Accountability for sexual and reproductive health and rights in development practice: building synergies

Abstract

The 2030 Agenda for Sustainable Development is the culmination of 25 years of global efforts to embed human rights in the development discourse. Epitomising the principle of Leaving No-one Behind, the 2030 Agenda contains concrete references to the realisation of human rights as the ultimate purpose of sustainable development as well as to governments’ accountability towards citizens. Despite this compelling narrative, the information produced by States in reviewing progress on Sustainable Development Goals (SDGs) reveals a gap between rhetoric and practice. Voluntary National Review (VNR) reports have emerged as a central tool to inform and guide the national and global reviews of SDGs progress. The UN system recommends that States build upon information from existing platforms, the Universal Periodic Review (UPR) and UN Treaty Bodies, in order to reduce reporting burdens. However, an analysis of information on Sexual and Reproductive Health and Rights (SRHR) in VNR reports from 12 countries shows that States are missing the opportunity to build on the wealth of information they themselves have produced in their engagement with human rights mechanisms. Although many first generation VNRs did not come across as very substantive, their emphasis on participation and multi-stakeholder dialogue has created important, and sometimes unprecedented, national political traction for civil society. This engagement can be built upon to inject a human rights perspective towards the achievement of more equitable development outcomes.

Résumé

Le programme de développement durable à l’horizon 2030 est l’aboutissement de 25 années d’efforts internationaux pour ancrer les droits de l’homme dans le discours sur le développement. Illustrant parfaitement le principe qui consiste à ne laisser personne de côté, le programme 2030 contient des références concrètes à la réalisation des droits de l’homme comme objectif ultime du développement durable ainsi qu’à l’obligation des gouvernements de rendre des comptes aux citoyens. En dépit de ce texte qui emporte l’adhésion, l’information produite par les États lors de l’examen des progrès sur les objectifs de développement durable (ODD) révèle un écart entre la théorie et la pratique. Les rapports sur les revues nationales volontaires (RNV) sont apparus comme un outil central pour informer et guider les examens nationaux et mondiaux des progrès vers les ODD. Le système des Nations Unies recommande que les États se fondent sur les informations issues de plateformes existantes, de l’examen périodique universel et des organes de suivi des traités des Nations Unies, afin de réduire la charge d’établissement des rapports. Néanmoins, une analyse des informations sur la santé et les droits sexuels et reproductifs dans les rapports des RNV de 12 pays montre que les États ne saisissent pas la possibilité de se fonder sur la somme d’informations qu’ils ont eux-mêmes produite dans leur collaboration avec les mécanismes des droits de l’homme. Bien que beaucoup de revues nationales volontaires de première génération ne semblent guère présenter de données de fond, en mettant l’accent sur la participation et le dialogue multipartite, elles ont néanmoins créé une traction politique nationale importante, et parfois sans précédent, pour la société civile. Cette participation peut être utilisée pour injecter une perspective des droits de l’homme vers la réalisation d’un développement aux résultats plus équitables.

Resumen

La Agenda 2030 para el Desarrollo Sostenible es la culminación de 25 años de esfuerzos mundiales para incorporar los derechos humanos en el discurso sobre el desarrollo. Personificando el principio de No Dejar a Nadie Atrás, la Agenda 2030 contiene referencias concretas a la realización de los derechos humanos como el propósito final del desarrollo sostenible, así como a la responsabilidad de los gobiernos de rendir cuentas a su ciudadanía. A pesar de esta convincente narrativa, la información producida por los Estados al revisar el progreso sobre los Objetivos de Desarrollo Sostenible (ODS) revela una brecha entre la retórica y la práctica. Informes de Revisión Nacional Voluntaria (RNV) han surgido como una herramienta central para informar y guiar las revisiones nacionales y mundiales del progreso en los ODS. El Sistema de la ONU recomienda que los Estados se bas que los Estados se basen en la informaciónn en la información de plataformas existentes, como el Examen Periódico Universal (EPU) y los órganos de tratados de la ONU, con el fin de reducir las cargas de rendición de informes. Sin embargo, un análisis de información sobre Salud y Derechos Sexuales y Reproductivos (SDSR) en informes de RNV de 12 países muestra que los Estados no están aprovechando la riqueza de información que han producido en su interacción con los mecanismos de derechos humanos. Aunque muchas RNV de primera generación no parecen ser muy sustantivas, su énfasis en la participación y el diálogo con múltiples partes interesadas ha creado una importante, y a veces novedosa, tracción política nacional para la sociedad civil. Esta participación puede aprovecharse para impulsar la perspectiva de derechos humanos a fin de lograr resultados de desarrollo más equitativos.

Keywords:

• sexual and reproductive health and rights
• human rights
• sustainable development
• Voluntary National Reviews
• sexual and reproductive health services
• bodily autonomy
• agency
• adolescent health
• leaving no-one behind
• equality and non-discrimination

1. Introduction

Since the Vienna World Conference on Human Rights (1993) enshrined the principle that democracy, development and respect for human rights and fundamental freedoms are interdependent and mutually reinforcing,¹ the international community has advanced to making this principle operational in development practice.

The International Conference on Population and Development (ICPD) in 1994 was one of the first milestones in that journey. The ICPD placed people – women, men, girls and boys alike – at the centre of development and population policies, as empowered rights-holders with the ability to take control of their sexual and reproductive health (SRH), lives and wellbeing, and contribute to the development of their communities and countries through the exercise of their reproductive rights.

The adoption of the Millennium Declaration in 2000 was another important landmark. However, the accompanying eight Millennium Development Goals (MDGs) drove attention away from the human rights commitments within the Millennium Declaration, thus contributing to split human rights and development practice into separate siloes.² Unlike the MDGs, the 2030 Agenda for Sustainable Development adopted in 2015 and its accompanying Sustainable Development Goals (SDGs) have been heralded as representing a more genuine effort to embed human rights within an overarching sustainable agenda for people, planet, and prosperity. The 2030 Agenda comprises a comprehensive, far-reaching and people-centred set of universal and transformative goals and targets³ that seek to realise the human rights of all, and to achieve gender equality and the empowerment of women and girls (Preamble, paragraph 2).³ At least 156 of the 169 SDG targets have been considered to be inextricably linked to core human rights and labour standards,⁴ including sexual and reproductive health and rights (SRHR) which are enshrined in several international human rights treaties and reflected across different SDG goals and targets including those on maternal health (target 3.1), sexual and reproductive healthcare services, including for family planning, information and education (target 3.7), and sexual and reproductive choice (target 5.6).

