecologists (RCOG),⁹⁰ argued that the FCDO should consider investing in telemedicine and self-management for abortion as part of its aid programming. Self-management includes the use of medication by a pregnant woman to induce her abortion.⁹¹ Telemedicine for abortion care is the use of a telephone, video call or the internet to provide all or part of their care at home.⁹² The RCOG argued that the FCDO should “ensure that healthcare providers and health systems more broadly are supportive, equipped and willing to care for individuals opting for a self-managed or telemedical abortion”, noting this reduces transport costs, increases privacy, and enables abortions to be performed earlier in a pregnancy, reducing the risk of complications.⁹³ The Coalition of Health Professional Bodies and Royal Colleges for SRHR also stated that telemedicine and self-management of abortion give more equal access for marginalised groups, such as those living in rural communities, survivors of gender-based violence, LGBT+ people and people with disabilities, and this should be used more broadly for treatment and prevention of STIs, including HIV.⁹⁴ When asked about telemedicine, the Minister for Development (Andrew Mitchell) told the Committee that the FCDO had considered the benefits of “all modern advances.”⁹⁵

27. The Committee is pleased to see the FCDO’s continuing commitment to family planning as a core part of its work on sexual and reproductive health, including the provision of safe and legal abortion services. However, the FCDO’s abrupt and sudden cuts to SRHR programmes directly led to the reduction in vital services for women and girls and damaged the UK’s work and reputation in this area. As part of its renewed commitment to SRHR programmes, the FCDO should ensure that it meets its original funding commitment made in November 2019 to the UNFPA Supplies Partnership to enable the delivery of vital healthcare services for women and girls. It should also consider restoring core funding to the UNFPA to £20 million annually.

28. The use of telemedicine and self-management in SRHR programmes could increase the accessibility, reach and effectiveness of such programmes. The FCDO should consider how to incorporate the use of telemedicine and self-management of SRHR in its aid programming, such as in providing access to safe abortion, and update the Committee no later than Autumn 2024 on its progress.

3 Maternal and newborn health

29. In 2020, approximately 287,000 women died from pregnancy and childbirth. Almost 95% of all maternal deaths occurred in low-income and lower middle-income countries, and around 70% occurred in sub-Saharan Africa. Humanitarian, conflict, and post-conflict areas have particularly high levels of maternal mortality. Most complications during and following pregnancy and childbirth resulting in death are preventable or treatable. Increasing access to contraception, safe abortion, and high-quality healthcare are effective ways to reduce maternal mortality.⁹⁶ In 2020, 2.4 million children died in the first month of life, with 43% of global newborn deaths occurring in Sub-Saharan Africa, and 36% in central and southern Asia.⁹⁷

30. The UK Government’s White Paper on international development states

No woman or baby should die of preventable causes in pregnancy or childbirth. All people, especially women and girls, should have access to quality information, services and supplies, free of discrimination, coercion and violence. Women should face fewer risks during pregnancy and childbirth.⁹⁸

The UK has committed £95 million to the Global Financing Facility for Women, Children and Adolescents (GFF) between 2018–25. This is “a multi-donor World Bank trust fund that brings health stakeholders together under national government leadership to accelerate the ending of preventable deaths of preventable maternal, newborn, child and adolescent deaths.”⁹⁹ The GFF uses grant money to leverage World Bank loans and encourage governments to assign higher proportions of these loans to Reproductive, Maternal, Newborn, Child and Adolescent Health and Nutrition. The UK is also a member of the Partnership on Maternal, Newborn and Child Health (PMNCH) which works to advance the health and wellbeing of women, children and adolescents. It has committed £6 million to the partnership between 2021 and 2025.¹⁰⁰

31. In addition, the FCDO’s approach paper on ‘Ending preventable deaths of mothers, babies and children by 2030’ (EPD) contains a commitment in this area. The paper highlights that a disproportionate number of neonatal and maternal deaths occur in lower-income countries. The UK approach to ending preventable deaths is based on four pillars of action: strong health systems; human rights, gender and equality; healthier lives and safe environments; and research, technology and innovation. Pillar 2 declares that the FCDO will “boldly defend, progress and champion universal sexual and reproductive health and rights and other rights.” The paper states that progress on the approach paper will be monitored using a framework based on a mix of country level indicators that will track national progress, and indicators specific to UK activities, programmes and shifts in approach. It also says that “at a high level, the aim of the approach is to decrease the mortality rates of mothers, newborns and children under five by 2030, with expected impact on SDG goals on nutrition and [water, sanitation and hygiene] WASH as well.” The FCDO has another approach paper on ‘Health systems strengthening for global health security and universal health coverage’.¹⁰¹ The Minister for Development stated that this approach paper would be monitored and assessed under the EPD framework.¹⁰²

32. While the EPD paper is detailed and comprehensive in its approach, it is difficult to judge its implementation due to a lack of publicly available and detailed targets and any type of monitoring and evaluation on its work. The Committee asked the FCDO whether it would publish measurable targets and achievements per year for the strategies on EPD and HSS. The Minister said he would ensure that these figures were being published.¹⁰³ Subsequently, the FCDO told us that it provides updates on EPD in other publications, such as the FCDO Annual Report.¹⁰⁴ The Committee notes that these assessments refer to the EPD strategy briefly and are not a detailed assessment of the FCDO’s work and progress in this area. The FCDO also told the Committee that it intended to publish a short EPD progress report in 2024, including progress against key HSS commitments. The FCDO will look to update this in 2027 and 2030 as part of the SDG review.

33. The FCDO’s approach papers on ending preventable deaths of mothers, babies and children by 2030 (EPD) and health systems strengthening (HSS) show a positive step in the right direction. However, in the absence of key targets for progress or regular updates, it has proved difficult to assess the effectiveness of the UK’s work in this area. The Committee welcomes the FCDO’s commitment to publish a future progress report on its EPD and HSS work in 2024, and to provide future updates on this work. However, more frequent updates on the FCDO’s work on EPD and HSS are needed in order to map the progress towards SDG commitments by 2030. The FCDO should publish key targets and achievements on an annual basis for its approach papers on Ending Preventable Deaths and Strengthening Health Systems.

34. Evidence to the Committee emphasised the importance of skilled healthcare workers in the provision of maternal and newborn health services. Dr Sebastian Taylor from the Coalition of Health Professional Bodies and Royal Colleges for SRHR told the Committee

… most newborn deaths happen within the first few days after delivery and most maternal deaths happen on the day of delivery. That tells us that the place where the mother delivers and the newborn arrives needs to be a place of considerable safety and quality of care. We know that that is not yet the case and that investment needs to be made in ensuring that high-quality perinatal care is delivered around the world.¹⁰⁵

According to the Coalition of Health Professional Bodies and Royal Colleges for SRHR, midwives provide 90% of sexual, reproductive, maternal, adolescent and child health care but currently make up less than 10% of the global workforce in this area. The Coalition also states that midwives are a ‘best buy’ in public health, bringing up to a 16-fold return on investment.¹⁰⁶ Dr Taylor explained that without better investment in perinatal care, countries were unlikely to hit their SDG targets by 2030.¹⁰⁷

35. Dr Taylor argued that the FCDO’s strategy on EPD did not tackle the key challenges as the FCDO is not investing in health workers. Dr Taylor argued

… we have seen UK aid for health rising fairly consistently over the last 20 years up until what happened in 2020, but if you break it down by areas of expenditure you find that expenditure on health personnel development, medical education and training, and basic health infrastructure—three core elements of what a health system needs to be sustainably good—together total just under 1% of UK aid spending. That does not seem to me to be a recipe for investments that will leave behind lasting, sustainable healthcare that will save both mothers and newborns.¹⁰⁸

He went on to add

Unless we see a more meaningful approach to health worker development, particularly in the context of UK policy to recruit health workers internationally—there has to be a quid pro quo about this—and that element of strategy being strengthened somewhat, I have doubts that we will see the kind of progress that we need.¹⁰⁹

36. Evidence also underlined the vital importance of water, sanitation and hygiene (WASH) to sexual and reproductive health, particularly maternal and newborn health and mortality. WaterAid explained

Every minute a new-born dies from infection caused by lack of safe water and an unclean environment. … Practising straightforward hygiene during antenatal care, labour and birth reduces the risk of healthcare-acquired infections, sepsis and death for infants and mothers. Yet, women are still giving birth in environments that do not have clean water, soap and sanitation and are attended to by carers who cannot observe basic hygiene practices.¹¹⁰

According to the WHO and UNICEF, in 2021, 3.85 billion people used healthcare facilities without basic hand hygiene services, 1.7 billion used facilities that lacked basic water services, and 780 million used facilities with no sanitation services.¹¹¹ Babies born in hospitals in low-and middle-income countries (LMICs) are up to 20 times more likely to develop neonatal sepsis than hospital-born babies in high-income countries. Over half of healthcare-associated sepsis cases are thought to be preventable through basic WASH services and appropriate infection, prevention and control measures.¹¹²

37. Pillar 3 of the FCDO’s approach paper on ending preventable deaths of mothers, babies and children by 2030 specifically notes the need to have safe climate resilient water, sanitation and hygiene services in communities, schools, and health facilities.¹¹³ However, like other aspects of ODA spending, ODA spending on WASH has been cut from 2020 onwards, as the table below shows.

Table 2: <UK bilateral Official Development Assistance spending on water, sanitation and hygiene 2015 to 2022>

Year	Bilateral ODA spend on WASH (£ million)	Percentage of bilateral ODA spend on WASH (%)	Multilateral ODA spending on WASH (£ million)	Percentage of multilateral ODA spend on WASH (%)
2015	183	2.4	273	7.2
2016	170	2.0	197	5.4
2017	177	2.0	211	4.9
2018	207	2.2	323	8.1
2019	176	1.7	148	4.1
2020	110	1.2	118	3.3
2021	78	1.1	103	4.1
2022	46	0.5	-	-

Source: <Foreign, Commonwealth & Development Office, Statistics on International Development: final UK aid spend 2022, published 14 September 2023, updated 20 September 2023 and Foreign, Commonwealth & Development Office, Statistics on International Development: Final UK Aid Spend 2019, published 24 September 2020, last updated 20 July 2021¹¹⁴>

38. Access to clean water and the provision of adequate sanitation and hygiene reduces the risk of maternal and newborn mortality. In complementarity to its approach on SRHR spending, the FCDO should calculate and justify a minimum bilateral ODA percentage that it must spend on WASH to reach its development targets. This target should not be lower than 2% per annum. The FCDO should also ensure that WASH and SRHR programmes adopt a complementary and integrated approach.

39. The involvement of trained health personnel and access to adequate health care facilities for maternal and newborn health improves health outcomes for the mother and child. The FCDO should support the strengthening of healthcare systems by prioritising investment in the development of health infrastructure, particularly WASH infrastructure. The FCDO should prioritise support for training and retention of health personnel in low-and-middle-income countries. The FCDO should calculate a minimum percentage of ODA to be spent on the training of health personnel in low-and-middle-income countries. It should explain to the Committee why it has chosen this target and ensure adequate commitment of funding.

4 Women and girls’ health

Menstruation

40. It is estimated that 1.8 billion women and girls experience a period each month, but women and girls continue to face social stigma and discrimination around menstruation and barriers to menstrual hygiene management (MHM). Access to adequate hygiene and sanitary facilities and products and accessing education on menstruation is essential for MHM.¹¹⁵ However, the World Bank has estimated that at least 500 million women and girls do not have access to menstrual products and adequate facilities for MHM.¹¹⁶ WaterAid explained that non-inclusive infrastructure, such as a lack of female friendly public toilets, hamper the “ability for women and girls to manage their periods safely, privately, hygienically, and without stigma.”¹¹⁷

41. Women and girls may be unable to access education due to a lack of sanitary facilities.¹¹⁸ According to UNICEF and WHO, in 2021, 28% of schools worldwide did not have basic sanitation services, impacting 539 million children.¹¹⁹ During its work on water, sanitation and hygiene, the Committee heard that one third of girls in South Asia miss up to three days a month of schooling as a result of this.¹²⁰ Schools having sanitary facilities which enable women and girls to manage their periods is therefore essential to SRHR and helping women and girls access education. This provides an opportunity for the FCDO to ensure that work on SRHR and education are integrated and complementary.

42. To meet menstrual health needs, women and girls must be able to access accurate, timely and age-appropriate information about menstruation. In addition, they need access to WASH services and inclusive infrastructure. Without adequate services and facilities, managing menstruation can be a challenge for women and girls in low-and-middle-income countries, preventing them from education and employment opportunities. This could undermine the UK Government’s work in other sectors, particularly in education.

