In 2008, a small discussion meeting organised by RHM, mostly involving RHM board members, explored what was happening globally in the work being done towards achieving sexual and reproductive health and rights. We began with the fact that although conferences are an essential forum for communication in our field and have played an important role in public health efforts to galvanise support, share critical information and determine policy direction, in recent years the culture of reproductive and sexual health conferences, as with the international AIDS conferences, has evolved in line with corporatized global trends, with star-studded casts and millions of dollars and tens of thousands of person-hours spent on them.Footnote* We questioned whether such conferences were making a valuable contribution to our work. From there we moved on to examine the consequences of what we perceived to be the fragmentation of work in our field and the depoliticisation of the process and the goals involved as the number of issues taken up and groups and networks involved has burgeoned, and as some of the issues have become mainstreamed. The issues we raised included:
| • | the narrowing down and simplification of the goals developed in the 1990s in several UN meetings, where the participation of sexual and reproductive health and rights advocates was influential; | ||||
| • | the consequences of huge amounts of money being given to specific aspects of the disease burden and next to nothing to others; | ||||
| • | the potential and limitations of using human rights to promote sexual and reproductive rights; | ||||
| • | the privatisation of health systems as part of neo-liberal economic pressures to dismantle states’ responsibility for social welfare; | ||||
| • | the denigration of the value of public health systems and consequently their being starved of resources; | ||||
| • | short-term targets for achieving the Millennium Development Goals (MDGs) instead of long-term goals and plans; | ||||
| • | a failure to support, beyond lip service, developing country ownership of their own health goals; | ||||
| • | an obsession on the part of many donors with measuring and counting, even in the absence of the resources needed to make change happen; and | ||||
| • | the absence of collectively agreed accountability mechanisms that all the key players in the health field, including donors, governments and civil society, adhere to. | ||||
As researchers, advocates and activists, academics, health professionals, and staff of non-governmental, governmental and inter-governmental organisations and agencies, we also acknowledged the failure of our movement to work together internationally for a common agenda that crosses reproductive health, reproductive rights, sexual health and sexual rights – as these affect everyone, not only women.Footnote†
The call to “repoliticise” sexual and reproductive health and rights
The call to “repoliticise” sexual and reproductive health and rights arose from this and later conversations. As the “Repoliticising group” we organised a small but globally representative meeting in Langkawi, Malaysia, in August 2010, hosted by the Asian-Pacific Resource and Research Centre for Women (ARROW). In February 2011, RHM and ARROW published a report from that meeting,Footnote* which focused on six main themes: macroeconomic influences on health, public health education, the role of the pharmaceutical industry, human rights approaches, funding, and the perpetuation of power. The meeting made a long list of recommendations on how to move forward, included in full at the end of the report. This journal issue goes into greater depth on these issues and raises new ones. The journal does not supersede the report, however, not least because the report is full of the insights and experience of the more than 50 people at the meeting; hence, they are worth reading together. The Langkawi report begins as follows:
“Over the past 18 months, our group has discussed shared concerns about what we perceive to be the fragmentation in and weakening and depoliticization of our field, in spite of the considerable gains that have been made in some countries, where political will and an active civil society Footnote† have worked together on common goals. We have observed a discouraging trend of larger and larger amounts of money being granted to governments, large NGOs and megaconferences run primarily from the global North. Funding to governments has also not paid sufficient attention to research, policy and programming efforts, building from the ground up in countries, leading to little if any apparent social change. The failure to improve service delivery beyond commodity-driven outreach services in order to link empowerment at the individual level within families and communities to timely and affordable access to curative care services, especially in the most resource-poor countries, is a prime example of this. In 2015, the Programme of Action of the International Conference on Population and Development will be two decades old, without having reached fruition, and the Millennium Development Goals related to health will remain unfulfilled. We believe there is a need to develop a forward-looking vision, drawing on but moving beyond both the ICPD Programme of Action and the limited interpretation and implementation to date of the health MDGs, to a transformative approach, taking into account 21st century realities.” (p.3)
Identifying political tools to solve political problems
Substantially revised versions of some of the papers presented at that meeting, as well as other submissions on the theme received by RHM over the past year, form this current journal issue. These papers, and the papers in the two journal issues on privatisation that preceded this one, represent a step forward in addressing sexual and reproductive health in a political context, which began in 2002 when RHM organised a workshop at Bellagio on health sector reform. Up to that point, we had treated sexual and reproductive health as health problems, as health services issues, as the subject of specific laws, and as rights issues. From 2002, we began to address the health systems issues that affect efforts to achieve sexual and reproductive health at a population level in countries. These included health sector reforms, integration of services, the influence of power and money, human resources and task shifting, and criminalisation of HIV, sexuality and reproduction. Then, with the two journal issues on privatisation of health systems, we looked at the political and economic context in which privatisation is occurring, the consequences for equity of access to health and health care, and the role of donor aid, international agencies and national policy and practice in pushing a privatisation agenda. At each step, the journal has examined the role of key political actors and the power they wield – for both good and bad – to influence whether and how change happens on the ground.