While the MDGs responded to a “recipient-to-donor-country” accountability logic,^5,6 the Declaration on the 2030 Agenda emphasises that governments are accountable to their own citizens (paragraph 47)³ through SDGs follow-up and reviews taking place at national, regional, and global levels. These culminate in an annual High Level Political Forum (HLPF) under the auspices of the UN Economic and Social Council, and a four-year HLPF at the UN General Assembly. The Declaration further indicates that review processes should be voluntary, country-led, inclusive, participatory, transparent, people-centred and gender-sensitive, respect human rights, and have a particular focus on the poorest, most vulnerable and those furthest behind (paragraph 74).³ Voluntary National Review (VNR) reports are the main tool to inform and guide national and global SDG reviews. From 2016 to 2019, 142 developed and developing states prepared and presented 158 VNRs at the HLPF (paragraphs 74 (f) and (i)).³ However, several states only reported on a selected group of SDGs, sometimes leaving out SDGs 3 and 5, despite the recommendation by the UN system to report on all SDGs.

1.1. Voluntary National Reviews: building on UN human rights mechanisms

The 2030 Agenda establishes that review processes will build on existing platforms and processes to avoid duplication and that they will benefit from the active support of the UN system and other multilateral institutions (paragraphs 74 (f) and (i)).³ In that respect, the UN guidance to States for preparing VNRs recommends the use of information from reports submitted to international bodies, including human rights mechanisms, such as the Universal Periodic Review (UPR) and international treaties.⁷

For SDG reviews, the added value of international human rights mechanisms rests on their legitimacy to review human rights progress, based on an objective framework of international legally binding norms, standards, and principles.⁸ Moreover, the wealth of information and recommendations generated by these mechanisms result from rigorous and highly inclusive dialogues with States, as well as Civil Society Organisations (CSOs) and other relevant stakeholders, invited to supplement the information provided by States in their national reports.⁹

The UPR is a mechanism of the Human Rights Council,¹⁰ whereby all States review the fulfilment by each State of its human rights obligations and formulate recommendations. The review is informed by a national report prepared by the State under Review (SuR) and supplemented with a “Compilation of UN Information” prepared by the OHCHR with inputs from international human rights mechanisms and UN agencies, as well as a “Stakeholders Summary Report” with information from National Human Rights Institutions and CSOs. These three reports allow some level of triangulation of information and perspectives on critical human rights issues and implementation measures. The SuR has the primary responsibility to implement the outcome of the UPR process, which is a report containing all supported and noted (or rejected) recommendations. Four years later, at the next UPR cycle, the SuR will produce a new national report explaining progress on the implementation of UPR recommendations from the previous review and identifying emerging human rights issues.

Due to its political nature and its comprehensive scope covering the full range of human rights, the UPR can serve as a powerful accountability mechanism for the realisation of SRHR.¹¹ Studies show that a substantial number of UPR recommendations are related to SRHR: 27% in the 1st cycle (2008–2011) and 29% in the second cycle (2012–2016).¹² The same studies have found that 90% of States report having taken action on at least half of the accepted SRHR-related recommendations.

Human Rights Treaty Bodies (TBs) are committees of independent experts that monitor the implementation of international human rights treaties. These Committees monitor and review progress by State Parties in meeting legally binding human rights obligations under each treaty. The outcome of State Parties’ reviews is a set of Concluding Observations containing specific recommendations to help states meet their human rights obligations. In practice, all core international human rights treaties† enshrine standards and obligations of relevance to SRHR,¹³ and some of them have issued concrete guidance to help State Parties advance the application of those standards, such as the General Comment on the Right to Sexual and Reproductive Health of the Committee on Economic Social and Cultural Rights (CESCR).

While the UPR reporting and review schedule has been highly predictable throughout its three cycles of existence, in the case of TBs only 16% of States have been able to meet all their reporting obligations on time.¹⁴ Nevertheless, in view of the fact that most States have ratified several Treaties, a fair number of reports are made available over a 10-year period, which helps track SRHR progress in many countries. The 12 countries selected for analysis in this paper have produced on average five reports to different TBs over the period 2013–2019.

2. Methodology

This article examines the manner in which different review processes have reported progress on SRHR as articulated in the SDGs, and identifies reporting gaps and complementarities with a view to helping States manage the wealth of available information at the country level to fill those gaps, without creating additional reporting burdens.

This analysis is based on a review of documentation from 12 selected countries (Azerbaijan, Bangladesh, Burkina Faso, Canada, Cambodia, Costa Rica, Ethiopia, Fiji, Jordan, Mexico, Nigeria, and Turkmenistan). The country selection was done according to regional balance, different levels of development, countries in humanitarian situations, and countries of different geographic and population characteristics, including landlocked countries, a small island State and countries with minority groups and indigenous populations.

To ensure a complementary analysis of review processes, each selected country had to have the following reports available: at least one VNR report with a dedicated section on SDGs No. 3 on health and 5 on gender equality; 3rd cycle UPR review reports to be able to assess the implementation of recommendations from the second cycle; and at least two States Parties reports to TBs. As many states are not up-to-date with their reporting obligations a minimum requirement was established to have at least two recent TB reports from highly relevant Conventions (CESCR, CCPR, CEDAW and CRC). The OHCHR Universal Human Rights Index¹⁵ was also used to identify relevant recommendations issued by human rights mechanisms during the reporting period 2014–2019.

For the comparative analysis of SRHR information, a set of 41 quantitative and qualitative indicators (see Appendix) was defined based on the framework of structural, process and outcome indicators developed by OHCHR.¹⁶ These indicators serve to assess the access to and quality of SRH services as well as the application of human rights values and principles of agency, participation, accountability and equality and non-discrimination, in the context of health services.

Qualitative information on SRH-related structural and process indicators was classified according to a coding system. Information on human rights principles of participation, accountability and equality and non-discrimination was collected through word searches in order to capture information outside of SRHR dedicated sections.

2.1. Limitations

The main limitation in conducting this research was related to time and capacity due to the significant number of documents to review. Consequently, the number of TB national reports was limited to two per country and shadow reports were not included. Even so, the amount of information provided by TBs was comparatively higher than UPR and VNR reports in terms of the percentage of indicators covered. Due to similar capacity constraints, country reports by Special Procedure mandate-holders of the Human Rights Council were not considered.