43. The FCDO should support menstrual health by supporting the provision of WASH services and infrastructure and access to menstrual products. In particular, the FCDO should ensure that its work in the education and WASH sectors complement its SRHR work in this area, for example, ensuring that education programmes include the provision of appropriate sanitary facilities. It should also support age-appropriate education on menstruation.

Gynaecological disease

44. The Royal College of Obstetricians and Gynaecologists (RCOG) has explained that upcoming research states that “overall, morbidity for women and girls due to so-called ‘benign’ gynaecological conditions outweighs the combined morbidity from malaria, TB and HIV/AIDS in low and middle-income countries.”¹²¹ The RCOG told the Committee that “the FCDO’s programming does not currently address the global burden of gynaecological disease, as a priority in its own right nor as a key element of its integrated SRHR response.”¹²² When asked about integrating gynaecological healthcare into the FCDO’s SRHR programming, the Minister for Development stated that he could not answer at that moment but that “it is an entirely logical approach that one would expect to be integrated.”¹²³

45. Cervical cancer is the fourth most common cancer among women globally, causing 342,000 deaths in 2020, 90% of which were in low-and-middle-income countries. Additionally, women living with HIV face a six times higher risk of developing cervical cancer, and there is new evidence showing that women with persistent HPV infection are at a higher risk of HIV acquisition.¹²⁴ The Global Alliance for Vaccines and Immunization (Gavi) told us that the human papillomavirus (HPV) vaccine averts 17 deaths for every 1,000 children vaccinated and that “is the key intervention towards achieving cervical cancer elimination and provides a unique opportunity to invest in the health of women and the future of girls.”¹²⁵ Global HPV vaccination coverage with both doses (the full series) remains low at 12%. Gavi is aiming to reach over 86 million girls by 2025, averting over 1.4 million deaths from cervical cancer. The UK Government is the largest sovereign donor to Gavi’s core programmes, contributing £1.65 billion to its fifth strategic period between 2021–2025. Gavi suggested that “there is an opportunity to integrate HPV vaccination with other critical adolescent health needs”, including menstrual health and sexual reproductive health and rights.¹²⁶

46. The FCDO has not sufficiently addressed the threat of gynaecological disease in its SRHR programming, despite the risk it poses to the SRH of women and girls. The prevalence of cervical cancer among women and girls in lower-income countries is also concerning, especially as adequate provision of the HPV vaccine could greatly reduce the threat of cervical cancer to women and girls. The FCDO should look to incorporate care of gynaecological disease, including so-called ‘benign’ gynaecological disease, into its SRHR programming. It should also continue to support the provision of the HPV vaccine to women and girls and look to align this with its SRHR programming where possible.

Female genital schistosomiasis

47. The Committee heard about female genital schistosomiasis (FGS). Schistosomiasis is a neglected tropical disease (NTD) “caused by parasitic worms, transmitted to humans through snails that live in lakes, rivers and ponds.”¹²⁷ Schistosomiasis is considered a disease of poverty. It is linked to “a lack of access to safe, clean water, good hygiene and sanitation facilities and quality, affordable healthcare services.”¹²⁸ Schistosomiasis disproportionately affects women and girls because they are often responsible for household chores that expose them to contaminated water sources. They also often care for infected individuals, causing them to drop out of employment or education.¹²⁹ Untreated schistosomiasis can cause FGS. Symptoms of FGS include significant pelvic pain, bloody vaginal discharge, painful intercourse, post-coital bleeding and genital itching and burning.¹³⁰ FGS can lead to serious SRH complications including infertility and still birth. It is linked to increased risk of HIV transmission as well as bladder and cervical cancer. Around 56 million women are estimated to suffer from FGS in Sub-Saharan Africa and the Middle East.¹³¹

48. FGS can be treated with a short course of medication, praziquantel, which kills the adult worms.¹³² Praziquantel is donated by a pharmaceutical company for free and is given to children yearly in endemic areas. Treatments are often distributed through schools.¹³³ However, girls often drop out of school and this treatment does not reach non-school age women and girls.¹³⁴ The FGS Integration Group (FIG) told the Committee that FGS is not routinely included in medical textbooks or training for health professionals, so health professionals in countries where FGS is endemic are not aware of FGS and cannot diagnose it properly, often diagnosing it mistakenly as an STI or cervical cancer. This contributes to “ineffective health seeking behaviour, unnecessary treatment, and clinical investigations that fail to treat symptoms.”¹³⁵ If FGS is incorrectly diagnosed as a sexually transmitted infection, it can put women at risk of gender-based violence due to their perceived sexual activity or behaviour.¹³⁶

49. Evidence to the Committee suggested that FGS could be best tackled through better integration of FGS care into wider sexual and reproductive health programmes. Improvements to access to adequate water, sanitation and hygiene (WASH) facilities can help prevent women and girls from contracting the disease by reducing or eliminating exposure to contaminated water sources. Educational material on WASH can also help reduce FGS acquisition and “encourage early treatment and reduce the risk of stigmatisation and exclusion of affected women.”¹³⁷ Schools offer an opportunity to distribute FGS treatment (praziquantel). Services working on HIV and AIDS prevention and treatment also offer an opportunity to integrate FGS.¹³⁸ The UNAIDS Global AIDS Strategy 2021–2026 sets goals for women and girls to access FGS screening and/or treatment, including those integrated with HIV prevention, testing and treatment services.¹³⁹ Equally, the Global Fund offers an opportunity to integrate FGS and HIV and AIDs programmes.¹⁴⁰

50. Female genital schistosomiasis is a painful and debilitating but treatable condition affecting up to 56 million women. FGS is best tackled through an integrated approach with wider SRHR programming, as well as with other areas of programming such as education, WASH, and HIV and AIDS. The UK should integrate female genital schistosomiasis (FGS) care into its SRHR programming. This should include (a) improving access to adequate water, sanitation and hygiene facilities, (b) increasing girls’ enrolment in education and supporting distribution of FGS medicine in schools, (c) distributing educational materials on WASH, and (d) considering integrating FGS and HIV and AIDS programming, including by discussing the integration of HIV and AIDS programming with FGS care with its multilateral partners, such as the Global Fund.

Female genital mutilation

51. Female genital mutilation (FGM), also referred to as female genital cutting (FGC), includes “all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.”¹⁴¹ No form of FGM provides health benefits for girls and women, and all are associated with health complications. Currently, more than 200 million girls and women have been subjected to FGM, with an estimated 3 million girls at risk of FGM annually.¹⁴² The majority of FGM occurs in 30 countries in Africa and the Middle East but continues in other countries in Asia and Latin America. In Djibouti, Guinea, Mali and Somalia, FGM remains almost universal.¹⁴³ FGM has lifelong impacts and is a human rights violation.¹⁴⁴

52. FGM is often done by “elderly people in the community (usually, but not exclusively, women) designated to perform this task or by traditional birth attendants”, often without anaesthetic and antiseptics. However, there have been growing concerns of the ‘medicalisation’ of FGM which is when a medical professional performs FGM.¹⁴⁵ Estimates vary as to the number of cases of FGM performed by health personnel; based on data from 24 countries, the UNFPA found that 18 percent of girls under age 15 who had undergone FGM had the practice performed by a health care provider.¹⁴⁶ Asenath Mwithigah explained that “communities think that it is a safer way to practise FGM, but there is no safe way to practise FGM.”¹⁴⁷ The medicalisation of FGM gives “a false legitimacy to FGM practice.”¹⁴⁸ The Coalition of Health Professional Bodies and Royal Colleges for SRHR told the Committee that “the FCDO should complement its support to FGM and gender-based violence programmes by working with medical bodies and colleges to tackle the rising medicalisation of FGM.”¹⁴⁹

53. The drivers of FGM are complex. Asenath Mwithiga, Chief Executive Officer at the Orchid Project, a charity working to help end FGM, identified several different drivers of FGM:

• FGM is “deeply entrenched in gender inequalities” and “a social and a gender norm” with “reward and sanction mechanisms.”
• FGM is perpetuated by sociosexual drivers, where it is about controlling women’s sexuality and is “deeply rooted in power imbalances.”
• FGM can be seen as the process of moving from childhood to adulthood and “getting to marriageability”.
• FGM is driven by socioeconomic aspects, such as bride wealth, where girls are seen as a commodity, so communities will recommend that girls and women undergo FGM to be married off at a young age.
• FGM may be driven by religion where FGM is seen as a religious practice, “although it is not endorsed by any religion”.¹⁵⁰

Equally, drivers of FGM differ between communities and the type of FGM.¹⁵¹ Ending FGM does not have a one-size fits all solution.¹⁵² The Committee heard that solutions need to be data-driven and evidence-based.¹⁵³ Tinebeb Berhane emphasised that passing laws is not enough, they must be enforced.¹⁵⁴ This is increasingly challenging due to ‘cross-border cutting’, where girls or ‘cutters’ cross national borders to carry out FGM.¹⁵⁵

54. United Nations Sustainable Development Goal 5.3 explicitly calls for the end of FGM,¹⁵⁶ and the UK has committed to ending FGM in its International Development Strategy and the International Women and Girls Strategy.¹⁵⁷ The UK has funded the Africa-led Movement to end FGM since 2013. The current phase has run from 2019 and is scheduled to seemingly finish in 2027 and consists of £35 million in funding.¹⁵⁸ The FCDO told the Committee that this phase of the programme works with “activists, communities, grassroots organisations and harnesses evidence-based solutions to take end-FGM efforts to scale, with a focus on Kenya, Ethiopia, Somalia and Senegal.”¹⁵⁹ The UK also funds the United Nations Joint Programme to end FGM and, since 2013, the UK has also worked with the UN to support the Government of Sudan and others to end FGM in the Sudan Free of Female Genital Mutilation programme.¹⁶⁰ However, Plan International told us that of April 2023 that they were “concerned at the delay in progression of new programmes over the past 18 months, such as a new programme in Somalia which was due to be released in July 2022 and has had no further update.”¹⁶¹ Beyond ODA spending, the FCDO told us that it engages in consular and diplomatic activity to end FGM and leads the UK’s negotiations on international resolutions relating to FGM, including at the Human Rights Council.¹⁶²

55. The UK Government has long been an opponent of female genital mutilation (FGM) and has worked against FGM both bilaterally and multilaterally. The UK Government should renew its commitment to preventing female genital mutilation through funding multilateral and bilateral programmes, including those tackling the medicalisation of FGM and ‘cross-border cutting’, which involves moving women and girls across national borders to undergo FGM or cutters across national borders to perform the practice.

5 Sexually transmitted infections, including HIV and AIDS

Sexually Transmitted Infections

56. There are over 30 different types of sexually transmitted infections (STIs), also known as sexually transmitted diseases (STDs). Some STIs can be transmitted from a mother to her child during pregnancy, childbirth, and breastfeeding. According to the World Health Organization, one million new STIs are acquired every day. Some STIs are curable, whereas others are not. Curable STIs include gonorrhoea and chlamydia, and incurable STIs include hepatitis B, herpes simplex virus (HSV), human papillomavirus (HPV), and HIV.¹⁶³ Some STIs are symptomless, making them harder to detect.¹⁶⁴ Beyond immediate pain and discomfort, STIs can have serious health consequences. Some STIs increase the risk of HIV acquisition or can cause infertility. The transfer of STIs from mother to child can also cause neonatal death, stillbirth, low-birth weight and prematurity, sepsis, neonatal conjunctivitis, and congenital deformities.¹⁶⁵

57. Prevention of STIs is key. Vaccines are available for hepatitis B and HPV, and more vaccines are under development.¹⁶⁶ Condoms, when used correctly, are one the most effective ways to protect against STIs, including HIV, although they are not effective against all STIs.¹⁶⁷ Access to vaccines and contraceptives is therefore essential to preventing STIs. The World Health Organization states that information, education, and counselling can improve people’s recognition of symptoms and increase the chances that someone will seek treatment. However, a lack of public awareness and stigma around STIs presents a barrier. Equally, accessing healthcare services for STIs may be challenging, including reasons such as the cost and poor quality of services with tests for certain STIs largely unavailable, expensive or inaccessible.¹⁶⁸

HIV and AIDS

58. HIV, Human Immunodeficiency Virus, is an STI that attacks the body’s white blood cells, weakening the immune system. Untreated HIV can progress to AIDS, Acquired Immunodeficiency Syndrome, the most advanced stage of the disease. HIV is spread from the body fluids of an infected person, including blood, breast milk, semen, and vaginal fluids, and can spread from a mother to her baby.¹⁶⁹ In 2022, an estimated 39 million people globally were living with HIV and 1.3 million people became newly infected. Some 630,000 people died from AIDS-related illnesses in 2022.¹⁷⁰