This journal issue represents a culmination of attention in RHM to health policy development and implementation in relation to sexuality and reproduction in the context of the social determinants of health. It offers an in-depth analysis of the extent of depoliticisation of health and health policy in our field, and by implication in health more broadly – taking on board not only the role of the MDGs and what they have spawned,Footnote* but also the role and power of the pharmaceutical industry, bilateral and multilateral development aid agencies, public health education in universities, human rights bodies and mechanisms, and the macroeconomic environment. Above all, it is about who owns the issues and about being accountable. Taken together, the papers serve as a warning that unless we step back and reconsider where we are going, and what we aim to achieve – and for whom – we are at risk of losing our way.
Berit Austveg's paper reminds us that sexual and reproductive health and rights are political problems, not just technical problems, that we need political tools to solve political problems, and that there are deep conflicts in values that have led to work in our field being stalled. She calls for the redistribution of power in order to promote and achieve equity of access to sexual and reproductive health and rights. “Political” is in this sense about policy and the values that underpin it, which for us means policy that aims to achieve social justice. Thus, the need for “repoliticisation”.
The papers in this issue address the following problems:
| • | that while countries may be signatories to international agreements such as the ICPD Programme of Action, the Beijing Platform of Action and the Millennium Development Goals, the commitments these agreements contain may not take priority in decision-making on resource allocation in countries; | ||||
| • | that women’s health and rights activists have rarely been sufficiently concerned with how fulfillment of these agreements will be financed, organised and managed; whether the health systems in many developing countries have the capacity to establish and run such services effectively; and how macroeconomic changes affect countries' ability to fulfil these commitments; | ||||
| • | that the health MDG indicators and targets have been boiled down to the lowest common denominator, and equity of access is not being measured in relation to whether or not targets are being met; | ||||
| • | that the powerful global pharmaceutical companies are at war against the producers of generic and affordable essential medicines, have invested heavily in non-essential and dangerous drugs such as hormone replacement therapy, and have failed to invest in many essential medicines and devices for our field because they do not bring in enough profit; | ||||
| • | that integration of HIV and sexual and reproductive health services has barely taken place on the ground, 30 years into the epidemic, despite the evidence of the crucial links between them; | ||||
| • | that investment in social franchises for the provision of limited reproductive health services, which has grown exponentially in the past decade through donor aid, does not appear to be justified in the absence of evidence of their value; | ||||
| • | that public health education has not incorporated sexual and reproductive health analysis and training into the core curriculum in almost any university studied; | ||||
| • | that an analysis of trends, commitments and achievements in all world regions reveals acute inequality across socioeconomic, ethnic and geographic lines, with many of the gains made only partial, and evidence of widening gaps between the haves and have-nots; | ||||
| • | that advocacy for sexual and reproductive health and rights is a crucial, long-term activity, that the funding and organisation of it should seldom be undertaken as a short-term proposition, and that it is grossly under-funded; | ||||
| • | that vertical global health (funding) initiatives, which now account for the bulk of funding for health globally, exclude attention to sexual and reproductive ill-health (with the exception of HIV/AIDS, which is very well-funded, and maternal, neonatal and child health, in which the great majority of the funding is not for women); | ||||