As the research is mostly based on the desk review of national reports, there is an obvious limitation to triangulating the information through other methods, including interviews with relevant stakeholders and impact assessment of reported measures. Only in the case of the UPR was triangulation possible by comparing information from the three main reports feeding into the State’s review. A country visit was also conducted to Costa Rica in order to assess how review processes worked in practice and their complementarity from the perspective of different stakeholders.

3. Results and discussion

SRHR is a complex concept encompassing the rights of individuals and couples to make informed decisions on matters concerning one’s body and sexual and reproductive health, free from coercion, discrimination and violence, as well as the right to enjoy the highest attainable standard of sexual and reproductive health.¹⁷ SRHR are enshrined in several international human rights treaties and reflected across different SDG goals and targets.

Despite the centrality of SRHR in international human rights and development frameworks, an analysis of SRHR in the review work of different mechanisms denotes marked disparities in scope, breath and emphasis. Based on documentation from the 12 countries selected and presented below (full table available in Appendix), on average, TBs provide information for 67% of the 41 pre-defined indicators, whereas UPR covers 43%, and VNR reports cover 26%. This section delves into the details of these indicators, according to two broad categories: (1) SRH services – availability, accessibility, acceptability and quality; and (2) human rights values and principles. The sub-section on human rights values and principles is further divided into analyses based on discussions related to (a) agency; (b) participation and accountability; and (c) equality and non-discrimination.

3.1. Sexual and reproductive health services – availability, accessibility, acceptability and quality

3.1.1. Type of services

To ensure full enjoyment of SRHR, rights-holders are entitled to unhindered access to a range of health facilities, goods and services, and information. In the ICPD Programme of Action (1994), States committed to making accessible, through primary health care, a comprehensive package of reproductive healthcare services.¹⁸ However, assessing the information 12 states have provided in their VNR reports, shows maternal health to be the most mentioned service (10/12 countries), with a predominant focus on actions to reduce maternal mortality. Nevertheless, explicit references to maternal morbidity reduction measures are marginal (only in two countries, Azerbaijan and Nigeria). Prevention and treatment of HIV and other STIs ranks second with references in seven VNR reports compared to UPR (9) and TB reports (11 countries). Although access to family planning is explicitly stated in SDG target 3.7, this service does not get the same level of attention in VNRs (6 out of 12 country reports), while TBs give practically full and equal attention (11 countries).

Other SRH services deemed politically sensitive (abortion, post-abortion care and assisted reproductive technologies) are not mentioned in VNRs. Conversely, human rights mechanisms, especially TBs (12 countries), are much bolder in addressing sensitive issues by: expressing concern about the criminalisation of abortion; recommending the adoption of clinical protocols to ensure effective access to legal abortions (Costa Rica); regulating conscientious objection to avoid a negative effect on access to safe abortion in practice (Mexico); facilitating access to family planning in order to minimise the recourse to abortion as a birth control method (Azerbaijan); and providing access to high-quality post-abortion care, especially in cases involving complications resulting from unsafe abortions (Bangladesh).

3.1.2. Availability, accessibility, acceptability and quality of SRH services

As defined by the CESCR, sexual and reproductive healthcare services, goods, and information have to be available, accessible, acceptable and of good quality.¹⁷ However, VNRs provide a very uneven description of actions addressing each of those SRH components (Table 1).

Table 1. Access to quality SRH services

	UPR (12)	TBs (12)	VNR (12)
2.2. Increased access to SRH services	9	10	2
5.2 Adolescents’ access to SRH services	4	7	1
2.3 Increased quality of SRH services	6	10	2
5.3. Adolescent/youth-friendly SRH services	4	8	2
3.2. Increased access to maternal health services	11	12	8
3.3 Quality of maternal health services	8	11	3
4.2. Increased access to family planning	9	12	3
4.3 Quality of family planning services	0	5	1

While eight VNRs describe measures to increase access to maternal health services, only three VNRs provide some generic information on measures to improve the quality of these services.

With regards to access to maternal health services, VNRs mainly focus on measures to increase the availability of services and mitigate economic and social barriers. This includes the expansion of infrastructure, prenatal care services, obstetric care, and the availability of qualified personnel, in particular of midwives (Burkina Faso and Ethiopia); the creation and expansion of health workers’ programmes and community clinics offering basic primary healthcare services in rural areas (Bangladesh, Burkina Faso, Cambodia, Ethiopia and Nigeria); and the offering of free healthcare for pregnant women (Nigeria).

On the other hand, human rights mechanisms, particularly TB reports, also emphasise legal, social, and cultural barriers. For instance, in Burkina Faso regarding access to contraception, the Committee on Civil and Political Rights (CCPR) 2016 expresses concern about “reports of violence against women who raise questions about contraception with their partners”,¹⁹ the high cost of contraceptive methods, as well as the lack of information on contraception, including emergency contraception. In its turn, the VNR 2019 simply mentions the amount spent in purchasing contraceptives and announces that family planning will be free of charge by 2019.

Adolescents often face a multiplicity of barriers preventing access to SRH services, information and education. The sensitive nature of adolescent sexuality in many cultural settings may be one of the reasons explaining why only one VNR (Burkina Faso) touches on this issue by describing measures to lift economic barriers in access to youth-friendly SRH services. In turn TB (7) and UPR (4) reports refer to diverse policy, administrative and legal measures such as the removal of third party authorisation requirements for adolescents to be able to access contraception, including emergency contraception, and safe abortion services (Costa Rica, Fiji and Jordan).

As seen before, States are not inclined to refer to certain services deemed sensitive (e.g. safe abortion) and the existence of legal barriers to SHR services in their VNRs. Due to the expert nature of TB reviews, States may be more open to engage in dialogue on those issues, as in Jordan’s report to the Committee on the Elimination of Discrimination against Women (CEDAW). The State report acknowledges that the legality of abortion, which due to religious or social reasons is only accepted when there is a risk to the life and health of the mother, should be re-examined in order to consider including coverage for cases of rape and incest.