59. The risk of acquiring HIV is not uniform across the population. Some 53% of all people living with HIV were women and girls in 2022, with adolescent girls and young women at particularly high risk. In Sub-Saharan Africa, 77% of new infections among those aged 15–24 years old were among young women and girls. At particular risk of infection are marginalised groups including sex workers, prostituted people, gay men and other men who have sex with men, people who inject drugs, transgender people, and people in prison.¹⁷¹

60. HIV can be prevented with PrEP, a medicine that stops HIV entering the body and replicating, which also treats HIV once acquired.¹⁷² The PrEP ring (a version of the drug which can be inserted into the vagina) was recommended by the WHO for women at substantial risk of HIV in January 2021.¹⁷³ Only one version of the ring has been approved to date.¹⁷⁴

61. CAB-LA (Cabotegravir LA) is also a recently developed drug that prevents HIV and is administered as an injection every two months. It has been found to be more effective than a daily pill as it is easier to take regularly. It is also therefore more discreet, which reduces barriers to taking PrEP.¹⁷⁵ ViiV Healthcare, the developer of the drug, told the Committee that it was making CAB-LA available at non-profit pricing for over 60 countries.¹⁷⁶ ViiV has estimated a not-for-profit price of $240-$270 (£195-£220) annually per patient.¹⁷⁷ However, concerns remain that low-and-middle-income countries cannot afford this. The Clinton Health Access Initiative (CHAI) has estimated that the cost of the ingredients might be $20-$40.¹⁷⁸ ViiV has stated that CAB-LA has a complex manufacturing process.¹⁷⁹ ViiV announced a comprehensive voluntary licence agreement with the Medicines Patent Pool, allowing generic manufacture of the drug for 90 countries. Cipla has confirmed that a generic version of drug would be manufactured in South Africa. However, the technology behind the manufacturing may not have been shared in as timely a manner as needed, which means it could take up to 5 years before the product is on the market.¹⁸⁰

62. The Committee heard that covid-19 set back care for HIV and AIDS. STOPAIDS told the Committee that “people reached with HIV prevention programs and services declined by 11% while young people reached …. declined by 12%. The number of mothers receiving medicine to prevent transmitting HIV to their babies also dropped by 4.5%. Testing also dropped by 22%.”¹⁸¹

63. At the same time, the UK’s ODA spending on HIV and AIDS has also declined. STOPAIDS et al. stated that, in 2021, the UK Government “… cut global health R&D spending in half; and effectively wiped out what remained of the UK’s bilateral funding going directly to HIV civil society and community-led organisations”.¹⁸² The UK Government cut funding to key agencies like UNAIDS, Unitaid and UNFPA by over 80%. Some “60% of the Global Fund’s spending is specifically targeted to programmes for women and girls and around one-third of Global Fund investments directly benefit Sexual and Reproductive Health and Rights”.¹⁸³ Evidence emphasised the importance of the Global Fund and encouraged the UK Government to make a supplementary allocation to the fund.¹⁸⁴ Additionally, the Committee notes that the new White Paper fails to recognise the importance of continuing progress towards delivering on the goal of ending AIDS, reflecting concerns raised by witnesses that HIV and AIDS have largely been omitted from recent FCDO policy documents on both health and women and girls, despite AIDS-related illness remaining the leading cause of death for women of reproductive age in Africa.

64. The goal of ending AIDS cannot be reached without access to proper care and treatment for all people living with HIV, and action to bring down the large numbers of people newly acquiring HIV (1.3 million in 2022, far above the global target of 500,000 by 2025).¹⁸⁵ More than 40 years after the first cases, the AIDS pandemic continues to pose a major barrier to global development, and COVID-19 has had a serious and significant impact on the ability of healthcare services to reach global targets on HIV and AIDS. Recent reductions in the UK’s bilateral aid spending on HIV and AIDS, alongside major cuts to its funding to UNAIDS, Unitaid and the Global Fund at the same time is, therefore, particularly concerning.

65. To support the achievement of global targets on ending AIDS, and to retain the UK’s historical leadership in this important area of SRHR, the FCDO should retain bilateral investments in HIV prevention and treatment, both through dedicated HIV programming and in its support for integrated SRHR, with a special focus on marginalised groups such as adolescent girls and young women, as well as key population communities. The FCDO should continue to support, and pay its fair share to, the Global Fund, which is a major funder of HIV prevention and treatment, and invest in the community-led responses and human rights programmes which are so essential to an effective AIDS response.

66. The FCDO should also actively encourage the effective integration of HIV into sexual and reproductive health services, by explicitly including HIV in SRHR policy documents and funding calls and requiring the inclusion of organisations with HIV expertise in the SRHR programmes that it funds. These services should also be designed, implemented, monitored and evaluated in close partnership with community-led and civil society organisations, recognising the vital role that they play in ensuring that services are responsive to local needs and are able to reach those most left behind.

Complementarity of approach

67. Throughout this inquiry, the Committee has heard evidence of how different areas of sexual and reproductive health and rights programming should be integrated and complementary. Fionnuala Murphy from Frontline AIDS told the Committee that “it is unacceptable that you have young women coming in and getting family planning, but not getting a conversation about their HIV risk”.¹⁸⁶ She noted that, in particular, marginalised people “cannot keep making different visits to different parts of the health system to have their multiple needs met when, actually, there is no reason why they could not get things like contraception, HIV prevention, STI testing and FGS testing all in one place at the same time.” She underlined that accessing SRHR services can involve losing wages, paying travel costs, and user fees.¹⁸⁷

68. The FCDO should have a holistic and integrated approach to all of its sexual and reproductive healthcare programming to enable recipients to live a healthy life and reach their full potential. When funding sexual and reproductive healthcare, the UK should also consider investing in a ‘one-stop shop’ approach to SRHR which would help to ensure truly comprehensive sexual and reproductive healthcare and reduce barriers to accessing lifesaving HIV and SRHR services, such as travel costs, time, and stigma.

6 Reaching marginalised and hard-to-reach groups

69. The Committee heard that marginalised and hard-to-reach people suffered additional challenges in access to sexual and reproductive health services. These groups include but are not limited to adolescents, people with disabilities, LGBT+ people, people living in humanitarian contexts, low-income people, people living with HIV, and people living in rural areas. Intersectionality is also a factor in marginalisation, where membership of two or more marginalised groups may increase challenges and obstacles to achieving SRH. The FCDO approaches aid programming under the ‘Leave No One Behind’ banner, which seeks to prioritise those furthest behind.¹⁸⁸

Adolescents

70. Evidence to this inquiry indicated that adolescents face many challenges regarding their sexual and reproductive health, yet often do not have access to the same services as adults. Dr Sarah Neal, an Associate Professor in Global Health at the University of Southampton, told the Committee that there are a variety of reasons for sexual activity among very young adolescents,¹⁸⁹ which may include an informed decision to begin a sexual relationship, coerced sex or rape.¹⁹⁰ Girls aged 15 or below have an increased risk of maternal mortality and some studies find that women and girls between 15–19 also have an increased mortality rate. Newborns also have a higher rate of mortality if the mother is less than 15 years old. Around 2.5 million girls are estimated to give birth before the age of 16 each year. West and Central Africa have particularly high early birth rates, with four countries reporting more than 20% of women and girls having their first birth before 16 years of age.¹⁹¹ Young adolescent mothers are also more likely to experience repeat adolescent pregnancy. Adolescent pregnancy is more frequent among the poorest and least educated groups.¹⁹²

71. Plan International state that adolescents have unique needs and face barriers due to a combination of both age and gender in respect to SRHR.¹⁹³ Healthcare policies may restrict access to SRHR services below a certain age or if an adolescent is not married. Even when there is no such legislation, adolescents may assume this to be the case. Stigma and societal censure may also affect access to SRHR services. There are often concerns raised about the appropriateness of sexual activity among adolescents. For young adolescents, sexual activity could be “coercive or abusive”.¹⁹⁴ However, enabling access to contraception can be a form of harm reduction. By allowing adolescents to access SRHR without masking their age means that SRHR professionals can identify their vulnerabilities. Linkages to child protection and gender-based violence services are therefore important, although this may be difficult in settings where child protection services are poorly developed. In addition, staff need to be able to identify where referring SRHR care recipients to other services is appropriate and make the correct referrals.¹⁹⁵

72. Evidence to the Committee strongly promoted the provision of comprehensive sex education.¹⁹⁶ Dr Sarah Neal stated that comprehensive sex education can “improve SRH outcomes for adolescents and reduce risky behaviour including early sexual debut.”¹⁹⁷ Comprehensive sex education is designed to be taught throughout childhood with different curriculum depending on age group. Dr Neal explained that there is often resistance to this education, with comprehensive sex education often occurring after young people have become sexually active, reducing its effectiveness.¹⁹⁸ Disability rights organisations also emphasised that the provision of comprehensive sex education should include people with disabilities.¹⁹⁹

73. Access to SRH services for adolescents may also improve educational attainment as pregnant girls and young mothers are “systematically excluded from or miss out on educational opportunities.²⁰⁰ The Coalition of Health Professional Bodies and Royal Colleges for SRHR stated concern over the limited crossover between SRHR programming and the ‘three Es’ framework, including education programming.²⁰¹ The Global Long-Acting Reversible Contraceptive (LARC) Rights Collaborative (GLRC) stated that in Uganda, for example, SRHR and girls’ education programming were not sufficiently integrated.²⁰²

74. Access to SRHR services and comprehensive sex education is vital to adolescents; however, adolescents may often face barriers to accessing sexual and reproductive health services. Ensuring that women and girls are fully educated on sexual and reproductive health can empower them and give them the autonomy to make informed decisions in life. Better education among women and girls is also linked to better sexual and reproductive health outcomes. Considering the UK’s commitment to girls’ education, the FCDO should embed comprehensive age-appropriate sex education into its ODA-funded education programmes.

75. People accessing SRHR services may be vulnerable, such as adolescents. The FCDO should ensure that staff who are delivering FCDO-funded aid programmes receive training to be able to recognise safeguarding concerns when interacting with aid recipients. These staff should be empowered to signpost aid recipients to the appropriate services and support.

People with disabilities

76. Globally, an estimated 16% of the population and 18% of women have one or more disabilities.²⁰³ Some 22.1% of women in lower-income countries have a disability compared to 14.4% in higher-income countries.²⁰⁴ The Committee heard that SRHR services and aid programming often excludes people with disabilities. Kirsty Smith, CEO of CBM UK, an organisation working on disability rights worldwide, said that there are numerous barriers for people with disabilities to access SRHR services: information may not be accessible, particularly for those who are blind or deaf, people may face economic barriers and the infrastructure may be inaccessible with no ramps, doorways that are too narrow, and signs that are too small.²⁰⁵

77. Hospital staff may also show attitudinal barriers towards women with disabilities. The Committee heard that the right to informed consent of women with disabilities is often violated when it comes to access and choosing SRHR services, resulting in reproductive coercion from an assumption that women with disabilities do not have the capacity to make decisions and that health workers are better placed to do so.²⁰⁶ Women with disabilities are often shunned by their communities and may struggle to continue education or find employment.²⁰⁷ Husbands may stop their wives with disabilities going to SRH appointments through control of the family finances.²⁰⁸

78. The FCDO disability inclusion and rights strategy 2022 to 2030 (DIRS) states that it aims to allow people with disabilities to “access and use affordable, accessible and quality health services through their life.” In terms of SRHR services, it suggests it will do so through “influencing global advocacy programmes such as the Partnership for Maternal, Newborn and Child Health.”²⁰⁹ The UK has stated that it champions SRHR for people with disabilities, and it runs programmes including people with disabilities. For example, the Disability Inclusive Development Programme provided “over 800 people with disabilities (and a further 1,100 family members) in Nepal with access to inclusive sexual and reproductive health and rights services.”²¹⁰ Nevertheless, CBM UK criticised the IWGS for not sufficiently addressing SRHR for women and girls with disabilities or taking the DIRS into consideration.²¹¹ The Committee heard that it is important that aid programmes set out to include people with disabilities from the needs assessment and planning stage of an aid programme.

