Submission to the Global Thematic Consultation on Health: World Health OrganizationCall for Papers

Health Priorities Post 2015: What is the priority health agenda for the 15 years after 2015?

Sexual and reproductive health and rights are a cornerstone of people’s human rights, health and well-being, and fundamental to the empowerment of women and gender equality across the world. On these grounds they merit the highest order of prioritization in the post-2015 development agenda, as well as for being preconditions for defeating poverty, advancing sustainable development and making progress across all major goals of shared global concern.

Simply put, these are the most intimate and fundamental of human rights, encapsulating the right to make informed decisions about very basic, universal aspects of life – one’s body, sexuality, relationships, and having children. Yet millions of people all over the world, especially women, adolescents and youth, and people from marginalized groups and those living in poverty, suffer discrimination that preclude them from exercising these rights and face barriers to obtaining critical information and services, making educated and informed choices and getting the care they need, with harmful and devastating health and other consequences for themselves, their families and communities.

While in recent decades, important strides have been made in the area of sexual and reproductive health – including reduction in maternal and child deaths and improved access to treatment for people living with HIV/AIDS – progress has been uneven within and across countries, with women and young people living in poverty especially afflicted. Among the starkest manifestations of these inequities is that complications during pregnancy and childbirth still kill 800 women every day, 99 per cent of them in developing countries, and maternal mortality remains the leading cause of death for adolescent girls in low- and middle-income countries. Despite progress in tackling the HIV/AIDS pandemic, 2.5 million people were newly infected by HIV in 2011.

Most people in the world – in all countries and cultures – will be sexually active in their lifetime. Without access to quality, accurate information and services, problems related to sexual and reproductive health take a huge toll on individuals’ well-being, especially for women and adolescent girls in the prime of their lives and productivity, with consequences that persist into old age, and implications for social and economic development. Some of the barriers people face and the negative health outcomes are portrayed by these realities:

  • More than 200 million women in developing countries want to prevent pregnancy, but lack access to effective contraception—contributing to 80 million unintended pregnancies, 30 million unplanned births and 40 million abortions – half of them unsafe and life threatening.
  • 34 million people are currently living with HIV and AIDS, affecting all age groups, including children under 15 (3.4 million) and older persons (over 3 million aged 50 and over in sub- Saharan Africa alone). The leading cause of death for women of reproductive age is HIV/AIDS.
  • Every year, 499 million new cases of curable sexually-transmitted infections occur, with consequences for overall health and well-being, including for maternal and newborn health, as well as increasing the risk of HIV infection by three-fold or more. The burden is concentrated in low-income countries, where the resources to diagnose asymptomatic infections may be limited. Many cases of chlamydia and gonorrhea, for example, exhibit no symptoms and go undetected without proper laboratory testing, but can lead to serious health problems, including pelvic inflammatory disease, ectopic pregnancy and infertility.
  • In low-income countries, only 36% of pregnant women receive adequate antenatal care, limiting opportunities to address pregnancy-related health issues such as nutrition, gestational diabetes and anaemia. Over half of pregnant women and children under five in developing countries are affected by anaemia. While entirely preventable, anemia contributes to maternal and child mortality, and impairs children’s physical and cognitive development and adult productivity.
  • Ten to 15 million women per year suffer debilitating consequences from pregnancy complications, including obstetric fistula and prolapse, as well as depression, anaemia, and other physical and mental health conditions. These conditions are most prevalent in developing countries, though treatable with proper post-partum care.
  • Some cancers of the reproductive system, like breast and cervical cancer, are among the top cancers that kill women. Many of these deaths could be prevented by early detection and proper treatment. For example, over 250,000 women die of cervical cancer each year, with nearly 80 percent of new cases occurring in developing countries. The WHO estimates that over 4 million cervical cancer deaths could be avoided over the next decade if widespread Human Papilloma Virus (HPV) vaccination were achieved in middle- and low-income countries.
  • Globally, 1 in 5 girls give birth before they turn 18.20 Sixteen million adolescent girls aged 15 to 19 years give birth annually and an estimated 3 million undergo unsafe abortions. Youth (15 to 24 years old) are the group most affected by HIV/AIDS, accounting for 40% of all new HIV infections among people 15 and over. Young women are especially at risk, with infection rates twice as high as young men, representing some 60% of the 5 million young people in the world living with HIV and AIDS. Meanwhile, only 36% of young men and 24% of young women in low- and middle-income countries know how to prevent HIV.
  • Domestic and sexual violence affects as many at 6 in 10 women, making it not only one of the most pervasive human rights violations in the world, but also another cause of poor sexual and reproductive health for women and girls.