In promoting dialogue on politically sensitive issues, national advocacy actors have devised strategies to engage incrementally with subsequent review processes by building on the entry points provided by TBs. For instance, the Costa Rican CEDAW review in 2017 empowered national advocates to build political traction around ensuring access to therapeutic abortion, which was legal but not accessible in practice. The issue was subsequently repositioned at the UPR review in 2019, resulting in specific recommendations supported by Costa Rica to adopt a clinical protocol on therapeutic abortion that was finally enacted by Presidential Decree in December 2019.²⁰

In terms of measures to improve the quality of SRH services, TB reports provide information for a larger number of countries (11 countries on Maternal Health and 5 countries on Family Planning). Some of the measures mentioned in national reports to the UPR and TBs include the development of knowledge and skills of healthcare workers (doctor, nurses and midwives) through training and the development of guidelines and protocols consistent with international standards. For instance, Turkmenistan’s report to CEDAW (2017) provides a detailed description of measures to incorporate WHO standards and guidelines in different clinical interventions in maternal health, including the introduction of effective perinatal technologies and the provision of medical assistance in obstetrics in more than 70% of the maternity hospitals across the country.

As laid out by TBs, quality also entails that SRH services will be deemed acceptable by users/patients. Acceptability translates into gender-sensitive, youth-friendly, LGBTI-friendly, disability-inclusive, and culturally appropriate services and information. Users’ acceptability is reflected in several UPR and TB recommendations and reports. For instance, TBs (8 countries) and UPR reports (4 countries) elaborate on measures to improve youth-friendly services while only two VNRs (Burkina Faso and Jordan) make an explicit mention. In addition, Ethiopia’s VNRs refer to the development and roll-out of a manual on Health Sector Gender Issues in relation to maternal health; and Canada’s VNR report notes the provision of financial support for culturally appropriate and safe midwifery in First Nations and Inuit communities.

3.2. Discussion points

• The predominant VNRs’ focus on access to maternal health services is consistent with the emphasis on reproductive health during the MDGs era (MDG5). On the other hand, human rights recommendations and state reports to Human Rights mechanisms cover a broader range of SRH services such as family planning, HIV prevention and treatment, safe abortion and post-abortion care. The limited information in VNR reports on issues explicitly stated in the SDGs, such as access to family planning and reproductive rights, is an indication of selectivity in the choice of topics. While this is a matter of concern, it could be that first generation VNR reports were conceived as a baseline, rather than progress reports based on available indicators and information from the MDGs period. To ensure that second generation VNRs provide a more comprehensive account of progress, human rights mechanisms could concentrate their review work to help fill those information gaps: for example, by systematically including questions on relevant SDG indicators in the their lists of issues.‡

• Another aspect of VNRs, inherited from the MDGs era, is the overemphasis on access to SRH services to the detriment of quality. This is often the logical consequence of basing development interventions on the achievement of numeric targets.²¹ Moreover, access measures noted in VNRs tend to focus on the mitigation of economic and physical barriers, while reports to human rights mechanisms usually describe a much broader range of measures addressing legal and cultural access barriers, as well as quality and acceptability of SRH services. Beyond political sensitivities around those barriers, governments will certainly find an incentive to invest in infrastructure development and social protection packages, in order to show more immediate and visible results (low-hanging fruits), rather than longer-term investments in changing social norms and behaviours. However, a concern remains as to the sustainability and community ownership of development gains in contexts where there is a strong social and political resistance to SRHR, unless underlying and root causes of poor SRH outcomes are addressed comprehensively.

• SDG reporting does not occur in a vacuum. Reporting is the culmination of a national policy process which starts with the national adaptation of SDGs. Therefore, a more systematic use of SRHR recommendations in the formulation of SDG-related strategies and plans will facilitate the integration of broader legal, social and cultural determinants of SRH and a stronger focus on quality and acceptability of services. Stronger coordination and synergy across different departments of government leading on SDGs (Ministries of Planning, Ministries of Health) and Human Rights (e.g. Ministries of Justice, inter-ministerial human rights commissions, etc.) will help to break old siloes from national planning down to the use of concrete monitoring and tracking tools for more integral reporting.

• Ensuring a continuum of engagement with different SDG, ICPD and human rights review processes on a key set of SRH priorities will help to push sensitive SRHR issues forward in the political and policy realms. For that, national advocacy organisations are advised to map the schedule of different review processes significantly ahead of time and plan a comprehensive engagement strategy, accordingly.

3.3. Human rights values and principles: agency, participation, accountability and equality and non-discrimination

3.3.1. Agency in SRHR

Agency is a cornerstone of SRHR. It is central to the vision of the ICPD Programme of Action, whereby population dynamics respond to the expanding rights of individuals and couples to control their fertility, as opposed to government-driven population control policies.

Agency is a fundamental human rights value requiring: (i) the recognition of a person’s autonomy, (ii) access to information and the means to act accordingly, and (iii) freedom from discrimination, coercion, and violence.²² Regarding human sexuality and reproduction, agency is embedded in SDG target 5.6 on universal access to sexual and reproductive health and reproductive rights, with two concrete indicators measuring sexual and reproductive decisions (5.6.1.), and the existence of enabling legal frameworks within which those decisions are made (5.6.2).

Nonetheless, analysis of the 12 countries consulted shows that VNRs are slow to incorporate this human rights dimension, by failing to provide data on those indicators, or information on factors and measures affecting progress (Table 2).

Table 2. SRH freedoms and agency

	UPR (12)	TBs (12)	VNR (12)
2.4. Autonomous decision making and bodily autonomy	3	12	3
3.4. Freedom from coercion and violence in maternal health services	1	4	0
4.4. Freedom from coercion and violence in family planning services	2	6	0
5.4. Access to comprehensive sexuality education	10	12	3

A few positive VNR examples can be highlighted, such us Mexico’s 2016 VNR underscoring that human rights are central to the 2030 Agenda, which includes the recognition of bodily autonomy and self-determination. Costa Rica’s 2017 VNR refers to a UNFPA-led initiative to empower adolescent girls with information and knowledge to make decisions about their own bodies, contraceptive use, and prevention of unwanted pregnancies. Nigeria’s VNR includes data on SDG indicator 5.6.1 (24.8% of women aged 15–49 make their own informed decisions regarding sexual relations, contraceptive use, and reproductive healthcare) without providing further analysis of measures taken.

One reason for the limited information in VNR reports on indicator 5.6.1 is that it is a newly constructed indicator for which pre-existing baseline data from the MDGs period is not available. By 2019, however, 51 countries are reported to have generated data on this indicator.²³ Therefore, it is expected that future VNRs will provide more nuanced analysis of challenges and progress towards sexual and reproductive autonomy.