79. Sightsavers told the Committee that “analysis of available OECD DAC data suggests that only 25% of the UK’s SRHR programming is disability inclusive.”²¹² CBM UK stated that reaching with disabilities “is seen as an additional extra, a luxury even, rather than being a core and prioritised component,” adding that “when budgets are constrained, provisions which support people with disabilities are often the first to be cut.”²¹³ This view seems to be reflected in the Equalities Impact Assessments. Kirsty Smith also told the Committee

The style of funding that we are all pushed into competing for moves you away from trying to find the most marginalised, because they tend to be more expensive and more difficult, and it takes more time. We are pushed into providing proposals that reach bigger numbers rather than those that reach the most difficult to reach and, in this way, they are left behind.²¹⁴

Similarly, Humanity & Inclusion stated that the FCDO should “take measures to avoid unintended consequences leading to exclusion, for example through over emphasis on quantitative targets that inadvertently reduce the likelihood of women or adolescent girls with disabilities being included in interventions.”²¹⁵ To improve this, evidence to the Committee suggested that the FCDO must target funding towards people with disabilities.²¹⁶ Sightsavers suggested that the “FCDO’s SRHR programmes should include a dedicated budget, baselines, targets, and key performance indicators focusing on the inclusion of people with disabilities.”²¹⁷ To track the effectiveness of these interventions, CBM UK and the Commonwealth Children & Youth Disability Network suggested that the FCDO should publish disaggregated data on the aid recipients of its aid programming and that this helps to view the impact of aid programmes through an intersectional lens.²¹⁸ One programme referenced in the IWGS disaggregated all data by disability status.²¹⁹

80. People with disabilities may face additional barriers to accessing SRHR programmes and providing services to people with disabilities may often take additional resources. Consequently, organisations implementing development programmes may be disincentivised from reaching marginalised groups as programmes are often required to show that they have reached as many recipients as possible. The FCDO should ensure that all SRHR programmes are accessible to people with disabilities. FCDO’s SRHR programmes should include a dedicated budget, baselines, targets, and key performance indicators so that people with disabilities are fully integrated into aid programmes. In addition, all FCDO programming on SRHR should record disaggregated data on aid recipients, including age, sex, and disability to assess how successful they are at inclusivity.

LGBT+ people

81. LGBT+ people face unique challenges in accessing SRHR services. Saskia Perriard-Abdoh from the Kaleidoscope Trust told the Committee that “they often face a double stigma, both for the type of service they are seeking and for individual characteristics that might be visible or they may be forced to disclose as they seek those services.”²²⁰ She went on to add that a person may end up outing themselves to members of their community or to professional services. In these cases, LGBT+ people may find that their lives are at risk or that authorities may report them.²²¹ The Committee engaged with the FCDO over reports that it had given money to an anti-LGBT+ organisation and a SRHR programme where LGBT+ people had reportedly been discriminated against.²²² The Committee asked the FCDO whether it would withdraw funding if a recipient country was not being inclusive. The Minister for Development explained

It is a very tricky equation. If you withdraw grant support, if you withdraw aid from a country that is doing something of which you strongly disapprove, then you will not normally affect the elite who are making those decisions but you will affect the people we are trying to help.²²³

In November 2023, Andrew Mitchell announced that the FCDO had launched a new five-year £40 million LGBT+ programme which included improving access to services and enabling legislative reform.²²⁴ Where LGBT+ people can access services, Saskia Perriard-Abdoh said that “there is a lack of awareness and education when it comes to the specific needs of members of the LGBT+ community.”²²⁵

Other groups

82. The Committee heard that other groups may face challenges in accessing SRHR services due to marginalisation. These groups include, but are not limited to, people living in poverty in urban and rural areas, sex workers, prostituted people, people who inject drugs, and survivors of gender-based violence.²²⁶ Some marginalised people, such as sex workers and prostituted people, and LGBT+ people, are more at risk of poor sexual and reproductive health, as well as significantly elevated risks of HIV acquisition.²²⁷ The Committee heard evidence that marginalised people are more likely to be pushed into sex work as a means of economic survival, restricting access to SRHR services but increasing the risk to their SRH.²²⁸

83. People from marginalised groups, such as people with disabilities and LGBT+ people, may face additional and unique challenges in accessing SRHR services. The FCDO should ensure its commitment to the principle of ‘Leave No One Behind’ in all its SRHR aid programmes. The FCDO should include hard-to-reach aid recipients, often those belonging to often marginalised and excluded groups, in the planning, development, and delivery of aid programmes on SRHR and should invest in community and civil society organisations led by these populations, recognising that they are essential partners in achieving health outcomes.

Humanitarian contexts

84. The Committee heard that SRHR services are essential in fragile, conflict-affected, and humanitarian contexts, but often are difficult to deliver. In reference to adolescents, Plan International told the Committee that challenges are amplified and risks, such as gender-based violence, child, early and forced marriages and union, unintended pregnancy and maternal mortality are increased while “the structures, networks and systems that can protect them–such as education settings and health services–are likely to be weakened or destroyed.”²²⁹

85. The Committee heard that the FCDO has undertaken work on the provision of SRHR services in its response to humanitarian situations. The FCDO has adopted the Minimum Initial Services Package which is a core package of services that should be implemented with 48 hours of the onset of a crisis.²³⁰ Equally, UK support to the UNFPA helped with the distribution of essential dignity and menstrual kits to women and girls in Ukraine and dignity kits in Moldova, including to refugee populations.²³¹ However, Plan International UK told the Committee that “funding for SRHR within humanitarian settings is a significant gap for many donor governments, including the UK, with global funding only reaching 43% of the required $1 billion needed in 2022.”²³²

86. The FCDO has made positive progress in tackling sexual and reproductive health in humanitarian contexts, such as by adopting the Minimum Initial Services Package. The FCDO should ensure that SRHR services in these contexts reach the most marginalised groups and consider how to further implement SRHR aid programming in humanitarian contexts to meet need. This should include knowledge-sharing between teams within the FCDO who work on fragile, conflict-affected, and humanitarian contexts and sexual and reproductive health, such as teams working on global health, humanitarian crisis response and the Office for Conflict, Stabilisation and Mediation.

7 Diplomatic support for sexual and reproductive health

87. The delivery of SRHR aid programming, particularly under the approach of ‘Leave No One Behind’, may be particularly challenging in certain countries and contexts. Evidence to the Committee underlined a global pushback against women’s rights, particularly in relation to sexual and reproductive health. In its International Women and Girls Strategy 2023, the FCDO stated

In recent years, systematic attempts by regressive actors to roll back on women’s and girls’ rights have gained momentum at the international, national and community level, and are amplified online. … These attempts at rollback threaten to reverse the gains that have been made since the Beijing Declaration, undermining the global and grassroots progress towards gender equality that the UK has for so long championed and supported. This attack on women’s and girls’ rights is an attack on our values and the fabric of democracy, and a key part of the broader global trend towards authoritarianism.²³³

The FCDO’s White Paper on International Development, published in November 2023, committed to defending and progressing SRHR, including safe abortion, and delivering on the campaign to end preventable deaths of mothers, babies and children through a variety of means including diplomacy.²³⁴

88. In its most recent Human Rights and Democracy Report, the FCDO stated that it had used its membership of the UN Human Rights Council and other multilateral bodies to promote the rights of women and girls and “the broader equalities agenda”, which included comprehensive sexual and reproductive health and rights and the protection of LGBT+ rights.²³⁵ It added that the UK co-led on a joint statement on SRHR and bodily autonomy that was signed by 71 countries and delivered for the first time at the United Nations General Assembly 3rd Committee for Human Rights. It stated that the UK would continue to take a leading role on progressing SRHR, including by supporting the Rwandan-hosted Women Deliver Conference, the largest gathering of women’s rights organisations globally.²³⁶

89. LGBT+ people may also face additional challenges in accessing SRHR services due to the criminalisation of their sexuality or gender expression. This may also bring additional challenges to the FCDO in ensuring that SRHR aid programming is inclusive. The Committee also heard that there had been a rollback of LGBT+ rights, particularly in Ghana and Uganda.²³⁷ Minister Mitchell argued that many countries were “on a journey” in relation to LGBT+ rights, as the UK had been previously, adding

We do not shy away from difficult conversations and we ensure that LGBT+ inclusion is, like disability, central to our programmes. We use our diplomatic clout to advance legal protection and decriminalisation and, in particular for us, to ensure inclusive access to HIV/AIDS prevention and treatment. We are using every tool at our disposal to try to make progress to reduce discrimination, to use our technical assistance and support for partnerships in countries where there are people who are trying to move civil society in the right direction.²³⁸

90. Contributors to the inquiry recognised that the FCDO has long been a champion for sexual and reproductive health and rights. They also agreed that there had been a global pushback against women’s rights, and praised the FCDO’s acknowledgment of this.²³⁹ However, MSI Reproductive Services suggested that the FCO-DFID merger offered an opportunity for the UK to do more by using “the involvement of UK embassies, High Commissions and other FCDO international offices in supporting SRHR through diplomatic negotiations and support to SRHR civil society organisations”.²⁴⁰ The Independent Commission for Aid Impact (ICAI) also acknowledged potential future benefits from combining development and diplomatic skills when it looked at the merger of the Foreign and Commonwealth Office and the Department for International Development, but it warned “whether the merger will deliver this potential, however, remains uncertain.”²⁴¹

91. Over recent years, there has been an alarming rollback on the rights of women and girls globally, of which SRHR are integral, and further criminalisation of LGBT+ people. The merger of the Foreign and Commonwealth Office with the Department for International Development offers an opportunity for the FCDO to better use its diplomatic position to obtain its development goals on sexual and reproductive health and rights, such as by supporting access to these rights by women and girls and other marginalised groups. The UK should continue to position itself as a global leader on SRHR by (a) continuing to advance the principle of ‘Leave No One Behind’ across its aid programming and (b) continuing to raise the issue of the rights of women and girls, LGBT+ people and other marginalised groups both in multilateral fora and in bilateral conversations with partners in regard to SRHR. It should ensure that its diplomatic and development work on SRHR are integrated and complementary.

8 Conclusions and recommendations

The FCDO’s work on sexual and reproductive health

1. The cuts to bilateral and multilateral Official Development Assistance on sexual and reproductive health and rights (SRHR) since 2020 have had a considerably negative impact upon the aid recipients of SRHR programmes, particularly on women and girls and those belonging to marginalised groups. The abrupt nature of the aid cuts damaged the UK’s relationships with aid partners and its reputation as an aid delivery partner. (Paragraph 15)

2. The Committee welcomes the FCDO’s recent policy statements which have renewed the FCDO’s commitment to SRHR. To turn words into action, this should be backed up by consistent and long-term funding. (Paragraph 16)

3. In order to meet previously set targets in this area, the FCDO should calculate a minimum percentage of bilateral Official Development Assistance to be spent on sexual and reproductive health and rights (SRHR). It should explain to the Committee why it has chosen this target and ensure adequate commitment of funding. This should not be lower than spending levels before the covid-19 pandemic. The proportion of bilateral spending on population programmes/policies and reproductive health should also not be any lower than before the covid-19 pandemic at 4% of bilateral ODA spending per annum. To ensure reliability and predictability of funding, the FCDO should ensure that programme funding is given on a multiyear basis. Programmes should run for a minimum of 5 years where possible. (Paragraph 17)

4. Multilateral organisations are sometimes best placed to act and implement aid programming on sexual and reproductive health. The UK has historically been a key donor to multilateral organisations working on sexual and reproductive health. Evidence to the Committee has shown the benefits of both bilateral and multilateral funding. The FCDO should continue to support key multilateral organisations such as the UNFPA, the Global Fund, Unitaid and UNAIDS that are uniquely placed to work with national governments, and with civil society and communities, on aspects of SRHR. As a minimum, it should meet its prior commitments to these organisations. It should also restore discretionary funding to at least the same levels as before the covid-19 pandemic. (Paragraph 18)

Family planning

5. The Committee is pleased to see the FCDO’s continuing commitment to family planning as a core part of its work on sexual and reproductive health, including the provision of safe and legal abortion services. However, the FCDO’s abrupt and sudden cuts to SRHR programmes directly led to the reduction in vital services for women and girls and damaged the UK’s work and reputation in this area. As part of its renewed commitment to SRHR programmes, the FCDO should ensure that it meets its original funding commitment made in November 2019 to the UNFPA Supplies Partnership to enable the delivery of vital healthcare services for women and girls. It should also consider restoring core funding to the UNFPA to £20 million annually. (Paragraph 27)

6. The use of telemedicine and self-management in SRHR programmes could increase the accessibility, reach and effectiveness of such programmes. The FCDO should consider how to incorporate the use of telemedicine and self-management of SRHR in its aid programming, such as in providing access to safe abortion, and update the Committee no later than Autumn 2024 on its progress. (Paragraph 28)