The health consequences and deaths associated with inadequate access to quality, sexual and reproductive health information and services, and with restrictions on people’s ability to exercise their fundamental human rights, can be avoided. They are preventable problems with proven, cost-effective solutions. The international community must place the advancement of sexual and reproductive health and rights for all women, men and young people as a bedrock of public health priorities to improve overall health and well-being, prevent unwanted pregnancies, unsafe abortions and maternal mortality and morbidity, stop the spread of HIV, and improve infant and child health.

Without addressing the rights and empowerment of women and young people more broadly, however, efforts could fall short of aspirations, since sexual and reproductive health issues are so closely inter-related with many other facets of their lives, capabilities and potential. Women and young people living in poverty, with limited education and income-earning opportunities, are especially at risk of poor sexual and reproductive health. Gender discrimination is at the root of the multiple barriers that women and adolescent girls face to exercising their sexual and reproductive rights and accessing related information, education and services. Women who are migrants, disabled, living with HIV/AIDS, indigenous, living in rural settings or urban slums, or belonging to minority groups, suffer compounded and intersecting forms of discrimination that further exacerbate these barriers. Gender discrimination begins early, with strong son preference in some cultures resulting in the phenomenon of “missing girls” and imbalanced sex ratios at birth, and sometimes forcing women to become pregnant multiple times, risking their life and health.

Violence against women and girls, which is the result of deeply ingrained gender discrimination and one of the most pervasive human rights violations in the world, is a major factor fueling poor sexual and reproductive health outcomes. For example, the millions of women in abusive relationships have limited control over decision-making, including contraceptive use, and thus more likely to face unwanted pregnancy. Similarly, gender inequality and violence against women and girls has been a driving factor behind the feminization of the HIV/AIDS pandemic, restricting women’s options on condom use for all those in situations of fear, abuse, assault and exploitation, with risks of HIV infection further exacerbated during forced intercourse.

Abuse during pregnancy affects as many as 1 in 4 women, increasing the likelihood of miscarriage, stillbirth, premature labour and low birth weight. The 100 million to 140 million girls and women who have undergone female genital mutilation run increased risks of various sexual and reproductive health problems, including obstructed labor, childbirth complications, newborn deaths, postpartum bleeding, infections and maternal mortality. The estimated 60 million child brides in the world are even more at risk of having their sexual and reproductive rights trampled and being pressured to produce children, with high risks to their health and very survival. Top priorities for a visionary action agenda on health in the 21st century, grounded in human rights, equality and equity principles, should encompass:

  • Providing recognition and protections in national legislation that affirm fundamental human rights, specifically sexual and reproductive rights, the right to the highest attainable standard of health and freedom from gender-based violence, including by removing legal, policy and regulatory barriers and punitive provisions, and guaranteeing people’s ability to exercise these rights, including through human rights education and awareness-raising about legal rights and access to relevant information and services, without discrimination, coercion or violence on any grounds, regardless of age, sex, race, ethnicity, culture, religious, marital, disability, HIV, national origin, migrant, language, sexual orientation, gender identity or other factors and status.
  • Accelerating implementation of universal access to quality, comprehensive and integrated sexual and reproductive information, education and services throughout the life-cycle, from younger to older age groups, with emphasis on prevention. This must include access to a wide range of modern contraceptive methods, counseling and services related to maternal health, safe abortion care, prevention and treatment of HIV and sexually transmitted infections, and prevention or early detection of non-communicable diseases of the reproductive system, in particular breast and cervical cancers. Every effort should be made to ensure that all women and girls who have undergone unsafe abortions have access to prompt, quality and compassionate care to avert needless deaths and injuries, without fear of stigma, or any form of reprisal or punitive sanction. A holistic approach to people’s needs should ensure the provision of integrated services, especially of those related to HIV with other sexual and reproductive health services, as well as integration of responses to violence against women and girls and supports for all victims of sexual assault.
  • Particular attention should be paid to high-quality, youth-friendly information and services that respect young people’s right to confidentiality, privacy and informed consent, with a focus on prevention of unintended and unsafe pregnancy, HIV and sexually transmitted infections, and timely health, psychological, social, and legal supports in cases of violence. Particular attention should be paid to outreach and quality service access for adolescent girls, including to reduce unintended pregnancies and maternal deaths among this age group.
  • Ensuring universal access to comprehensive sexuality education for all young people, in and out of school, as part of their basic ‘life literacy’, to enable them to understand and make informed decisions about their sexuality, health and to plan their lives; for girls to be able to complete their education, avoid unwanted pregnancy, unsafe abortion and related mortality and morbidity, and for boys to understand and act responsibly on these issues; as well as to promote values of respect for human rights, tolerance, gender equality and non-violence.
  • Developing age-friendly sexual and reproductive health information and services for older women and men, whose needs and realities regarding their sexual health and lives have largely been neglected to date, exposing them to HIV and sexually transmitted infections.
  • Strengthening health system capacities to provide for the delivery of quality, comprehensive, integrated sexual and reproductive health information, counseling and services, in compliance with human rights, ethical and professional standards, including as regards enabling policies, protocols, commodities and supplies, equipment and expanded rights-based provider training.
  • Making access to essential sexual and reproductive health contraceptives, commodities, drugs and services affordable to all who need and want them, by ensuring that these receive priority attention in national health plans and budgets, and within universal health coverage and insurance schemes, and through free or subsidized care and the removal of user fees. Low-cost means of delivering information and services should be sought, such as employing technological innovations where feasible (including mobile phones), which can increase access to information and services.
  • Eliminating all forms of gender-based violence against women and girls, including domestic and sexual violence, sexual abuse of children, sexual harassment, exploitation and trafficking, and harmful practices such as early and forced marriage and female genital mutilation, including through legislative reforms and enforcement to end impunity of perpetrators, and sustained prevention efforts involving public education, community mobilization and multi-media campaigns to transform underlying genderdiscriminatory attitudes and practices that perpetuate the violence. Specific strategies should be developed to engage boys and men in eliminating gender-based violence in their families, communities and countries. All survivors of gender-based violence should have access to immediate protection for their safety and to quality health, legal, housing and other social services, including through sexual and reproductive health programmes.
  • Effectively addressing men’s roles in eliminating gender discrimination and genderbased violence, and fulfilling sexual and reproductive rights for women, with emphasis on outreach and involvement of young men, through policy and programmatic interventions designed to redress negative gender norms and behaviors.

To ensure meaningful, inclusive progress, robust, transparent accountability mechanisms involving civil society, especially women, young people and marginalized groups, must be established to track fulfillment of political, programmatic and financial commitments by the State, as well as of other development partners, including the UN system, donors, international NGOs, and the private sector. The role of academic and research organizations in providing critical data and evidence for monitoring and evaluation efforts should be supported.

Particularly relevant for ensuring equitable access and quality services are participatory accountability mechanisms at subnational and local levels, and quantitative and qualitative disaggregated data and indicators to assess how groups living in poverty, and those with least power and voice and most underserved, are faring under the new development framework. The empowerment of women and girls and gender equality, the human rights and empowerment of adolescents and youth, and sexual and reproductive health and rights should be reflected in the post-2015 agenda as core elements of human rights and human security, underpinning the achievement of all other development objectives. Fully enabling the realization of sexual and reproductive health and rights is not only an ethical and human rights imperative in its own right, it is also crucial to all other aspects of health and well-being and a prerequisite for achieving gender equality, educational, economic, and sustainable development objectives.

For example, adolescent girls who are able to avoid early pregnancy and early motherhood are more likely to complete their education, with improved incomeearning prospects: An extra year of secondary school increases future wages by 15-25%. Healthy, better educated women tend to have healthier, better educated children, resulting in a stronger future workforce. When women are able to exercise their sexual and reproductive rights and choose the timing and size of their families through access to contraceptive information and services, they tend to opt for a number of children they can best provide for, and are better placed to enter the workforce more effectively.

If the next global agenda can inspire the political will and resource investments required in these critical and strategic areas, humanity will be better placed on a path to equitable and inclusive development. The international community now has the opportunity, and the obligation, to build partnerships and channel resources towards advancing sexual and reproductive health and rights for a healthier, more just, and prosperous world for all.