| • | that human rights bodies are too nervous to promote and defend abortion rights even if they now feel able to support certain sexual rights; | ||||
| • | that abuses of sexual and reproductive health and rights may be a cause and/or a consequence of other human rights abuses, yet are seldom named in other struggles for human rights; | ||||
| • | that although the global significance of the role of caregivers, especially in relation to HIV, the need for a strong state role, and the centrality of caregivers’ participation in policy debates were agreed at the 53rd Committee on the Status of Women, the caregiving frame also constrained debate, particularly about disability rights and variations in family formation, because of the participation of conservative NGOs; and | ||||
| • | that the resurgence of opposition to sexual and reproductive rights, spearheaded by the Vatican, is conspiring alongside competing priorities, to sideline much of the work in our field, in spite of how much remains to be accomplished. | ||||
Moreover, our own movement has also contributed. While it has grown over the past decades, it has ended up becoming fragmented, as different groups often focus on only one aspect of the issues. Sexual identity politics, anti-violence campaigns, anti-FGM campaigns, abortion rights campaigns – these are just a few of the examples of subjects where advocates are understandably concentrating all their efforts on specific pieces of the puzzle, but not taking account of each others’ issues, with the risk of the overall picture being lost.
Single issue campaigns with very narrow agendas and perspectives have also emerged – e.g. support for maternal health that excludes attention to miscarriage, stillbirths, and the need for contraception and safe, legal abortion, and the reassertion in some quarters of a narrow family planning agenda that is de-legitimising the notion of choice of method by pushing only IUDs, implants and injectables. HIV/AIDS has been a single-issue campaign since the beginning, even though HIV is only one form of sexually transmitted disease needing testing and treatment (a narrow focus that will only get worse as funding levels drop, at a point when universal access to treatment is probably finally achievable, except financially).
Distinguishing reproductive health, sexual health, reproductive rights, and sexual rights
The Langkawi meeting sought to put the distinctions between reproductive health, sexual health, reproductive rights, and sexual rights back into the work and to stress the comprehensiveness of the agenda. This agenda is constantly obscured linguistically by the near-universal use of the “SRHR” acronym, as if it were only one thing that isn’t even necessary to name any more because it takes too long to type out the words, let alone use them with precision to focus on what each of them actually encompasses. We hear moans from lukewarm supporters that a comprehensive agenda is too complicated, too “sensitive”, that we haven’t been clear about what it includes, let alone that it will cost too much and take too much time – which is what they really mean – implying that it isn’t deserving enough.
This has led to a well-meaning simplification of the problems and solutions for them, in the hope that at least the most basic aspects will be taken care of. In fact, this reductive simplification of the complexity of the issues has happened across the MDGs, with a focus on “quick wins” or “quick impacts”, as described by Fabienne Richard et al, leading to a diminution of what the MDGs were intended to accomplish, which above all was the reduction of poverty and its consequences, including widespread poor health. Is there anyone who thinks eliminating poverty isn’t complicated and will take a long time? The fact is that “SRHR” includes a broad range of lifelong health needs across reproduction and sexuality. Sexual and reproductive ill-health not only constitute a huge burden of disease which, as Sharon Fonn and TK Sundari Ravindran point out, has been under-emphasised in burden of disease assessments, it also includes needs such as for contraception, abortion and pregnancy care, which are nothing to do with illness but are necessary to maintain good health and be able to control the number and spacing of children, thereby allowing women the bodily integrity and autonomy they need to live their lives with dignity.