Maternal and newborn health

7. The FCDO’s approach papers on ending preventable deaths of mothers, babies and children by 2030 (EPD) and health systems strengthening (HSS) show a positive step in the right direction. However, in the absence of key targets for progress or regular updates, it has proved difficult to assess the effectiveness of the UK’s work in this area. The Committee welcomes the FCDO’s commitment to publish a future progress report on its EPD and HSS work in 2024, and to provide future updates on this work. However, more frequent updates on the FCDO’s work on EPD and HSS are needed in order to map the progress towards SDG commitments by 2030. The FCDO should publish key targets and achievements on an annual basis for its approach papers on Ending Preventable Deaths and Strengthening Health Systems. (Paragraph 33)

8. Access to clean water and the provision of adequate sanitation and hygiene reduces the risk of maternal and newborn mortality. In complementarity to its approach on SRHR spending, the FCDO should calculate and justify a minimum bilateral ODA percentage that it must spend on WASH to reach its development targets. This target should not be lower than 2% per annum. The FCDO should also ensure that WASH and SRHR programmes adopt a complementary and integrated approach. (Paragraph 38)

9. The involvement of trained health personnel and access to adequate health care facilities for maternal and newborn health improves health outcomes for the mother and child. The FCDO should support the strengthening of healthcare systems by prioritising investment in the development of health infrastructure, particularly WASH infrastructure. The FCDO should prioritise support for training and retention of health personnel in low-and-middle-income countries. The FCDO should calculate a minimum percentage of ODA to be spent on the training of health personnel in low-and-middle-income countries. It should explain to the Committee why it has chosen this target and ensure adequate commitment of funding. (Paragraph 39)

Women and girl’s health

10. To meet menstrual health needs, women and girls must be able to access accurate, timely and age-appropriate information about menstruation. In addition, they need access to WASH services and inclusive infrastructure. Without adequate services and facilities, managing menstruation can be a challenge for women and girls in low-and-middle-income countries, preventing them from accessing education and employment opportunities. This could undermine the UK Government’s work in other sectors, particularly in education. (Paragraph 42)

11. The FCDO should support menstrual health by supporting the provision of WASH services and infrastructure and access to menstrual products. In particular, the FCDO should ensure that its work in the education and WASH sectors complement its SRHR work in this area, for example, ensuring that education programmes include the provision of appropriate sanitary facilities. It should also support age-appropriate education on menstruation. (Paragraph 43)

12. The FCDO has not sufficiently addressed the threat of gynaecological disease in its SRHR programming, despite the risk it poses to the SRH of women and girls. The prevalence of cervical cancer among women and girls in lower-income countries is also concerning, especially as adequate provision of the HPV vaccine could greatly reduce the threat of cervical cancer to women and girls. The FCDO should look to incorporate care of gynaecological disease, including so-called ‘benign’ gynaecological disease, into its SRHR programming. It should also continue to support the provision of the HPV vaccine to women and girls and look to align this with its SRHR programming where possible. (Paragraph 46)

13. Female genital schistosomiasis is a painful and debilitating but treatable condition affecting up to 56 million women. FGS is best tackled through an integrated approach with wider SRHR programming, as well as with other areas of programming such as education, WASH and HIV and AIDS. The UK should integrate female genital schistosomiasis (FGS) care into its SRHR programming. This should include (a) improving access to adequate water, sanitation and hygiene facilities, (b) increasing girls’ enrolment in education and supporting distribution of FGS medicine in schools, (c) distributing educational materials on WASH, and (d) considering integrating FGS and HIV and AIDS programming, including by discussing the integration of HIV and AIDS programming with FGS care with its multilateral partners, such as the Global Fund. (Paragraph 50)

14. The UK Government has long been an opponent of female genital mutilation (FGM) and has worked against FGM both bilaterally and multilaterally. The UK Government should renew its commitment to preventing female genital mutilation through funding multilateral and bilateral programmes, including those tackling the medicalisation of FGM and ‘cross-border cutting’, which involves moving women and girls across national borders to undergo FGM or cutters across national borders to perform the practice. (Paragraph 55)

Sexually transmitted infections, including HIV and AIDS

15. The goal of ending AIDS cannot be reached without access to proper care and treatment for all people living with HIV, and action to bring down the large numbers of people newly acquiring HIV (1.3 million in 2022, far above the global target of 500,000 by 2025). More than 40 years after the first cases, the AIDS pandemic continues to pose a major barrier to global development, and COVID-19 has had a serious and significant impact on the ability of healthcare services to reach global targets on HIV and AIDS. Recent reductions in the UK’s bilateral aid spending on HIV and AIDS, alongside major cuts to its funding to UNAIDS, Unitaid and the Global Fund at the same time is, therefore, particularly concerning. (Paragraph 64)

16. To support the achievement of global targets on ending AIDS, and to retain the UK’s historical leadership in this important area of SRHR, the FCDO should retain bilateral investments in HIV prevention and treatment, both through dedicated HIV programming and in its support for integrated SRHR, with a special focus on marginalised groups such as adolescent girls and young women, as well as key population communities. The FCDO should continue to support, and pay its fair share to, the Global Fund, which is a major funder of HIV prevention and treatment, and invest in the community-led responses and human rights programmes which are so essential to an effective AIDS response. (Paragraph 65)

17. The FCDO should also actively encourage the effective integration of HIV into sexual and reproductive health services, by explicitly including HIV in SRHR policy documents and funding calls and requiring the inclusion of organisations with HIV expertise in the SRHR programmes that it funds. These services should also be designed, implemented, monitored and evaluated in close partnership with community-led and civil society organisations, recognising the vital role that they play in ensuring that services are responsive to local needs and are able to reach those most left behind. (Paragraph 66)

18. The FCDO should have a holistic and integrated approach to all of its sexual and reproductive healthcare programming to enable recipients to live a healthy life and reach their full potential. When funding sexual and reproductive healthcare, the UK should also consider investing in a ‘one-stop shop’ approach to SRHR which would help to ensure truly comprehensive sexual and reproductive healthcare and reduce barriers to accessing lifesaving HIV and SRHR services, such as travel costs, time, and stigma. (Paragraph 68)

Reaching marginalised and hard-to-reach groups

19. Access to SRHR services and comprehensive sex education is vital to adolescents; however, adolescents may often face barriers to accessing sexual and reproductive health services. Ensuring that women and girls are fully educated on sexual and reproductive health can empower them and give them the autonomy to make informed decisions in life. Better education among women and girls is also linked to better sexual and reproductive health outcomes. Considering the UK’s commitment to girls’ education, the FCDO should embed comprehensive age-appropriate sex education into its ODA-funded education programmes. (Paragraph 74)

20. People accessing SRHR services may be vulnerable, such as adolescents. The FCDO should ensure that staff who are delivering FCDO-funded aid programmes receive training to be able to recognise safeguarding concerns when interacting with aid recipients. These staff should be empowered to signpost aid recipients to the appropriate services and support. (Paragraph 75)

21. People with disabilities may face additional barriers to accessing SRHR programmes and providing services to people with disabilities may often take additional resources. Consequently, organisations implementing development programmes may be disincentivised from reaching marginalised groups as programmes are often required to show that they have reached as many recipients as possible. The FCDO should ensure that all SRHR programmes are accessible to people with disabilities. FCDO’s SRHR programmes should include a dedicated budget, baselines, targets, and key performance indicators so that people with disabilities are fully integrated into aid programmes. In addition, all FCDO programming on SRHR should record disaggregated data on aid recipients, including age, sex, and disability to assess how successful they are at inclusivity. (Paragraph 80)

22. People from marginalised groups, such as people with disabilities and LGBT+ people, may face additional and unique challenges in accessing SRHR services. The FCDO should ensure its commitment to the principle of ‘Leave No One Behind’ in all its SRHR aid programmes. The FCDO should include hard-to-reach aid recipients, often those belonging to often marginalised and excluded groups, in the planning, development, and delivery of aid programmes on SRHR and should invest in community and civil society organisations led by these populations, recognising that they are essential partners in achieving health outcomes. (Paragraph 83)

23. The FCDO has made positive progress in tackling sexual and reproductive health in humanitarian contexts, such as by adopting the Minimum Initial Services Package. The FCDO should ensure that SRHR services in these contexts reach the most marginalised groups and consider how to further implement SRHR aid programming in humanitarian contexts to meet need. This should include knowledge-sharing between teams within the FCDO who work on fragile, conflict-affected, and humanitarian contexts and sexual and reproductive health, such as teams working on global health, humanitarian crisis response and the Office for Conflict, Stabilisation and Mediation. (Paragraph 86)

Diplomatic support for sexual and reproductive health

24. Over recent years, there has been an alarming rollback on the rights of women and girls globally, of which SRHR are integral, and further criminalisation of LGBT+ people. The merger of the Foreign and Commonwealth Office with the Department for International Development offers an opportunity for the FCDO to better use its diplomatic position to obtain its development goals on sexual and reproductive health and rights, such as by supporting access to these rights by women and girls and other marginalised groups. The UK should continue to position itself as a global leader on SRHR by (a) continuing to advance the principle of ‘Leave No One Behind’ across its aid programming and (b) continuing to raise the issue of the rights of women and girls, LGBT+ people and other marginalised groups both in multilateral fora and in bilateral conversations with partners in regard to SRHR. It should ensure that its diplomatic and development work on SRHR are integrated and complementary. (Paragraph 91)

Formal minutes

International Development Committee

Tuesday 9 January 2024

Members present:

Sarah Champion, in the Chair

Dr Rosena Allin-Khan

Mr Richard Bacon

Theo Clarke

Mrs Pauline Latham

Chris Law

Nigel Mills

Rt Hon David Mundell

Kate Osamor

Mr Virendra Sharma

Draft Report (FCDO’s approach to sexual and reproductive health), proposed by the Chair, brought up and read.

Ordered, That the draft Report be read a second time, paragraph by paragraph.

Paragraphs 1 to 91 read and agreed to.

Summary agreed to.

Resolved, That the Report be the First Report of the Committee to the House.

Ordered, That the Chair make the Report to the House.

Ordered, That embargoed copies of the Report be made available (Standing Order No. 134).

Adjournment

[Adjourned till Tuesday 16 January at 2.00 p.m.]

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Witnesses

The following witnesses gave evidence. Transcripts can be viewed on the inquiry publications page of the Committee’s website.

Tuesday 23 May 2023

Caroline Guinard, FCDO Programmes Director, MSI Reproductive Choices; Mr Matt Jackson, Chief of the London Representation Office, United Nations Population Fund (UNFPA); Dr Milly Kaggwa, Senior Technical Advisor, Global Medical Team, Population Services International; Dr Sebastian Taylor, Representative, Coalition of Health Professional Bodies, Royal Colleges for SRHRQ1–53

Asenath Mwithigah, Chief Executive Officer, Orchid Project; Tinebeb Berhane, Country Director, ActionAid EthiopiaQ54–71

Tuesday 04 July 2023

Kirsty Smith, Chief Executive Officer, CBM UK; Dr Tsitsi Chataika, CBM Zimbabwe Country Advisory Panel (non-exec role), CBM UK; Saskia Perriard-Abdoh, Head of Policy and Public Affairs, Kaleidoscope Trust; Alessandra Aresu, Director, Global Inclusive Health, Humanity & InclusionQ72–80

Alice Welbourn, Founding Director, Salamander Trust; Dr Camilla Ducker, Senior Advisor, Global NTD Programme, WHO HQ, Representative for the FGS Integration Group (FIG); Ms Fionnuala Murphy, Head of Global Advocacy, Frontline AIDSQ81–91

Tuesday 12 September 2023

Rt Hon Andrew Mitchell MP, Minister of State (Development and Africa), Foreign, Commonwealth & Development OfficeQ92–151

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Published written evidence

The following written evidence was received and can be viewed on the inquiry publications page of the Committee’s website.

SRH numbers are generated by the evidence processing system and so may not be complete.

