Universal health coverage: another political space in which to expand the elimination of sexual and reproductive health and reproductive rights

KEYWORDS:

• sexual and reproductive health
• reproductive rights
• far right populism
• universal health coverage
• mexico city policy

Introduction

The women’s health movement fought for decades for the recognition of sexual and reproductive rights, as well as accessible and quality sexual and reproductive health (SRH) services as a crucial element of health care provision and gender equality.¹ Universal health coverage (UHC), including sexual and reproductive health and reproductive rights (SRHR), is part of global efforts for reaching the United Nations (UN) Agenda 2030.² However, the inclusion of SRHR as part of broader efforts to achieve UHC has come under unprecedented threat as a result of far-right coalition building and active opposition orchestrated by the United States Trump administration throughout the United Nations and its agencies.^3–5 In this commentary, we discuss key concerns in relation to SRHR and UHC.

UHC and the attempts to eliminate SRHR

UHC recognises that all people should

“have access, without discrimination, to nationally determined sets of the needed promotive, preventive, curative, rehabilitative and palliative essential health services, and essential, safe, affordable, effective and quality medicines and vaccines, while ensuring that the use of these services does not expose the users to financial hardship, with a special emphasis on the poor, vulnerable and marginalized segments of the population”. ²

Access to SRH services and the recognition of reproductive rights has been proven to lower the number of abortions, prevent unwanted pregnancies, reduce maternal deaths, and improve maternal and reproductive health.⁶ Therefore, inclusion of SRH services and the recognition of reproductive rights are a critical component of UHC. Unfortunately, with SRHR being heavily politicised,^4,7 UHC discussions on the inclusion of SRHR have become a further political space in which SRHR is being contested. While this has been part of the broader politics on SRHR for some time,⁷ debates have gone from the usual objections to abortion, access to modern contraceptives and comprehensive sexuality education,¹ to consistent calls by the Trump administration for the complete exclusion of any mention of SRH or SRHR.^8–10

The 2019 UHC declaration seeks to “ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development (ICPD) and the Beijing Platform for Action” (p. 10).² However, these original references to SRHR in the ICPD already contained a compromise. The term “sexual and reproductive health and reproductive rights” specifically separates reproductive rights from sexual rights. Yet even this compromised language is still unacceptable to some states which oppose SRHR, including, most notably, the Trump administration.⁸ After the 2019 UHC conference, the United States submitted its country statement stating: “We do not accept the terms ‘sexual and reproductive health’ and ‘sexual and reproductive health and reproductive rights’ in this Declaration”.⁹ The longstanding objections over rights and, in particular, sexual rights¹¹ have broadened into a refusal to accept SRH services, let alone rights.

The goal of completely erasing SRHR has intensified amidst these vocal objections by the Trump administration.⁸ This articulation has gained support from an increasing number of far-right populist groups that have adopted objections to SRHR into their political strategies at the national level.⁷ The US leadership under the Trump administration has provided more legitimacy and grounds for a global opposition to SRHR for different governments, who have found a powerful ally in the United States due to its ability to influence the global SRHR agenda.⁷ The reference to SRHR in the 2019 UHC declaration was overshadowed by a broader anti-SRHR conservative agenda and coalition-building of 18 countries involving the United States.⁵ After the 2019 meeting, a joint statement by the United States on behalf of Bahrain, Belarus, Brazil, Democratic Republic of the Congo, Egypt, Guatemala, Haiti, Hungary, Iraq, Libya, Mali, Nigeria, Poland, Russia, Saudi Arabia, Sudan, United Arab Emirates and Yemen, explicitly stated:

“We do not support references to ambiguous terms and expressions, such as sexual and reproductive health and rights in UN documents, because they can undermine the critical role of the family and promote practices, like abortion, in circumstances that do not enjoy international consensus and which can be misinterpreted by UN agencies”, and

“Such terms do not adequately take into account the key role of the family in health and education, nor the sovereign right of nations to implement health policies according to their national context” and

“Further, we only support sex education that appreciates the protective role of the family in this education and does not condone harmful sexual risks for young people”.¹⁰

Such statements illustrate the attempt to replace SRHR with patriarchal family-based language which excludes individual rights. While the systemic and expanding anti-SRHR politics is new, there are tactics which have been applied previously. Similar efforts have been used in the earlier manipulation of legal and human rights-related arguments to oppose sexual rights and refer only to rights which relate to the family.¹¹ However, the expanded attempts to remove the language on SRHR completely are important as, according to Allen & Shepherd,⁸ they “must be read through the lens of the Trump administration’s continued war on women”.⁸ They also form part of the broader politics of silencing of women’s rights by the Trump administration, including through the expanded Mexico City Policy (MCP). The MCP, also known as the “Global Gag Rule”, specifically prohibits the use of funding for organisations which, among other SRH services, provide safe abortion, and has now expanded to cover those which would refer patients to other providers or simply offer information on abortion.⁸

“Norm spoiling” efforts

Universal health coverage (UHC) has been in alignment with the 1994 ICPD, yet the politics of “norm spoiling”¹ seek to undo this connection by de-normalising the inclusion of SRH services under UHC. Sanders’ concept of “norm spoiling” describes the efforts by conservative actors to “undermine women’s rights norms”, such as those set out in the ICPD and the Beijing Declaration that form part of the UN Agenda 2030.¹ The aim of such actors is to remove existing and previously agreed language on SRHR from all future UN documents. This is articulated in footnotes or separate statements, if previously agreed language is used, to ensure that local laws, national or religious context take precedence.¹ This tactic seeks to move to a “new normal”, where SRHR is not part of agreed normative language, but is considered an aberration. This was demonstrated in January this year, following a meeting of foreign health leaders in Washington DC, in a statement released by the United States, which said:

“I am sure you are all familiar with the constant drumbeat in the halls of the United Nations and the WHO to normalize the terms ‘sexual and reproductive health’ and ‘reproductive rights.’ What reproductive rights are they talking about? In this context, it is increasingly becoming clear that some U.N. agencies and countries want this to mean unfettered access to abortion, and we cannot let this threat go unanswered”.³

Although SRHR has been agreed language since the 1994 ICPD, this statement shows the attempt to instead de-normalise SRHR.

Opposition to SRHR is not new to feminist scholars and scholarship on SRHR. Yet there is a risk that the politics of norm-spoiling and silencing of SRHR is missed where discussions and decision-making take place in different decision-making forums. For example, in what is supposed to be a step towards UHC, the Astana Declaration on Primary Health Care mentions sexual and reproductive health¹² but does not mention reproductive or sexual rights. It does, however, include a footnote from the United States referring to the section of the ICPD which states that abortion should not be promoted “as a method of family planning”. Through forum shifting, it can become possible to create new language and references, which do not mention SRHR and which can then become established as new normative ground for policymaking. Another example of explicit action is the UN Security Council Resolution 2467 on sexual violence in conflict, where the reference to SRH was dropped in order to pass the resolution, after the United States threatened to veto it if it included SRH services.⁸ Commitments which do not focus solely on SRHR, such as UHC, could therefore become a means to establish new language which is silent on SRHR, as governments do not want to undermine the broader commitments to UHC.

Emerging policy challenges

An increase in “hyper-conservative leaders”⁵ has led to an increasing opposition in all UN conferences on issues that include SRHR.^1,5 The UHC declaration recognises that UHC is fundamental for “achieving gender equality and women’s empowerment”.² However, anti-SRHR actors have attempted to distort existing international human rights norms^7,11 into rights that refer to the “natural family” and “traditional values”,¹ which do not include reproductive rights, LGBTQI rights, or rights for migrants.⁴ This is where opposition to SRHR has become integrated with a broader agenda of populist politics.⁷ Far-right populism has seen a resurgence in nationalism,¹ which emphasises “traditional family values and gender roles”, also perceives immigration as a threat, and migrants are painted as a risk to national values and way of life.⁴ Franklin & Ginsberg have described how this resurging populist nationalism with anti-immigration strategies has heightened in recent years in the United States and in countries within the European Union, which focus on increasing birth rates among citizens, and include discriminatory practices, such as restricting migrant access to healthcare.⁴ This directly contradicts the very heart of UHC, which “reaffirms the right of every human being, without distinction of any kind, to the enjoyment of the highest attainable standard of physical and mental health”.²

Populism and nationalism can be linked with reproductive politics, which consider reproductive rights as a threat to the family.¹ In the European Union and the United States in particular, the politics of race and reproduction has seen an alignment with a desire to preserve “white national sovereignty”.⁴ In an earlier editorial, Pugh provided an overview of studies which detailed the anti-gender populist movements taking place in Hungary and across Europe, the political agendas in Lebanon, and the lack of access to abortion in Brazil.⁷ There is a clear danger that attacks on SRHR become a staple of emerging populist regimes, which are not recognised until they are able to shape international debates, including those on UHC.

Lo & Barry have shown that the Mexico City Policy has increased the number of abortions and argue that it represents an “evidence-free” policy approach based on ideology and domestic politics.⁶ Furthermore, the existence of the expanded Mexico City Policy under the Trump administration may mean that SRH services which are delivered through global health assistance may be excluded, creating a concrete gap in UHC.

Implications for SRHR

The very principle of UHC is that “all people have access, without discrimination”.² However, UHC targets cannot be achieved without access to SRH services, as SRHR is an essential component of UHC, with SRH services being part of a broader package of health service delivery. There is a danger that through the politics of silencing on SRHR, SRH services can be more easily removed, even in countries with governments which currently support SRHR.

We are in danger of losing the mechanisms of follow up and support for SRHR at the global level, including as part of UHC. If the language on SRHR and SRH services is removed, it will be even harder to bring back action at the national level or engage in more global oversight, especially if SRHR has been “de-normalised” as a global agenda. The lack of global focus will also result in poorer support for national level activism and engagement. This cannot only be considered as a temporary problem of the current US Trump administration, as these anti-SRHR activities have built on earlier groundwork. It is thus important to recognise that this anti-SRHR agenda has the potential to stay and move further both as part of global politics, as well as within countries.

Just as the women’s health movement fought for the recognition of SRHR,¹ we must continue to defend it. An alliance of women’s rights organisations lobbied successfully for the inclusion of the reference to SRHR in the 2019 UHC declaration.⁵ However, under far-right coalition building, challenges on the inclusion of SRHR will continue in future international UHC conferences. Advocacy efforts must also mobilise to support women’s rights organisations, including at the national level, to ensure SRHR is realised as part of UHC, particularly in countries facing opposition. In response to coalition building against SRHR, there is a necessity not only to monitor SRH and SRHR, but also to create a plan of action to maintain and defend SRHR as an essential part of UHC which cannot be removed.