The MDGs: a silent coup d'état
The insights in these papers are sometimes overwhelming. For example, Ortiz Ortega, in describing the history of how the MDGs emerged, says:
“A key element in this process, which deserves special attention, is that the change of priorities and content of the development agenda emerged after only limited interaction between governments, civil society and international agencies. It was not just that women's movement activists were left out. Instead, the global agenda – covering issues that ranged from population and sustainable development to human rights and gender – was taken over by the World Bank and the International Monetary Fund. This new leadership diluted the multilateral approach to global problems and privileged a corporate vision. This “coup” was a by-product of the consolidation of power by these new stakeholders, who asserted their leadership at the expense of the United Nations, whose leadership was previously responsible for global governance. In the new scenario, public policy was transformed into services for “consumers” or “clients” – as opposed to policies for citizens – and was handed over to private companies to provide instead of being functions of the state…
Women migrants and their children sleeping rough in Kolkata, India, 2008
“The original dismay with which the MDGs were met by women's groups in different parts of the world has been followed by a growing awareness of the change of scenario that has required women to pay greater attention to macroeconomics; for example, the understanding that increased access to education for girls does not necessarily translate into secure and well-paid employment for women. And, that reaching a critical mass of women in the labour market does not necessarily translate into access to political office or decision-making positions in the private or public domain.”
Is there really no money?
Is there really not enough money, or are the doors to money for certain things closing for political reasons? In Langkawi, Sylvia Estrada-Claudio called for universal access to public health care, of which comprehensive sexual and reproductive health care is an integral component. With regard to how much it would cost, she said:
“Universal health care should be publicly financed through quantum increases in tax-based funding. There is enough money in the global economy and within the national economies of many middle- and low-income countries to afford this. For example, the US government's bail-out of the corporate sector in response to the economic crisis was around US$9.7 trillion, while the increased health spending per year needed in low-income countries to achieve the MDGs is a miniscule proportion of this: about US$10 billion.” (p.11)
Yet so-called middle-income countries, who still have a long way to go before their poor and rural populations ever have “middle incomes”, have been declared no longer eligible for development aid or public sector pricing for medicines, no matter how good or poor their public health status, or any other important indicators, let alone their reproductive and sexual health status, as Richardson and Birn show for Latin America.
Attention to sexual and reproductive health and rights has clocked up major successes in the past several decades – such as fewer maternal deaths; more skilled attendance at birth; positive abortion law reform in a growing number of countries; acknowledgement of the importance of reproductive and sexual health; new technologies such as HPV vaccines, a vaginal microbicide gel and medical abortion pills; acceptance of certain sexual rights; the support of a growing number of human rights bodies for some of these issues, the global convention on disability rightsFootnote** – and many of these gains are described and celebrated in the Langkawi report and these journal papers.
And yet, and yet… at the same time, it feels like a never-ending battle, mostly uphill, even just not to go backwards. Perhaps the worst thing that is happening, from the point of view of advocacy for sexual and reproductive health and rights, is that in many cases we are seeing the loss of grants and the closing down of many small and medium-sized advocacy NGOs and networks around the world, often the very groups who have been in the leadership in our field for decades, who have been its engine, its political and intellectual leadership, its innovators and its conscience.Footnote††
What will happen if countries are left without sexual and reproductive health and rights advocacy organisations that have the skills, the capacity and the brief to make political change happen on the ground? At what stage was the awareness lost – or the evidence ignored – that autonomous groups working at national and local levels need funds, as Barbara Klugman's paper shows, for advocating for sexual and reproductive health and rights policies, for doing the necessary research to hold governments accountable for implementation, for building new generations of leadership, to organise themselves collectively to build understanding and commitment to these issues among those advocating for other human rights, and to engage those setting the agenda internationally. Without them, indeed, we will be lost. In the long term, their continuing existence and their strength to act is the only way that sexual and reproductive health and rights, not just services, are likely to be accepted, made sustainable through national funding and mainstreamed in national health systems, health and rights law and policy, and social welfare policies.