1 CBM UK (SRH0032)

2 CBM UK (Global Disability Inclusion) (SRH0011)

3 Commonwealth Children & Youth Disability Network (CCYDN) (SRH0010)

4 Eastham, Dr Rachael ; Limmer, Professor Mark ; Ibembe, Dr Peter ; Muhangi, Lawrence ; Quintero-Veloz, Ximena ; Karp, Dr Celia ; Maharjan, Manju ; Mercer, Raul ; and Ramirez, Carlota (SRH0007)

5 FGS Integration Group (FIG) (SRH0030)

6 Fledderjohann, Dr Jasmine (Senior Lecturer, Lancaster University); Mishra, Dr Swayamshree (Postdoc, Indian Institute of Technology Kanpur); Rathi, Dr Ankita (Postdoc, Lancaster University); and Vasudev, Dr Charumita (Postdoc, Lancaster University) (SRH0006)

7 Foreign, Commonwealth & Development Office (SRH0033)

8 Foreign, Commonwealth & Development Office (SRH0003)

9 GNP+ (Global Network of People Living with HIV) (SRH0023)

10 Gavi, the Vaccine Alliance (SRH0021)

11 Humanity & Inclusion UK (SRH0012)

12 International Community of Women Living with HIV (ICW) (SRH0024)

13 International Planned Parenthood Federation (IPPF) (SRH0015)

14 MENA Rosa (SRH0026)

15 MSI Reproductive Choices (SRH0016)

16 Neal, Dr Sarah (Associate Professor in Global Health, University of Southampton) (SRH0019)

17 Plan International UK (SRH0014)

18 Royal College of Obstetricians and Gynaecologists (SRH0002)

19 Royal College of Obstetricians and Gynaecologists; Royal College of Midwives; Royal College of Nursing; Royal College of Paediatrics and Child Health; Faculty of Sexual and Reproductive Healthcare; and British Society of Abortion Care Providers (SRH0004)

20 STOPAIDS, Frontline AIDS, Salamander Trust and Making Waves. (SRH0018)

21 Salamander Trust; and Frontline AIDS (SRH0029)

22 Sheffield Hallam University (SRH0022)

23 Sightsavers (SRH0013)

24 UNFPA - United Nations Population Fund (SRH0017)

25 Unlimit Health; FGS Integration Group (FIG); Frontline AIDS; and Global Schistosomiasis Alliance (GSA) (SRH0005)

26 VSO (SRH0025)

27 ViiV Healthcare (SRH0009)

28 WaterAid (SRH0008)

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List of Reports from the Committee during the current Parliament

All publications from the Committee are available on the publications page of the Committee’s website.

Session 2023–24

Number	Title	Reference
1st Special Report	Investment for development: The UK’s strategy towards Development Finance Institutions: Government response to the Committee’s Ninth Report	HC 367

Session 2022–23

Number	Title	Reference
1st Report	Racism in the aid sector	HC 150
2nd Report	Food insecurity	HC 504
3rd Report	From Srebrenica to a safer tomorrow: Preventing future mass atrocities around the world	HC 149
4th Report	(Fourth Report of the International Development Committee) - Developments in UK Strategic Export Controls	HC 282
5th Report	Extreme poverty and the Sustainable Development Goals	HC 147
6th Report	Aid spending in the UK	HC 898
7th Report	Debt relief in low-income countries	HC 146
8th Report	UK aid for refugee host countries	HC 426
9th Report	Investment for development: The UK’s strategy towards Development Finance Institutions	HC 884
1st Special Report	Afghanistan: UK support for aid workers and the Afghan people: Government response to the Committee’s Fifth Report	HC 152
2nd Special Report	Food insecurity: Government response to the Committee’s Second Report	HC 767
3rd Special Report	UK aid to Pakistan: Government Response to the Sixth Report of the Committee	HC 829
4th Special Report	From Srebrenica to a safer tomorrow: Preventing future mass atrocities around the world: Government response to the Committee’s Third Report	HC 992
5th Special Report	Racism in the aid sector: Government response to the Committee’s First Report	HC 956
6th Special Report	Extreme poverty and the Sustainable Development Goals: Government response to the Committee’s Fifth Report	HC 1177
7th Special Report	Aid spending in the UK: Government response to the Committee’s Sixth Report	HC 1367
8th Special Report	Debt relief in low-income countries: Government response to the Committee’s Seventh Report	HC 1393
9th Special Report	UK aid for refugee host countries: Government response to the Committee’s Eighth Report	HC 1917

Session 2021–22

Number	Title	Reference
1st Report	Assessing DFID’s results in nutrition Review: report from the Sub-Committee on the Work of ICAI	HC 103
2nd Report	Global Britain in demand: UK climate action and international development around COP26	HC 99
3rd Report	The UK’s approach to tackling modern slavery through the aid programme: report from the Sub-Committee on the Work of ICAI	HC 104
4th Report	International climate finance: UK aid for halting deforestation and preventing irreversible biodiversity loss: report from the Sub-Committee on the Work of ICAI	HC 730
5th Report	Afghanistan: UK support for aid workers and the Afghan people	HC 919
6th Report	UK aid to Pakistan	HC 102
1st Special Report	The humanitarian situation in Tigray: Government Response to the Committee’s Tenth Report of Session 2019–21	HC 554
2nd Special Report	The UK’s Support to the African Development Bank Group: report from the Sub-Committee on the work of ICAI: Government Response to the Committee’s Ninth Report	HC 555
3rd Special Report	DFID’s results in nutrition Review: report from the Sub-Committee on the work of ICAI: Government response to the Committee’s First Report	HC 780
4th Special Report	Global Britain in demand: UK climate action and international development around COP26: Government response to the Committee’s Second Report	HC 1008
5th Special Report	The UK’s approach to tackling modern slavery through the aid programme: report from the Sub-Committee on the Work of ICAI: Government response to the Committee’s Third Report	HC 1021

Session 2019–21

Number	Title	Reference
1st Report	Humanitarian crises monitoring: the Rohingya	HC 259
2nd Report	Effectiveness of UK aid: interim findings	HC 215
3rd Report	The Newton Fund review: report of the Sub-Committee on the work of ICAI	HC 260
4th Report	Effectiveness of UK aid: potential impact of FCO/DFID merger	HC 596
5th Report	Humanitarian crises monitoring: impact of coronavirus (interim findings)	HC 292
6th Report	The Changing Nature of UK Aid in Ghana Review: report from the Sub-Committee on the Work of ICAI	HC 535
7th Report	Progress on tackling the sexual exploitation and abuse of aid beneficiaries	HC 605
8th Report	Covid-19 in developing countries: secondary impacts	HC 1186
9th Report	The UK’s support to the African Development Bank Group: report from the Sub-Committee on the Work of ICAI	HC 1055
10th Report	The humanitarian situation in Tigray	HC 1289
1st Special Report	Follow up: sexual exploitation and abuse in the aid sector: Government Response to the First Report of the Committee	HC 127
2nd Special Report	Humanitarian crises monitoring: the Rohingya: Government Response to the First Report of the Committee	HC 658
3rd Special Report	The Newton Fund review: report of the Sub-Committee on the work of ICAI: Government response to the Committee’s Third Report	HC 742
4th Special Report	Effectiveness of UK Aid: Interim Report & Effectiveness of UK Aid: potential impact of FCO/DFID merger: Government Response to the Second & Fourth Reports	HC 820
5th Special Report	Humanitarian crises monitoring: impact of coronavirus (interim findings): Government Response to the Committee’s Fifth Report	HC 1160
6th Special Report	The Changing Nature of UK Aid in Ghana Review: report from the Sub-Committee on the Work of ICAI: Government response to the Committee’s Sixth Report	HC 1198
7th Special Report	Progress on tackling the sexual exploitation and abuse of aid beneficiaries: Government Response to the Seventh Report of the Committee	HC 1332
8th Special Report	Covid-19 in developing countries: secondary impacts: Government Response to the Eighth Report of the Committee	HC 1351

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Footnotes

1 The SDGs were agreed in 2015 by all UN Member States, with a goal of attainment by 2030.

2 United Nations, Sustainable Development Goals: Goal 3: Ensure healthy lives and promote well-being for all at all ages, accessed 30 October 2023

3 United Nations: Sustainable Development Goals: Goal 5: Achieve gender equality and empower all women and girls, accessed 30 October 2023

4 As above. For more information on the International Conference on Population and Development, see here. For more information on the Beijing Platform for Action and the outcome documents of their review conferences, see here.

5 Foreign, Commonwealth & Development Office, Statistics on International Development: final UK aid spend 2022, Additional Tables: Statistics on International Development, 14 September 2023, updated 20 September 2023

6 See table below for figures.
The European Parliamentary Forum for Sexual and Reproductive Rights developed a new standard methodology to capture donors’ ODA spending on SRHR. The DSW, a global development organisation, publishes an annual report which estimates the aid spending of donors based on this methodology. (PQ 137446 [on Development Aid: Health Services], 15 March 2022)
Key multilateral agencies have also faced major cuts, which are detailed below.

7 Details on the methodology for calculating the SRHR, FP and RMNCH spending can be found in the report. The report states that “All development finance statistics are measured in USD constant prices with reference to the year 2020, as per OECD DAC database. This allows for a closer idea of the volume of flows over time, as adjustments have been made to cover inflation and exchange rates between a donor’s currency and USD.”
The data for SRHR, FP and RMNCH cannot be treated as distinct spending funds, as there is overlap between the categories.

8 Bilateral ODA is “ODA provided for a specific purpose (normally a particular country, region or sector) which is given directly to recipient governments or delivered through other UK partners.” Bilateral through multilateral is “ODA provided for a specific purpose (normally a particular country, region or sector) which is given directly to recipient governments or delivered through other UK partners.” Multilateral spending is ‘ODA that is given directly to a multilateral organisation without being designated for a specific purpose. It is pooled with other donors’ funding’. (Foreign, Commonwealth & Development Office, Statistics on international development: final UK aid spend 2022, 14 September 2023, updated 20 September 2023)

9 PQ 2293 [on Development Aid: Genito-urinary Medicine], 21 November 2023. These figures have not been adjusted for inflation.

10 The DSW changed the methodology for calculating SRHR spending in the 2023 report, which gives SRHR, FP and RMNCH figures for 2019 to 2021. This report has therefore not used figures from earlier reports as these would not be directly comparable.

11 This report has used the UK Government’s spending on population policies/programmes and reproductive health as recorded according to the Organization for Economic Co-Operation and Development’s Development Assistance Committee Codes. The FCDO publish this data annually in its Statistics on International Development. The Donors Delivering for SRHR reports counts a proportion of this spending as SRHR as well as spending categorised under other DAC codes such as those for ‘basic sanitation’. (DSW, Donors Delivering for SRHR: Report 2023, 29 June 2023)

12 These figures have not been indexed.

13 PQ 197436 [on Developing Countries: Genito-urinary Medicine], 12 September 2023

14 Sightsavers (SRH0013), Plan International UK (SRH0014), International Planned Parenthood Federation (IPPF) (SRH0015) and MSI Reproductive Choices (SRH0016)

15 MSI Reproductive Choices (SRH0016)

16 International Planned Parenthood Federation (IPPF) (SRH0015)

17 Plan International UK (SRH0014) and Sightsavers (SRH0013)

18 DevTracker, DevTracker Programme GB-GOV-1–300713 Documents, accessed 11 December 2023

19 United Nations Population Fund (UNFPA) (ARA0002) and PQ 203848 [on UN Population Fund], 26 October 2023

20 PQ 1573 [on UN Population Fund], 22 November 2023

21 United Nations Population Fund (UNFPA) (ARA0002). This figure was given to the Committee in US Dollars. To maintain accuracy, the number has been kept in USD and not converted to GBP.

22 United Nations Population Fund (UNFPA) (ARA0002). The programme in Pakistan focused on family planning and improving maternal health. Cuts to the Syria programme affected essential sexual and reproductive services (including mobile medical teams and childbirth delivery points), dignity kits, capacity building and training. The Nigeria programme faced a £6.5 million cut, although UNFPA noted that some funding has since been restored, including a recent contribution of £1.6 million for Nigeria.

23 Q77 [Kirsty Smith]

24 As above.

25 See footnote 8 for an explanation on bilateral, bilateral through multilateral and multilateral ODA. The UK works with multilateral organisations including the UNFPA, UNAIDS, Unitaid, the Global Fund, and the Global Financing Facility to provide funding for sexual and reproductive health and rights.