Agency and bodily autonomy are mentioned in the TB-related information from all 12 countries consulted and information was also provided in three UPR reports. Illustrative examples include removing the requirement of parental consent for girls to be able to access contraceptives and reproductive and sexual health services (CEDAW recommendation to Turkmenistan). In 2018 CEDAW recommended that Fiji allocate the necessary resources to ensure that the confidentiality of female patients is fully respected; health personnel is adequately trained; and the public is made aware, with the help of the media, of the right of women to full autonomy regarding access to health services without having to seek spousal authorisation.

Social stigma associated with adolescent sexuality acts as a significant deterrent in accessing SRH services, even when services are legal and available. In the same example from Fiji, CEDAW 2018 recommends the elimination of negative stereotypes and discriminatory attitudes regarding female sexuality in view of the reluctance of many adolescent girls to seek access to SRH services because of stigma, and the need for parental consent for girls under the age of 18 years to obtain contraceptives.

Adolescents need access to information so that they can make their own decisions and be able to participate actively in those processes that affect them. Although this principle has been highlighted in numerous global forums and policy documents,²⁴ VNRs provide very limited information on measures that promote adolescents’ autonomy and agency. The jurisprudence of TBs has made it clear that comprehensive sexuality education (CSE), rather than a policy option, is a central human rights issue for the optimal development of adolescents.¹⁷ In that light, 10 UPR reports and TB reports from the 12 selected countries pay particular attention to CSE as a fundamental part of the school curriculum and a tool to help prevent unwanted pregnancies, child marriage, and the transmission of STIs, in addition to promoting equal gender relations and tolerance for diversity. In some countries, UPRs and TBs have recommended its full integration in the school curriculum, in accordance with approved international standards, and the allocation of resources to ensure quality delivery (Cambodia, Fiji, Mexico and Turkmenistan). In its report to CEDAW in 2018, Cambodia provides a detailed account of academic and financial efforts to integrate CSE at all levels of schooling from pre-primary to secondary, indicating the curriculum components for each level and the efforts to train teachers.^25§ This again illustrates how TB reviews, due to their technical dimension, can provide an enabling environment for a constructive dialogue that helps depoliticise issues deemed to be controversial in other global review processes and inter-governmental spaces.

In other countries where CSE is not part of the school curriculum, TBs recommend efforts to overcome social resistance (Jordan and Nigeria). The sensitive nature of CSE could explain why only three VNR reports make explicit mention of CSE (Ethiopia, Costa Rica and Canada). Despite its sensitive social context, the 2017 Ethiopian VNR provides a very strong and results-based paragraph stating that the “teenage fertility rate could be controlled lately at 12/1000 through efforts made to give teenage sex-education and enable them to make behavioural changes”. Agency is indeed implicit in the idea of promoting behavioural changes and is seen as a building block for the empowerment of women and girls. In that regard, the VNR report further affirms that “sex-education shall continue in light of achieving the relevant SDG”.²⁶

Measures to address coercion and violence in health settings were mentioned in some TB reports which focused on prevention of forced sterilisation and involuntary family planning (Mexico, Turkmenistan), particularly of women and girls with mental disabilities (Costa Rica and Jordan). Also included was the importance of the development of human rights education and training programmes for healthcare providers to prevent non-consensual sterilisation and/or manipulated consent of people with disabilities (CRPD recommendation to Canada). Relatedly, the UPR recommends that Canada investigate complaints by women from vulnerable groups. Azerbaijan’s State report to CEDAW (2013) notes the development of a draft law to regulate the right to reproductive freedom, the right to use contraception and medical sterilisation, among other issues. VNRs remained silent on any type of measures to address coercion and violence.

3.3.2. Participation and accountability in SRHR

The principles of participation and accountability are enshrined in international human rights law. They are also central to the notion of a human rights-based approach to development which requires their systematic application through all stages of the development process.²⁷ The principles of participation and accountability guide a dynamic relationship between rights-holders and duty-bearers in the context of policy dialogue and planning, budget formulation, monitoring and evaluation, seeking remedies for grievances, and redressing policy failures.

One would expect that UPR and TB reports and recommendations give these principles the level of attention commensurate with their centrality in human rights law. While both UPR and TBs do this in general terms, these mechanisms do not generate significant information on participation and accountability in relation to SRHR.

In terms of participation, only five UPR documents and six TB reports contained explicit references. Notably, this is the only indicator where VNRs excel compared to all the other review processes, which highlights their huge potential as a platform for a multi-stakeholder and cross-sectoral dialogue (Table 3).

Table 3. Accountability and participation

	UPR (12)	TBs (12)	VNR (12)
2.5 Access to accountability mechanisms	4	3	2
2.6. Participation of rights-holders	5	6	12
5.6. Participation of adolescents and youth in SRH services	1	3	2

The principle of participation is anchored in the SDGs review process both at the political level³ and in the guiding tools issued to help states run multi-stakeholder reviews. From 12 VNR reports, it is clear that the emphasis on participation and multi-stakeholder engagement has created important, and sometimes unprecedented, space for civil society engagement within the health sector and beyond. The wide scope of Agenda 2030 has also created the space for broad-based participation and dialogue among a multiplicity of stakeholders beyond their respective traditional siloes.

In Jordan, for instance, the 2017 VNR affirms that “the Ministry of Planning and International Cooperation prepared a stakeholder engagement strategy to ensure the widest participation from all Non-Governmental Organizations (NGOs) in the SDG implementation and VNR preparation” and that “the stakeholder engagement strategy also took into account challenges to the meaningful participation of all NGOs” (including difficulty reaching the most marginalized) … with special attention “to ensuring the inclusion of women, youth, children and people with disabilities”.²⁶

Similarly, in Costa Rica, NGO activists interviewed for this research described the participation processes led by the Ministry of Planning (MIDEPLAN) for the formulation of the 2017 VNR and the national ICPD report in 2018 as the most inclusive and broad-based participation processes held in the recent history of the country, even more so than the processes organised to prepare state reports to international human rights mechanisms. These activists indicated that the VNR multi-stakeholder process had the added value of bringing together, often for the first time, a very broad constituency of NGOs, faith-based organisations, less formal organisations, the private sector and academia, to combine their diverse agendas and reach consensus on a number of critical SRHR issues.

As noted earlier with regards to adolescents’ autonomy, the limited references in most documents to the participation of adolescents in designing SRH policies and programmes are a matter of concern. Only two VNRs (Cambodia and Jordan), one UPR national report (Mexico) and three TB documents make explicit mention of this. Mexico’s national report to the UPR provides an example of civil society engagement in the formulation and implementation of policies, programmes, as well as in the design of guidelines on comprehensive sexual and reproductive healthcare for adolescents in order to standardise administrative, training and service delivery activities, in line with international recommendations governing SRH services for adolescents.