Key strategies
The Langkawi meeting ended by supporting the following key strategies for moving forward:
| • | expanding spaces for engagement, e.g. between international and national level work, and deciding on a new set of strategies for the post-2015 era; | ||||
| • | creating new development agendas with social justice at their core, e.g. including men's issues in sexual and reproductive health and rights, as well as sexual orientation and gender identity issues, and exploring what repoliticisation means in concrete terms; | ||||
| • | taking advantage of opportunities, e.g. deepening the ICPD agenda and influencing the content of the new MDGs that will follow the current ones, creating a theory of social change to achieve social justice; | ||||
| • | influencing donors, e.g. creating a donor interest group, mapping who and what they fund and who and what we want them to fund; and advocating for donor accountability; | ||||
| • | fostering research, e.g. building multi-country, multidisciplinary, multi-level and multi-sector intellectual leadership; reviewing the available evidence on progress towards ICPD goals and identifying the gaps; mapping and documenting political work both in support of and against sexual and reproductive health and rights at the grassroots and country levels; and mainstreaming sexual and reproductive health and rights within public health and human rights research; | ||||
| • | forming an international sexual and reproductive health and rights alliance to work together across all the parts of the agenda to support action at national level as its primary goal; define an activist agenda with international, regional, and national relevance and specificity through a regular, representative, international conference; and reinvigorate and link existing national groups and networks, and existing regional networks. | ||||
There is a lot of work to be done and the importance of both experienced advocates and a new generation getting involved to define principles, develop a common platform and promote consensus positions was stressed in Langkawi. (p.58–59)
Both the conversation published in the Langkawi report and the in-depth examination of the issues in the papers here show just how challenging – in both the positive and negative senses of that word – this work will remain for generations to come. As Wanda Nowicka's paper in this issue concludes:
Human rights advocates must recognize the inherent and unavoidable difficulties of engaging in political processes and face the reality that the struggle for full recognition of sexual and reproductive rights, especially the right to abortion, will never be a linear process or lead to a final “victory”. Hence, it is crucial to try to find new ways to engage and new partners in our endeavours. The international community of sexual and reproductive health and rights advocates is realising that human rights work, and their own work as well, would be strengthened by being part of a larger movement for social justice and economic rights as these relate to sexual and reproductive health and rights.
Notes
* Berer M, Shameem S, Allotey PAA. Are recent international conferences advancing sexual and reproductive health and rights? (Unpublished paper, in Langkawi report, Annex 1. (See fn Footnote* page 5 for reference).
† Even though for most of us at that meeting women's rights and needs have historically been the motivating force behind our work.
* Repoliticizing sexual and reproductive health and rights: report of a global meeting, Langkawi, Malaysia, 3–6 August 2010. At: <www.rhmjournal.org.uk/events/meeting-reports.php>. A print copy can be ordered free from: <[email protected]>.
† Here, when talking about “civil society” and “NGOs”, I mean progressive, pro-SRHR groups. Given the increasing participation in this field of anti-choice and anti-rights NGOs, whose aim is to destroy the gains made in relation to sexual and reproductive health and rights, and of NGOs whose ethos is business- and market-oriented, neither of whom have social justice goals, it becomes important to qualify who is meant.
* This deserves serious, in-depth analysis at country as well as global level.
* The current UK government claims the country is heavily in debt and as a result is dismantling the public sector, slashing every existing social welfare programme, and privatising the National Health Service because, they claim, there is no money to fund them.
† GAVI funding meeting exceeds expectations. Lancet 2011;377:2165–66.
** Price J. The “politically 10%” group. Langkawi report, Annex 2. (See fn Footnote* page 5 for reference)
†† This, I believe, is due to poorly thought-out changes in donor priorities, in which funding is being shifted to NGOs dominated almost entirely from the USA and UK, which are organising unrepresentative mega-conferences or providing private reproductive health services, separate from public health systems, e.g. through social franchises, primarily contraception and in some cases antenatal and delivery care and abortion. These services, as TK Sundari Ravindran and Sharon Fonn show, are forced to charge user fees that often make them unaffordable for low-income women and may not be sustainable financially in the long run.