26 UNFPA - United Nations Population Fund (SRH0017)

27 United Nations Population Fund (UNFPA) (ARA0002)

28 The Global Fund combats HIV, TB and malaria in 126 countries, with around a third of its investments directly benefitting SRHR. (PQ 725 [on Women: HIV Infection], 17 November 2023)

29 Foreign, Commonwealth and Development Office, UK aid will save over one million lives from killer diseases, 14 November 2022

30 STOPAIDS, Frontline AIDS, Salamander Trust and Making Waves. (SRH0018)

31 UNAIDS is the UN agency working to end AIDS as a public health threat by 2030, in line with the SDGs. (UNAIDS, About UNAIDS, accessed 29 November 2023)

32 STOPAIDS, Frontline AIDS, Salamander Trust and Making Waves. (SRH0018) and UNAIDS, UNAIDS statement on UK’s proposed reduction in financial support, 29 April 2021

33 STOPAIDS, Frontline AIDS, Salamander Trust and Making Waves. (SRH0018)

34 Unitaid works to make “new health products available and affordable for people in low- and middle-income countries.” (Unitaid, About Us, 29 November 2023)

35 PQ 1574 [on Unitaid: Finance], 16 November 2023

36 ViiV Healthcare (SRH0009) and Unitaid, UK government funding cuts: statement from Unitaid’s Chair and Executive Director, 10 June 2021. The UK has contributed £574 million as of November 2023. (PQ 1574 [on Unitaid: Finance], 16 November 2023)

37 Qq9–10 [Matt Jackson]

38 Q77 [Kirsty Smith]

39 Q77 [Alessandra Aresu]

40 As above.

41 Q77 [Kirsty Smith]

42 MSI Reproductive Choices (SRH0016)

43 International Planned Parenthood Federation (IPPF) (SRH0015)

44 Humanity & Inclusion UK (SRH0012)

45 Kaleidoscope Trust, About Us, accessed 4 December 2023

46 Q80 [Saskia Perriard-Abdoh]

47 Foreign, Commonwealth and Development Office equalities assessment document and accompanying note (FUA0087)

48 As above.

49 Correspondence from the Minister for Development & Africa regarding the Equalities Index Assessment for ODA allocations in 2022–23 - 26 October 2023

50 As above.

51 Correspondence from the Minister for Development and Africa regarding ODA programme allocations for 2023–24–2024–25 and Equality Impact Assessments - 19 July 2023

52 As above.

53 As above.

54 Foreign, Commonwealth & Development Office, Ending preventable deaths of mothers, babies and children by 2030, 14 December 2021

55 Foreign, Commonwealth & Development Office, Health systems strengthening for global health security and universal health coverage, 14 December 2021

56 Foreign, Commonwealth & Development Office, FCDO disability inclusion and rights strategy 2022 to 2030, 16 February 2022

57 Foreign, Commonwealth & Development Office, UK government’s strategy for international development, 16 May 2022

58 Foreign, Commonwealth & Development Office, International women and girls strategy 2023 to 2030, 8 March 2023

59 Foreign, Commonwealth & Development Office, International development in a contested world: ending extreme poverty and tackling climate change. A white paper on international development, 20 November 2023

60 HC Deb, 12 July 2023, col 140WH [Westminster Hall]

61 Foreign, Commonwealth & Development Office, International development in a contested world: ending extreme poverty and tackling climate change. A white paper on international development, 20 November 2023

62 UNFPA, Family Planning, accessed 2 November 2023

63 United Nations Department of Economic and Social Affairs, World Family Planning 2022: Meeting the changing needs for family planning: Contraceptive use by age and method | UN DESA Publications, December 2022
“Modern contraception” includes pills, implants, intrauterine devices, surgical procedures, and barrier methods, such as condoms. (World Health Organization, Family planning/contraception methods, 5 September 2023)

64 United Nations Department of Economic and Social Affairs, World Family Planning 2022: Meeting the changing needs for family planning: Contraceptive use by age and method | UN DESA Publications, December 2022. The FCDO’s International women and girls strategy 2023 to 2030 offers a different estimate, stating that an estimated 218 million women in low and middle-income countries want to avoid or delay pregnancy but are not currently using modern contraception.
According to the World Health Organization (WHO), reasons for this slow increase include a limited choice of methods, limited access to services, particularly among young, poorer and unmarried people, fear or experience of side-effects, cultural or religious opposition, poor quality of available services, users’ and providers’ bias against some methods and gender-based barriers to accessing services. (World Health Organization, Family planning/contraception methods, updated 5 September 2023)

65 Commissioned by the Department for International Development and published in 2016, the report ‘Benefits of Investing in Family Planning’ identified individual, household, community/country and global level benefits to family planning. Benefits included poverty reduction, hunger reduction, empowerment of women, better educational outcomes, reduction in annual maternal deaths, and reduction in child death and injury. (Department for International Development, Benefits of Investing in Family Planning, 1 December 2016)

66 UNFPA - United Nations Population Fund (SRH0017)

67 FP2030, United Kingdom - Family Planning 2030, accessed 13 November 2023

68 As above.

69 Family Planning 2020, FP2020 Progress Report - Executive Summary, accessed 13 November 2023

70 Foreign, Commonwealth & Development Office (SRH0003)

71 Department for International Development, UK co-hosts international Family Planning Summit, 29 June 2017 and Department for International Development, Family Planning Summit: Summary of UK Commitments, 11 July 2017

72 PQ 104172 [on Development Aid: Family Planning], 9 December 2022

73 FP2030, Introducing FP2030 - Family Planning 2030, 27 January 2021

74 PQ 34832 [on Africa: Genito-urinary Medicine], 18 July 2022

75 Plan International UK (SRH0014)

76 Foreign, Commonwealth & Development Office, International development in a contested world: ending extreme poverty and tackling climate change. A white paper on international development, 20 November 2023

77 Qq17–18 [Matt Jackson]

78 Qq10–11. Commodities were described as “contraception and maternal health medicines as well, so anything that might be needed in family planning or delivery, all of those different component parts.”

79 Q10 [Matt Jackson]

80 Royal College of Obstetricians and Gynaecologists (SRH0002)

81 Foreign, Commonwealth & Development Office (SRH0003). The programme is on Development Tracker. (DevTracker, The Reproductive Health Supplies Programme, accessed 15 May 2023) The document Annual review (59432839) 300713 (Published - January, 2021) on DevTracker details the original budget for the programme.

82 Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Royal College of Nursing, Royal College of Paediatrics and Child Health, Faculty of Sexual and Reproductive Healthcare, British Society of Abortion Care Providers (SRH0004)

83 International Planned Parenthood Federation (IPPF) (SRH0015)

84 As above.

85 World Health Organization, Abortion, 25 November 2021

86 Foreign, Commonwealth & Development Office, International women and girls strategy 2023 to 2030, 8 March 2023

87 As above.

88 Foreign, Commonwealth & Development Office (SRH0003)

89 PQ 1173 [on Safe Abortion Action Fund], 23 May 2022 and Foreign, Commonwealth & Development Office, DevTracker, DevTracker Programme GB-GOV-1–300875 Transactions, last updated 30 June 2022

90 Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Royal College of Nursing, Royal College of Paediatrics and Child Health, Faculty of Sexual and Reproductive Healthcare, British Society of Abortion Care Providers (SRH0004). The submission from the Royal College of Obstetricians and Gynaecologists alone also made similar comments. (Royal College of Obstetricians and Gynaecologists (SRH0002))

91 Royal College of Obstetricians & Gynaecologists, Position statement: Self-managed abortion, accessed 13 December 2023
The World Health Organization defines self-management of abortion as “Self-management of the entire process of medical abortion or one or more of its component steps, such as self-assessment of eligibility for medical abortion, self-administration of medicines without the direct supervision of a health worker, and self-assessment of the success of the abortion process.” (World Health Organization, Abortion care guideline, 8 March 2022)

92 Royal College of Obstetricians & Gynaecologists, Best practice in telemedicine for abortion care, 2022
The World Health Organization defines telemedicine (or telehealth) as “A mode of health service delivery where providers and clients, or providers and consultants, are separated by distance. That interaction may take place in real time (synchronously), e.g. by telephone or video link. But it may also take place asynchronously (store and forward), when a query is submitted and an answer provided later, e.g. by email or text/voice/audio message.” (World Health Organization, Abortion care guideline, 8 March 2022)

93 Royal College of Obstetricians and Gynaecologists (SRH0002)

94 Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Royal College of Nursing, Royal College of Paediatrics and Child Health, Faculty of Sexual and Reproductive Healthcare, British Society of Abortion Care Providers (SRH0004)
The World Health Organization has recommended “the option of telemedicine as an alternative to in-person interactions with the health worker to deliver medical abortion services in whole or in part. (World Health Organization, Abortion care guideline, 8 March 2022)

95 Q148

96 World Health Organization, Maternal mortality, 22 February 2023

97 World Health Organization, Newborn Mortality, 28 January 2022 and Q34 [Dr Sebastian Taylor]

98 Foreign, Commonwealth & Development Office, International development in a contested world: ending extreme poverty and tackling climate change. A white paper on international development, 20 November 2023

99 Foreign, Commonwealth & Development Office, Ending preventable deaths of mothers, babies and children by 2030, 14 December 2021

100 Foreign, Commonwealth & Development Office (SRH0003)

101 Foreign, Commonwealth & Development Office, Health systems strengthening for global health security and universal health coverage, 14 December 2021

102 Q141

103 As above.

104 Foreign, Commonwealth & Development Office (SRH0033). The FCDO also stated that it provided updates in the International Development Strategy Annual Report and the Annual Human Rights and Democracy Report. The references to the UK’s ending preventable deaths approach in the FCDO annual report and accounts 2022 to 2023, Delivering the UK’s international development strategy: 2023 progress update, and the Human Rights and Democracy Report 2022 refer only briefly to the UK Government’s work on EPD.

105 Q34

106 Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Royal College of Nursing, Royal College of Paediatrics and Child Health, Faculty of Sexual and Reproductive Healthcare, British Society of Abortion Care Providers (SRH0004)

107 Q34
Perinatal health refers to health from 22 completed weeks of gestation until 7 completed days after birth. (World Health Organization, Regional Office for Europe, Maternal and newborn health, accessed 4 December 2023)

108 Q34

109 Q35

110 WaterAid (SRH0008)

111 WaterAid (SRH0008) citing World Health Organization and UNICEF, Progress on WASH in health care facilities 2000–2021: Special focus on WASH and infection prevention and control, 30 March 2023

112 WaterAid (SRH0008)

113 Foreign, Commonwealth & Development Office, Ending preventable deaths of mothers, babies and children by 2030, 14 December 2021

114 Statistics are taken from tables A7 and A9. Multilateral figures for 2022 are not yet available.

115 WaterAid (SRH0008)

116 World Bank, Menstrual Health and Hygiene, 12 May 2022

117 WaterAid (SRH0008). WaterAid, UNICEF and WSUP created guidance on the definition of female friendly, which includes having a clearly marked female toilet section with a separate entrance; having access to menstrual products; and means for washing and/or disposal of menstrual products. The guidance also suggested that “A separate gender-neutral or third gender toilet or section may be suitable. Consultation with transgender or third gender groups would be essential to ensure that this is their preferred option and that it would not increase their risk of violence.” (WaterAid, Female-friendly public and community toilets: a guide for planners and decision makers, 4 October 2018)

118 World Bank, In times of COVID-19, the future of education depends on the provision of water, sanitation, and hygiene services, 24 September 2020

119 UNICEF DATA, Progress on drinking water, sanitation and hygiene in schools: 2000–2021 Data update - UNICEF DATA, 23 June 2022

120 Oral evidence taken on 28 February 2023, HC (2021–22) 1174, Q2 [Tim Wainwright] and WaterAid (WAS0001)

121 Royal College of Obstetricians and Gynaecologists (SRH0002). Benign gynaecological conditions include endometriosis, fibroids, menstrual conditions, infertility and subfertility, urogynaecological problems and obstetric fistula, among others.

