The recently published report of the Guttmacher-Lancet Commission on Sexual and Reproductive Health and Rights (“The Commission”)1 has brought renewed vision and revived thinking around the sexual and reproductive health and rights (SRHR) agenda. Despite the definitional advances made in Cairo at the International Conference on Population and Development in 1994 and the World Conference on Women in Beijing in 1995, advocacy and implementation efforts have fallen short of the articulated commitments and goals. Progress towards the realisation of SRHR has been insufficient and retrogressive actions with regard to SRHR, such as increasingly restrictive abortion laws, renewed promotion of abstinence-only sex education, and laws prohibiting the dissemination of information about sexual diversity, are particularly troubling.
The Commission has proposed a new definition of SRHR that builds on previous progress and expands the ambit of issues and services included. The “comprehensive” definition draws on global and regional consensus documents as well as World Health Organization publications to consolidate evolutions in understandings of sexual health, sexual rights, reproductive health and reproductive rights. In addition to traditional services such as contraception, pregnancy-related care and HIV prevention, the package of SRH services identified includes often-neglected services such as comprehensive sexuality education; safe abortion services; the prevention and treatment of sexually transmitted infections, infertility and cancers of the reproductive system; and psychosexual counselling and treatment for sexual dysfunction and disorders. Service provision is framed within the right to health’s standards of availability, accessibility, acceptability and quality. Attention is also given to the needs of specific populations (such as adolescents and people of diverse sexual orientations and gender identities). Notably, the Commission calls for health systems strengthening as well as multi-sectoral action beyond the health sector, including ways to address laws and policies that affect health.
We welcome this explicit use of SRHR to frame an evidence-based, costed response towards realising and expanding commitments made over the past two decades. The Commission’s recognition of the broader legal and policy environment should also renew attention to the value of human rights in a multi-sectoral SRH response. Furthermore, the broad definition of SRHR proposed can be used to engage the wide range of actors required for an effective response. While the work of the Commission provides an important framing, concrete actions needed to improve SRHR around the world still require serious attention. The Commission’s report challenges the SRHR community to operationalise a broad set of recommendations. The best definitions are those that are evaluated, tested and re-formed in iterative processes that draw in a range of perspectives. Accordingly, three areas stand out where evidence generation can help move the Commission’s findings forward.
First, applied, critical analyses are needed in individual countries and sub-national settings to identify and prioritise feasible modes of action. SRHR issues vary by country and community, and priorities within a local context must drive action. Inclusion of areas such as menstrual hygiene, intermittent preventive treatment for malaria among pregnant women, or addressing female genital cutting, for example, may be critical to include in a definition of SRHR services in some settings, while they may be less relevant in others. Contextualised, people-centred research can provide much-needed nuances required to inform programmes. For example, research on issues such as women’s demand for Caesarean sections in Brazil; how menstrual taboos affect gynaecological care in India; how conditional cash transfers for women affect household-level gender dynamics in different parts of sub-Saharan Africa; or how providers’ attitudes towards women’s autonomy affect the quality of abortion services, are required to shape pragmatic, programme-centred pathways to advancing the SRHR agenda. Similarly, analysis of the politics of SRHR within countries, of how definitions must be framed, or how advocacy might position itself within, or align with, other movements is essential – even when political will exists. Findings may make some uncomfortable, for example, if traditional taboos around topics such as adolescent sexuality, menstruation, sexual orientation, gender identity, infertility or abortion are identified as impediments to fulfilling SRHR and therefore important to overcome. But nuanced evidence that speaks to local contexts and registers is essential if we are to move beyond frameworks and into understanding why services are inadequate and rights unfulfilled and how to address this.
Second, the development and application of accountability mechanisms within an SRHR framework is an area that requires research, advocacy and action. We have much to learn from within SRHR and beyond, such as how and where the intersection of HIV and human rights has led to localised accountability. We must break down silos by learning across, collaborating with and strengthening other work on rights-based accountability in health. Even where mechanisms for redress provide channels for recourse in the case of human rights violations, documentation and analysis of “bottom-up” accountability mechanisms might be needed to help direct how the rights framing of SRHR may be retained in practice. Moreover, understanding and addressing the interactions of public and private sectors will be critical to ensuring accountability, through tracking the availability, accessibility, acceptability, quality and use of services across sectors.
Lastly, we sorely lack appropriate metrics to assess equitable, rights-based progress towards SRHR. While some such metrics might be global in nature, others will have to be developed at national or sub-national levels. For this agenda to gain traction, metrics must be locally meaningful, useful and used. Tailoring measurements to reflect the nuances of each context may not yield internationally comparable data but will allow for learning to inform appropriate actions. In all of this, grounding in people’s lived experiences should be central. Thus, in addition to generation and synthesis of population-level data, qualitative data are needed that capture the perspectives of different groups of people with SRH needs, as well as service providers. In this way, data can inform local responses as well as expand global understandings of what SRHR means both conceptually and practically.
Moving forward, we need to test the contours of the definition of SRHR including what is encompassed and what might be missing. Applying a “definition” of SRHR to a country will naturally change what is prioritised: the “components” of SRH outlined in the Commission’s report might be considered a minimum package. The approach to developing and ensuring this minimum set of services and programmes, as well as those prioritised in addition to this, must be locally determined. Moreover, we require a diverse body of evidence on needs and responses – all of which must be framed within contextually appropriate systems and metrics. These lessons can be used to refine the newly proposed definition of SRHR, bringing in additional grassroots learning to augment the evidence base from which it has been created and, as a result, to shape both global and local SRHR agendas and actions. Reproductive Health Matters welcomes contributions that explore the application of the Guttmacher-Lancet Commission at the practical level, using it as a framework for national level action and seeking to further global knowledge on SRHR and how best this might be realised.
- Starrs AM, Ezeh AC, Barker G, et al. Accelerate progress – sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission. Lancet. 2018 [cited 2018 May 29]: [51 p.]. doi: 10.1016/S0140-6736(18)30293-9