Even in the context of human rights mechanisms there is a persistent perception of adolescents as vulnerable individuals in need of protection, rather than as autonomous agents of change. For example, over the last 10 years the CCPR has issued only two recommendations referring explicitly to adolescents and youth in relation to the specific participation challenges they face.²⁸ While youth organisations have signalled that human rights mechanisms could broaden their engagement with young people,²⁹ it is also acknowledged that many youth organisations do not have the experience of engaging with these mechanisms or are not always aware of their work and potential to protect and empower young people.**

Concerning the principle of accountability and access to remedies, both the UPR and TBs offer only general attention to this matter. A review of country documents did not provide many examples of accountability and access to remedies in relation to SRHR. Only UPR documents from four countries and TB documents from three countries provided some information. Despite the recent adoption by CESCR of General Comment No. 22 on the right to sexual and reproductive health (2016), this relatively low level of attention underscores the need to continue to mainstream SRHR in the monitoring work of national and international human rights mechanisms by reiterating that SRHR are indeed legally binding human rights.

The most cited remedial actions in TBs and the UPR refer to the criminal investigation of cases of forced sterilisation and coerced abortion (Canada, Costa Rica and Jordan) and obstetric violence (Mexico). For example, Jordan’s national report to the UPR (2018) stated that forced sterilisation was a punishable offence under the amended Criminal Code of 2017, and noted that the General Fatwa Department issued a decision in 2014 establishing criminal liability of persons and doctors responsible for removing the uterus of girls with disabilities, while granting girls the right to financial compensation.

Less frequently, accountability mechanisms are used to address broader SRH policy failures. This was precisely the case in the only two references to accountability measures in VNR reports (Jordan and Canada). Canada describes the strengthening of administrative accountability mechanisms within the health system (maternal and infant health surveillance) while Jordan’s 2017 VNR focuses on “strengthening civil registration and hospital records to enable proper capturing and investigating of maternal and child deaths, while also striving to address their causes”.²⁶

3.4. Equality and non-discrimination

Non-discrimination and equality are fundamental state obligations under international human rights law and essential principles in ensuring the exercise and enjoyment of all human rights.³⁰ They are also central to the concept of a human rights-based approach, which aims to address the underlying and root causes of inequalities, including discrimination on the basis of all prohibited grounds under international human rights law, both in the processes and outcomes of development.

The imperative of reducing inequalities and combating discrimination resonates strongly with the principle of “leaving no one behind” of the 2030 Agenda. This principle permeates all of the SDGs, with two dedicated goals (Goal 5 on achieving gender equality and Goal 10 on reducing inequalities) as well as a commitment to disaggregate data across all SDG targets. The 2030 Agenda acknowledges that a key barrier to reaching those furthest behind is discrimination, hence recognising that “people who are vulnerable must be empowered”.³¹

The UN guidance for states preparing their VNRs stresses the importance of identifying the specific needs of those left behind, the underlying reasons for their vulnerability, and the actions taken to empower them.⁷ From the 12 countries assessed in this study, it is clear that VNRs emphasise the implementation of affirmative actions and targeted social protection measures to meet the SRH needs of specific population groups (10 VNRs). However, VNRs make practically no reference to legal or policy measures to address discrimination, stigma and negative stereotypes against certain population groups in situations of disadvantage (1 VNR) (Table 4).

Table 4. Equality and non-discrimination

	UPR (12)	TBs (12)	VNR (12)
6.1 Legal measures	3	4	0
6.2 Awareness-raising against discrimination/stereotypes/stigma	4	6	1
6.3 Social protection measures	7	10	10

The most common social protection measures being referred to in VNRs consist of establishing fee waivers, subsidies and cash transfers, and targeted insurance schemes for mothers, pregnant women, and girls to be able to access SRH services. VNRs also refer to dedicated investments to deploy mobile clinics and health workers in rural and remote areas. By way of illustration, the Ethiopian VNR refers to investments in infrastructure and human capital in the health sector, especially the health extension programme deploying 38,000 trained health extension workers to provide basic healthcare services in urban and rural areas.

Bangladesh’s VNR is the only report containing an explicit note on measures against discrimination with reference to health. The report states the adoption of a “National Women Development Policy (NWDP)” in 2011 that aims to eliminate all forms of discrimination against women and create a favourable environment for them to access the economy, education, and health services.

As seen in Table 4, some TB and UPR reports have described anti-discrimination measures in the context of the health sector. These include the adoption, review and enforcement of anti-discrimination laws, the implementation of awareness-raising campaigns for the general public, and educational activities to combat stigma and discriminatory attitudes by healthcare workers. For example, in its third UPR, Cambodia was recommended to adopt, in consultation with CSOs, comprehensive legislation and policies against discrimination and violence based on sexual orientation or gender identity, and guarantee their implementation through all public entities, in particular in the education, health and labour sectors. In Turkmenistan, CEDAW 2018 recommended the provision of “training to medical and health professionals on non-discriminatory and scientifically appropriate treatment of women and girls living with HIV/AIDS” and to “take measures to combat discrimination and stigmatization faced by them”.³² VNR reports consulted remain silent on these issues.

In the UPR, TB and VNR reports from the 12 selected countries, the population groups most frequently mentioned in relation to measures to fight inequality and discrimination in the health sector are shown in Table 5

Table 5. Referenced population groups

	UPR (12)	TBs (12)	VNR (12)
1. Women	10	11	6
2. Adolescents	9	10	5
3. Rural populations	7	10	4
4. Persons with Disabilities	6	11	1
5. Indigenous Peoples	3	5	2
6. LGBTIQ+	3	4	2
7. Migrants, refugees, IDPs	2	5	0
8. Others:	5	7	3

On all counts, TBs stand out as the review mechanism giving more visibility to specific population groups, followed by the UPR.

Despite the centrality of the “leaving no one behind” principle in the 2030 Agenda for Sustainable Development, VNRs are on average less likely to provide disaggregated information by specific population groups. While VNRs often contain rhetorical references to this principle,³³ its practical pursuit would require deliberate strategies starting with visualising those population groups at a heightened risk of being left behind, and the social and economic disparities they face. The level of attention in VNRs to specific population groups in terms of their interaction with the health sector is consistent with the trend identified in more general studies on “leaving no one behind” in VNRs,³⁴ whereby attention is given mainly to sex (women), age (children/adolescents), and location (rural populations).