122 As above.

123 Q142

124 World Health Organization, WHO releases new estimates of the global burden of cervical cancer associated with HIV, 16 November 2020 and Medical News Today, HPV and HIV: Are they related?, 15 April 2022

125 Gavi, the Vaccine Alliance (SRH0021)

126 As above.

127 Unlimit Health, FGS Integration Group (FIG), Frontline AIDS, Global Schistosomiasis Alliance (GSA) (SRH0005)

128 As above.

129 As above.

130 FGS Integration Group (FIG) (SRH0030)

131 Unlimit Health, FGS Integration Group (FIG), Frontline AIDS, Global Schistosomiasis Alliance (GSA) (SRH0005)

132 As above.

133 Q83 [Dr Camilla Ducker]

134 Q83 [Dr Camilla Ducker] and FGS Integration Group (FIG) (SRH0030)

135 FGS Integration Group (FIG) (SRH0030)

136 As above.

137 Unlimit Health, FGS Integration Group (FIG), Frontline AIDS, Global Schistosomiasis Alliance (GSA) (SRH0005)

138 As above.

139 UNAIDS, Global AIDS Strategy 2021–2026, 25 March 2021

140 Unlimit Health, FGS Integration Group (FIG), Frontline AIDS, Global Schistosomiasis Alliance (GSA) (SRH0005), FGS Integration Group (FIG) (SRH0030) and Q91 [Dr Camilla Ducker]

141 World Health Organization, Female genital mutilation, 31 January 2023

142 As above.

143 United Nations, International Day of Zero Tolerance for Female Genital Mutilation, accessed 6 November 2023

144 World Health Organization, Female genital mutilation, 31 January 2023 and Tinebeb Berhane, Country Director at ActionAid Ethiopia, told the Committee, in reference to FGM, that “it is a violation of dignity and of human rights in general.” (Q56)

145 UNFPA, Female genital mutilation (FGM) frequently asked questions, February 2022

146 UNFPA, Brief on the medicalization of female genital mutilation, June 2018

147 Q60

148 Royal College of Obstetricians and Gynaecologists (SRH0002)

149 Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Royal College of Nursing, Royal College of Paediatrics and Child Health, Faculty of Sexual and Reproductive Healthcare, British Society of Abortion Care Providers (SRH0004)

150 Q59

151 As above.

152 Asenath Mwithiga told the Committee that “Female genital mutilation and cutting are underpinned by social and gender norms, as I said, and therefore there is no one way that cuts across.” (Q61)

153 Q61 [Asenath Mwithiga]

154 Q63 [Tinebeb Berhane]

155 Plan International UK (SRH0014)

156 United Nations, Goal 5 | Department of Economic and Social Affairs, accessed 6 November 2023

157 Foreign, Commonwealth & Development Office, UK government’s strategy for international development, 16 May 2022 and Foreign, Commonwealth & Development Office, International women and girls strategy 2023 to 2030, 8 March 2023

158 In the FCDO’s written submission to the inquiry submitted in April 2023, it stated that the programme would run from 2019 to 2025. (Foreign, Commonwealth & Development Office (SRH0003)) However, during an oral evidence session in September 2023, the Minister for Development, Andrew Mitchell, told the Committee that the programme would run to 2027 (Q149). The FCDO’s development tracker also has the programme running until 2027. (Foreign, Commonwealth & Development Office, Development Tracker, Supporting the Africa-led Movement to End Female Genital Mutilation (FGM): Phase II, accessed 6 November 2023)

159 Foreign, Commonwealth & Development Office (SRH0003)

160 Foreign, Commonwealth & Development Office (SRH0003), UNFPA - United Nations Population Fund (SRH0017) and Foreign, Commonwealth & Development Office, Development Tracker, Sudan Free of Female Genital Mutilation Phase 2 (SFFGM2), accessed 6 November 2023)

161 Plan International UK (SRH0014)

162 Foreign, Commonwealth & Development Office (SRH0003)

163 World Health Organization, Sexually transmitted infections (STIs), 10 July 2023

164 World Bank, Sexually transmitted infections in developing countries : current concepts and strategies on improving STI prevention, treatment, and control, 4 March 2008

165 World Health Organization, Sexually transmitted infections (STIs), 10 July 2023

166 See Chapter 4 for discussion of the HPV vaccine.

167 Although highly effective, condoms do not offer protection for STIs that cause extra-genital ulcers (i.e., syphilis or genital herpes). (World Health Organization, Sexually transmitted infections (STIs), 10 July 2023)

168 World Health Organization, Sexually transmitted infections (STIs), 22 August 2022

169 World Health Organization, HIV and AIDS, 13 July 2023

170 UNAIDS, Global HIV & AIDS statistics — Fact sheet, accessed 13 November 2023

171 UNAIDS, Global HIV & AIDS statistics — Fact sheet, accessed 13 November 2023

172 NHS, About Pre-Exposure Prophylaxis (PrEP), accessed 16 June 2023

173 World Health Organization, WHO recommends the dapivirine vaginal ring as a new choice for HIV prevention for women at substantial risk of HIV infection, 26 January 2021

174 PrEPWatch, PrEP Ring, updated 6 January 2023 and ViiV Healthcare (SRH0009)

175 The Guardian, Injectable HIV-prevention drug to be made in South Africa for the first time, 18 May 2023

176 ViiV Healthcare (SRH0009)

177 The Guardian, The HIV prevention drug that could save millions of people – if they can afford it, 3 August 2022

178 As above.

179 The Guardian, The HIV prevention drug that could save millions of people – if they can afford it, 3 August 2022 and AfricaNews, If the price is right: The anti-HIV jab could be in clinics by August 2023, 1 December 2023

180 The Guardian, Injectable HIV-prevention drug to be made in South Africa for the first time, 18 May 2023

181 STOPAIDS, Frontline AIDS, Salamander Trust and Making Waves. (SRH0018)

182 As above.

183 PQ HL3524 [on Global Fund to Fight AIDS, Tuberculosis and Malaria: Females], 28 November 2022 cited in STOPAIDS, Frontline AIDS, Salamander Trust and Making Waves. (SRH0018).

184 STOPAIDS, Frontline AIDS, Salamander Trust and Making Waves. (SRH0018) and Q90 [Fionnuala Murphy]

185 aidsfonds, Stop AIDS, Stop discrimination: World AIDS Day 2023, 2023

186 Q82

187 Q90

188 Foreign, Commonwealth & Development Office, Leaving no one behind: Our promise, 6 March 2019

189 Dr Sarah Neal (Associate Professor in Global Health at University of Southampton) (SRH0019). Dr Neal distinguished between adolescents as young adolescents (below 15 years of age) and adolescents (15–19 years of age).

190 Dr Sarah Neal (Associate Professor in Global Health at University of Southampton) (SRH0019) citing Alister C. Munthali, Agnes Chimbiri and Eliya Zulu, “Adolescent Sexual and Reproductive Health in Malawi: A Synthesis of Research Evidence”, Occasional Report: The Alan Guttmacher Institute, No.15 (2004)

191 Dr Sarah Neal (Associate Professor in Global Health at University of Southampton) (SRH0019)

192 Dr Sarah Neal (Associate Professor in Global Health at University of Southampton) (SRH0019) citing Sarah Neal, Venkatraman Chandra-Mouli and Doris Chou, “Adolescent first births in East Africa: Disaggregating characteristics, trends and determinants”, Reproductive Health, 12(1) (2015) and Sarah Neal, Venkatraman Chandra-Mouli, and Andrew Channon, “Disaggregated data on adolescent first birth in 20 sub-Saharan African countries: Trends and characteristics”, Union for African Population Studies, (2015)

193 Plan International UK (SRH0014)

194 Dr Sarah Neal (Associate Professor in Global Health at University of Southampton) (SRH0019)

195 As above.

196 Commonwealth Children & Youth Disability Network (CCYDN) (SRH0010), Sightsavers (SRH0013), Plan International UK (SRH0014), International Planned Parenthood Federation (IPPF) (SRH0015), MSI Reproductive Choices (SRH0016)
Plan International described CSE as “an essential tool to promote an understanding and awareness of SRHR, and to support girls and young women to develop the skills, knowledge, autonomy, and confidence to make free and informed decisions about their sexual and reproductive lives” (SRH0014)

197 Dr Sarah Neal (Associate Professor in Global Health at University of Southampton) (SRH0019) citing Evie Browne, “Comprehensive Sexuality Education”, GSDRC Helpdesk Research Report 1226, (2015)

198 Dr Sarah Neal (Associate Professor in Global Health at University of Southampton) (SRH0019)

199 Commonwealth Children & Youth Disability Network (CCYDN) (SRH0010) and Sightsavers (SRH0013)

200 Plan International UK (SRH0014) citing Human Rights Watch, Leave No Girl Behind in Africa: Discrimination in Education against pregnant girls and adolescent mothers, 14 June 2018

201 Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Royal College of Nursing, Royal College of Paediatrics and Child Health, Faculty of Sexual and Reproductive Healthcare, British Society of Abortion Care Providers (SRH0004)

202 Dr Rachael Eastham; Professor Mark Limmer; Dr Peter Ibembe; Lawrence Muhangi; Ximena Quintero-Veloz; Dr Celia Karp; Manju Maharjan; Raul Mercer; Carlota Ramirez (SRH0007)

203 Q72 [Alessandra Aresu]

204 CBM UK (Global Disability Inclusion) (SRH0011)

205 Q72 [Kirsty Smith]

206 Q72 [Alessandra Aresu] and Sightsavers (SRH0013)

207 CBM UK (Global Disability Inclusion) (SRH0011)

208 Q72 [Kirsty Smith]

209 Foreign, Commonwealth & Development Office, FCDO disability inclusion and rights strategy 2022 to 2030, 16 February 2022

210 Foreign, Commonwealth & Development Office, Human Rights and Democracy Report 2022, 13 July 2023

211 CBM UK (Global Disability Inclusion) (SRH0011)

212 Sightsavers (SRH0013)

213 CBM UK (Global Disability Inclusion) (SRH0011)

214 Q78

215 Humanity & Inclusion UK (SRH0012)

216 Sightsavers (SRH0013) and CBM UK (Global Disability Inclusion) (SRH0011). CBM UK specified that this should be done for women and girls with disabilities.

217 Sightsavers (SRH0013)

218 Commonwealth Children & Youth Disability Network (CCYDN) (SRH0010). Similar views were shared in Sightsavers (SRH0013), CBM UK (Global Disability Inclusion) (SRH0011), CBM UK (SRH0032), Q76 and Q78 [Alessandra Aresu].

219 The programme referenced in the International Women and Girls Strategy is ‘What Works to Prevent Violence’.

220 Q73

221 As above.

222 The Committee engaged with the UK Government on allegations clinics in Uganda, Kenya and Tanzania run by UK funded organisations discriminated against LGBT+ people and offered them conversion therapy. (Letter to the Secretary of State for Foreign, Commonwealth and Development Affairs regarding UK Aid spending to protect and promote LGBT rights - 7 July 2021 and Letter from the Secretary of State for Foreign, Commonwealth and Development Affairs regarding UK Aid spending to protect and promote LGBT rights - 27 July 2021) The Committee also raised these concerns with the UK’s aid partner, MSI Reproductive Choices, who had one of these clinics. MSI Reproductive Choices told the Committee that it had not been able to corroborate the original investigations findings, but it had reinforced its policy and had built up on skills and training. (Qq44–46) The Committee also wrote to the FCDO regarding its funding to Inter-Religious Council of Uganda following its support to the Anti-Homosexuality Bill in Uganda. The FCDO stated that it had stopped all funding to the IRCU. (Correspondence to the Minister for Development and Africa regarding UK aid funding to anti-LGBT+ organisations - 27 April 2023 and Correspondence from the Minister for Development and Africa regarding UK aid funding to anti-LGBT+ organisations - 19 May 2023)

223 Q126

224 X (formerly known as Twitter), Tweet from Minister for Development, Andrew Mitchell, 23 November 2023

225 Q73 [Saskia Perriard-Abdoh]

226 Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Royal College of Nursing, Royal College of Paediatrics and Child Health, Faculty of Sexual and Reproductive Healthcare, British Society of Abortion Care Providers (SRH0004) and Dr Rachael Eastham; Professor Mark Limmer; Dr Peter Ibembe; Lawrence Muhangi; Ximena Quintero-Veloz; Dr Celia Karp; Manju Maharjan; Raul Mercer; Carlota Ramirez (SRH0007)

227 ViiV Healthcare (SRH0009) and Dr Rachael Eastham; Professor Mark Limmer; Dr Peter Ibembe; Lawrence Muhangi; Ximena Quintero-Veloz; Dr Celia Karp; Manju Maharjan; Raul Mercer; Carlota Ramirez (SRH0007)

228 Q73 [Saskia Perriard-Abdoh]

229 Plan International UK (SRH0014)

230 As above.

231 UNFPA - United Nations Population Fund (SRH0017)

232 Plan International UK (SRH0014)

233 Foreign, Commonwealth & Development Office, Human Rights and Democracy Report 2022, 13 July 2023

234 Foreign, Commonwealth & Development Office, International development in a contested world: ending extreme poverty and tackling climate change. A white paper on international development, 20 November 2023

235 Foreign, Commonwealth & Development Office, Human Rights and Democracy Report 2022, 13 July 2023

236 As above.

237 Q73 [Saskia Perriard-Abdoh]

238 Q126

239 Plan International UK (SRH0014) and MSI Reproductive Choices (SRH0016)

240 MSI Reproductive Choices (SRH0016)

241 Independent Commission for Aid Impact, UK aid under pressure: a synthesis of ICAI findings from 2019 to 2023, 13 September 2023