http://orcid.org/0000-0001-5966-4969
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ABSTRACT
At a point in history when the future of sexual and reproductive health including HIV looks particularly uncertain, it is helpful to recognise that many of the challenges currently faced are neither new nor insurmountable. Reflecting on past achievements and lessons learned helps us to have confidence that positive change is feasible. This paper reflects on some of the changes observed in countries like India and Mozambique and identifies a range of factors which need to coalesce to enable these developments, along with specific contextual factors. It is the combination of these influences rather than any one of them alone that brought about the change in the three instances described – fostering a positive political response to HIV in its early years in India; bringing about policy reform on abortion in Mozambique; and increasing contraceptive prevalence and age at marriage in some districts in Bihar, India. Change is always fragile and susceptible to setbacks, but change-seekers can learn in the process and gain renewed hope that progress can and often does take place if they persevere.
Acknowledgements
Purnima Mane would like to thank the Rockefeller Foundation for a Bellagio Center Policy Fellowship (2016) and UNSW Sydney for a Senior Visiting Fellowship with the Arts and Social Sciences Practical Justice Initiative (2017), both of which provided for the opportunity to develop, document and present some of the ideas presented in this paper.
Disclosure statement
Purnima Mane was President and CEO of Pathfinder International between between February 2012 and April 2016.
ORCID
Peter Aggleton http://orcid.org/0000-0001-5966-4969
Notes
1 The last of these groups was later replaced by frequently travelling men including truck drivers, and transgender populations were added to the list.
3 Major exceptions were the education of clients of sex workers on the importance of using condoms and some public awareness campaigns for the ‘general public’.
4 Some of the major lawsuits litigated by the Lawyers Collective and other groups involved challenging the imprisonment of a person living with HIV in Goa (lost); argument against Ch XVI Section 377 of the Indian Penal Code criminalising homosexuality (won at High Court level but later overturned by the Supreme Court and now being reconsidered with alternate mechanisms for determination); discrimination against individual workers (mostly won); and actions related to Intellectual Property Rights to enable the manufacturing of generic ART drugs (won). For a summary, see www.lawyerscollective.org/hiv-and-law/judgements-a-orders.html.
6 These restrictions include higher standards of facilities providing such abortions, an ultrasound before an abortion, multiple visits to the service provider, the imposition of waiting periods, parental involvement for minors, insurance coverage restrictions, and bans on use of public funds for abortion and telemedicine for medical abortion (Center for Reproductive Rights, Citation2010; Donovan, Citation2017; Guttmacher Institute, Citation2017b).
7 Report by Justice Lucy Asuagbor, Special Rapporteur on the Rights of Women in Africa, to the 60th Meeting of the Commission on the Status of Women, 18 March 2016, NY.
8 IPAS and Pathfinder International have recorded the history of access to legal abortion in multiple documents, many of which are referenced in this section and provide considerable insight into the issues at stake.
9 This number has dropped dramatically from 1990, when it was 1390 (UNICEF, Citationn.d.).
10 Misoprostol had been registered in the country mainly for post-partum haemorrhage prevention but was difficult to obtain.
11 Both Ipas and Pathfinder International (Citation2016) have documented the multiple steps taken by the government, supported by civil society over a period of over 30 years to build on this change process. For further detail, see Hardy, Bugalho, Faundes, Alves Duarte, and Bique (Citation1997), Dgedge et al. (Citation2005), Usta, Osman, Matediana, and Dos Muchango (Citationn.d.), and Badiani (Citation2016).
12 Ipas and Pathfinder International (Mozambique) who were already working closely with local NGOs and part of the Coalition, raised funds through the Safe Abortion Action Fund and later the Royal Norwegian Embassy and provided technical support. Ipas also worked with the national government to conduct a needs assessment study of abortion and post-abortion services and trained staff, developed training on service delivery of post-abortion care, and conducted research to build the evidence base on the capacity of mid-level providers to offer safe medical abortion. Pathfinder Mozambique had worked with the government for many years and was appointed one of three organizations which comprised the Secretariat of the Coalition, the other two being local NGOs: Women and Law in South Africa and Forum Mulher.
13 i.e. below 18 years, which is also the voting age in India since 1988.
15 This section is informed by evidence in the Technical Brief on PRACHAR prepared by Pathfinder International (Citation2016), which provides a detailed description of the study, and other papers produced by Pathfinder India staff who worked on this project as well as the Evaluation team from Population Council, all of which can be accessed for more information.
16 Including those with no children, pregnant, and those with one child.
17 This group consisting mainly of women was introduced as part of the National Rural Health Mission for maternal and child health outreach launched by the Indian government in 2005 with the goal of reaching those requiring services in remote and under-served regions of the country (Nandan, Citation2010).
18 For further related discussion of some of these issues, see Aggleton and Parker (Citation2015)
19 See, for example, a Citation2016 special issue of the Journal of Adolescent Health, 59(3), S1–S32 for a review.