Due to political sensitivities, LGBTIQ+ people are not explicitly recognised in the 2030 Agenda and related SDG targets, and sexual orientation and gender identity is not listed as a disaggregation factor. This explains the little attention this population group received in the VNRs. Only Canada and Costa Rica provide specific information on measures to address stigma and discrimination in ensuring access to specialised or targeted programmes and services on prevention and treatment of STIs, including HIV infections.

While persons with disabilities have enjoyed greater recognition in the formulation of the 2030 Agenda, this has not automatically translated into a commensurate level of attention. Out of the 12 assessed VNRs, only Costa Rica’s report contains a reference to a UNFPA-supported project on SRH information campaigns and sexuality education for deaf boys and girls.

The lack of VNR references to the health situation of migrants, refugees, and IDPs (in countries in humanitarian situations and countries of destination) raises concerns as to whether national strategies are giving dedicated attention to these populations. This is of critical importance as these populations usually confront multiple barriers in access to health services, are not included in decision making processes, and have poorer health outcomes.

3.5. Discussion points

• The predominant VNRs’ focus on access to services, without incorporating measures that promote and protect people’s agency, particularly from the most marginalised and excluded groups, seems to be an outdated development approach in treating service users in vulnerable situations as passive beneficiaries. This is a matter of concern, given the information requirements established under SDG 5.6 on universal access to SRH and reproductive rights. Nevertheless, mindful that SDG 5.6 indicators are new, it is expected that the next generation of VNRs will gradually provide more information, for which the capacity of national statistical agencies will need to be further developed.

• In view of the rich and inclusive dialogue conducted by TBs in their country reviews, it is advisable that TBs concerned with SDG 5.6 indicators systematically include questions on measures pertaining to these indicators in their list of issues. This will help to visualise the concrete challenges and facilitating factors to guide legal reform processes, as well as the formulation and monitoring of SDG-related national strategies and plans.

• Adolescents’ agency is often hampered by persisting taboos and stigma around adolescent sexuality that perpetuate economic, legal and cultural barriers to SRH-related services, information and education. For instance, the relative silence of VNR reports on CSE is certainly due to the absence of explicit references in SDG targets, as well as its sensitive nature as a matter of political and social debate. Countering this neglect is the example of Ethiopia’s VNR which emphasises the need to invest in CSE as a tool to address underlying determinants of adolescent SHR and promote behavioural changes for the achievement of the SDGs.

• While human rights review mechanisms can supply SDG review processes with valuable information in addressing SRHR shortcomings affecting adolescents and youth, it appears that insufficient attention is given to the specific challenges preventing their meaningful participation as change agents. SDG and human rights review mechanisms will need to broaden their engagement with youth organisations by mainstreaming the rights and participation of young people into their working modalities, processes and outputs.²⁹ Additionally, youth-led organisations and groups will need to be supported with information and resources to become more aware of the work and potential of SDGs and human rights review processes and to enhance their advocacy skills as SRHR champions.

• SRHR encompasses legally binding human rights obligations subject to legal enforcement. The scant references in VNRs to measures that strengthen accountability systems and the narrow protection focus of human rights mechanisms on the provision of remedies for individual cases of human rights violations (e.g. forced sterilisation, obstetric violence, etc.), underscore the significant effort that must be made in order to integrate accountability at all stages of the policy cycle. Still needed is the introduction of administrative avenues of accountability to monitor and correct policy failures and of social accountability mechanisms to monitor budget execution in the design and delivery of more responsive local programmes and SRH services.

• Evidence from analysing the selected country documents demonstrates the guidance human rights mechanisms can provide to help SDG-related strategies address underlying and root causes of inequality in leaving no one behind. Human rights mechanisms can help to influence VNRs by using disaggregated information and measures in relation to population groups that are either ignored or invisible in development policy, such as LGBTIQ+ people, migrants, refugees, minority groups and indigenous peoples. The use of disaggregated information related to groups that have enjoyed greater success in positioning their agenda in the SDGs framework, such as persons with disabilities, should not be taken for granted. This realisation underscores that only a continuum of engagement with different policy and review processes, even by those who have secured a seat at the table, will sustain and increase attention in a resource restrained environment highly sensitive to the negative impacts of global pandemics and economic shocks.

4. Conclusions

The Declaration on the 2030 Agenda for Sustainable Development is the most advanced political document to date that binds development commitments and human rights obligations soundly together. As far as reporting on SDG progress, UN guidance to Member States has emphasised the value of using information and recommendations from human rights mechanisms, including from the UPR and TBs, to orient SDG planning and reporting processes. However, the 12 VNRs consulted for this study indicate that the wealth of available SRHR information from other review processes has not been utilised to its full extent. The VNRs’ focus on access to services, predominantly maternal health, without incorporating empowerment measures to promote and protect people’s agency and addressing root causes of inequality, reproduces the outdated development approach of treating service users and patients, particularly those seen as vulnerable or hard to reach, as passive beneficiaries. Conversely, the UPRs and TBs have consistently highlighted measures to: remove legal, cultural, and social barriers hindering access to services for women, youth, adolescents, and specific population groups; design and deliver more inclusive and better quality SRH services; and enhance the capacity of rights-holders, particularly women and girls, to make informed choices on their health and wellbeing and seek redress to their grievances due to situations of neglect, abuse, coercion, and discrimination. Using this available information will help states inform SDG strategies and plans while improving the quality of their second generation VNRs without increasing their reporting burdens.

Human rights mechanisms also help VNRs translate the rhetoric of “leaving no one behind” into a more complex web of measures to address not only the consequences but also deeply rooted drivers of inequalities, including intersecting discrimination. While VNRs have predominantly focused on highlighting targeted social protection measures to meet the SRH needs of specific population groups in vulnerable situations, human rights mechanisms can lend critical guidance to help governments confront deeply entrenched patterns of inequality and exclusion by adopting anti-discrimination measures and addressing unequal power structures and negative societal attitudes against women, adolescents and youth and other population groups. Ultimately, a human rights and population based approach to development will help reframe the principle of “leaving no one behind” to better understand why and how the most marginalised are still not included.

In comparison to national reports prepared for human rights review processes, first generation VNRs tend to be less substantive, partly due to the scope and breadth of a document covering 169 SDG targets. However, from reviewing 12 VNR reports, it is clear that the emphasis on participation and multi-stakeholder dialogue has created important, and sometimes unprecedented, national political traction for civil society engagement within the health sector and beyond. The wide scope of the 2030 Agenda has also created space for broad-based participation and dialogue among a multiplicity of stakeholders beyond respective traditional siloes. Human rights advocates can capitalise on the SDGs’ political traction and broader audience to position SRHR as a building block for sustainable development, including poverty reduction, climate action, and the humanitarian and development nexus. In turn, parliamentarians, national human rights institutions, CSOs, academics and other SRHR champions can engage strategically with human rights review and reporting processes to position recommendations on neglected SRHR issues (e.g. family planning, agency and autonomous decision making, freedom from coercion and violence in SRH services, adolescent SRH, elimination of intersectional discrimination). These recommendations can be used as future advocacy tools to influence national SDG planning and the formulation of second generation VNRs.

The 2030 Agenda for Sustainable Development is the culmination of more than 25 years of international commitments to embed human rights in development practice. While that journey is far from over, a continuum of engagement with human rights, SDGs and ICPD reviews, guided by deliberate efforts to bring these processes closer together, will help break silos, expand partnerships, and amplify the voices of those whose sexual and reproductive rights are at stake.

Acknowledgements

This article is the result of research conducted for UNFPA’s Sabbatical Programme with the valuable contributions of Alessandra Zanzi who was the research assistant for this project, and under the guidance of Dr. Sakiko Fukuda-Parr, Director of the International Relations Programme at the New School in New York; and Hans Otto-Sano, Director of Research at the Danish Institute for Human Rights (DIHR). In the process of elaborating this article numerous interviews were conducted with UN staff, government officials, experts, academics and civil society organizations. Particular mention goes to ASG Maria Francesca Spatolisano (UN-DESA); Gianni Magazzeni, Chief UPR Branch, OHCHR; H.E. Mr. Joaquin Maza Martelli (Permanent Representative of El Salvador in Geneva and former President of the Human Rights Council); H.E. Ms. Pilar Garrido, Minister of Planning of Costa Rica, Raquel Pereira, Permanent Mission of Paraguay in Geneva; Steven L.B. Jensen, (DIHR); Ignacio Saiz, Executive Director, CESR; and Elizabeth A. Nash.

Notes

† For more information on the core international human rights treaties and monitoring bodies, see: https://www.ohchr.org/EN/ProfessionalInterest/Pages/CoreInstruments.aspx

‡ State reports to TBs are prepared based on a list of issues identified by the monitoring body in consultation with the state, CSOs, UN agencies and other relevant stakeholders.

§ Cambodia’s national report to the CEDAW 2018 states that the Ministry of Education, Youth and Sport (MoEYS) “launched a life skill curriculum for primary school (Grades 5–6), lower secondary school (Grades 7–8), upper secondary school (Grades 10–11), and for youth out of school. The curriculum for each level includes: basic reproductive, sexual and health education, including HIV/AIDS, hygiene and gender concepts (Grades 5–6); gender roles, sexuality and gender expression (Grades 7–8); human rights, gender equality, gender roles, sexual harassment and gender'-based violence (Grades 10–11)” and mentions that “in 2016, MoEYS provided 3,500 life skill books on SRH for Grades 5–6 and trained 1,756 primary school teachers (59 per cent female) in three provinces”.

** From interviews with CSO activists, including youth-led organisations, in Costa Rica.

Appendix

Table A1. SRHR-related indicators for assessment of information in VNRs and Human Rights Reviews

1. General Indicators	UPR (12)	TBs (12)	VNRs (12)
1. Comprehensive SRH services
1.1. Maternal mortality	8	10	10
1.2. Maternal morbidity	1	7	2
1.3 Contraception	8	11	6
1.4 Safe abortion	5	12	0
1.5 Post abortion care	0	8	0
1.6 HIV & AIDS and STIs	9	11	7
1.7. Reproductive cancers	3	5	2
1.8. Assisted Reproductive Therapies	1	2	0
1.9. Adolescent SRH	12	12	6
2. SRHR indicators	UPR	TBs	VNRs
2.1. Existence of a national strategy or plan	6	7	3
2.2. Increased access to SRH, including measures to address barriers	9	10	2
2.3 Increased quality of SRH services	6	10	2
2.4. Agency and bodily autonomy	3	12	3
2.5 Access to accountability mechanisms	4	3	2
2.6. Beneficiaries’ Participation in design and monitoring of SRH services	5	6	12
2.7 Adequate financial resources for SRH services	5	10	4
3. Maternal Health (MH) indicators	UPR	TBs	VNRs
3.1. Existence of a national strategy or plan	6	9	4
3.2. Increased access to MH services	11	12	8
3.3 Quality of MH services	8	11	3
3.4. Freedom from coercion and violence in MH services	1	4	0
4. Family Planning (FP) indicators	UPR	TBs	VNRs
4.1. Existence of a national strategy or plan	5	5	3
4.2. Increased access to FP, including measures to address barriers	9	12	3
4.3 Quality of FP services	0	5	1
4.4. Freedom from coercion and violence in FP services	2	6	0
5. Adolescent SRH indicators	UPR	TBs	VNR
5.1 Existence of a national strategy or plan on Adolescent SRH	5	8	2
5.2. Barriers in access to SRH services by adolescents	4	7	0
5.3. Access to Adolescent & Youth friendly SRH services	4	8	2
5.4. Access to quality CSE or life-skills education	10	12	3
5.5. Social protection programmes for pregnant girls	3	8	1
5.6. A&Y participation in design and monitoring of SRH services	1	3	2
6. Equality and non-discrimination/indicators	UPR	TBs	VNRs
6.1 Legal anti-discrimination measures	3	4	0
6.2 awareness raising against stigma & discrimination	4	6	1
6.3 Social protection measures	7	10	10
6.4. References to discriminated population groups:	UPR	TBs	VNRs
6.4.1 Women	10	11	6
6.4.2 Adolescents	9	10	5
6.4.3. Persons with Disabilities	6	11	1
6.4.4 LGBTI+	3	4	2
6.4.5 Rural Populations, Patoralists, etc.	7	10	4
6.4.6. Indigenous Peoples	3	5	2
6.4.7 Migrants, Refugees, Asylum Seekers and IDPs	2	5	0
6.4.8. Others	5	7	3
TOTAL:	213 (43%)	329 (67%)	128 (26%)