Repoliticizing Sexual & Reproductive Health & Rights
A transformative framework: beyond ICPD and the MDGs
Langkawi 2010
Sexual and Reproductive
Health and Rights in Public
Health Education
PASCALE ALLOTEY
SIMONE DINIZ
JOCELYN DEJONG
SHARON FONN
SOFIA GRUSKIN
THÉRÈSE DELVAUX
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Aims: share our concerns about the current status of
sexual and reproductive heath and rights education in
PH
Issues of social justice and inequalities have taken a
back seat to more mainstream (de) politicized agendas
Politics, advocacy and activism cannot be separated
from the ‘objective’ evidence
Brief overview of the key challenges facing SRHR today
that should be addressed through the education of the
health workforce: 3 case studies (Middle East, South
Africa and Brazil)
Introduction
SRH is an area of need of both clinical practice and
public health
 SRH generates strong opinions steeped in social
values, ideology, religion and morality
 Cairo and Beijing legitimized SRHR perspectives,
broadening the focus (infant mortality, pop
growth)
 The momentum for SRHR waxes and wanes
depending on competing priorities and lobbies
 The urgency for a workforce that is sensitized to
these critical components of SRH can not be
overstated
 Capacity is required in technical skills, research,
policy formulation and advocacy
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Brief overview of the key challenges facing
education of the health workforce.
 A case study approach: institutions were
purposively chosen based on the regions of
practice or expertise of the authors
 The content of the programs was analyzed and
is reported based on the broad themes
identified (Yin 2009).
 We provide a critical analysis of the broader
contextual factors that support or hinder
education in SRHR.
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Activism and public health
education
Public health has its roots in social activism
 In some countries, the social justice and rights ethos
remains central to the development of schools of
public health
 Despite its roots in social justice, public health
education in most countries is currently
overwhelmingly technocratic
 Most training programs address SRH in some form,
but most focus on biomedical risk centered
approaches
 Near absence of strategies to address gender and
ethnic inequities that are an important part of
negotiating SR relationships and identities
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Case study 1: Sexual and Reproductive
Health Education in the Middle East
As in many regions, in the Middle East and North Africa
SRH field has lost momentum since ICPD
 Redirected political priorities, reduced donor funding
for a comprehensive approach, fragmentation of the
larger SRH constituency into different interest groups
 Interlinkages between the various SRH fields, and active
engagement between NGOs, advocates, researchers and
policymakers was more evident at that time than it has
been during the last decade
 Lack of an institutionalization for capacity building in
reproductive health in a sustainable manner
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Short courses
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Being short courses, however, they are vulnerable to the vagaries
of donor funding, limited long-term sustainability
Social Research Center at the American University of Cairo
(Ford Foundation) - once a year, in 2010 it was offered for the
12th time.
Strong focus on social determinants of reproductive health in
the region, inclusion of gender and rights perspectives, a critique
of existing information and providing a general introduction to
main research methods used in SRH.
5 main blocks: reproductive health paradigm, understanding RH
dimensions, concepts and measurements, policy approaches and
implications of RH for research and service delivery
Short courses
Part of the Transforming health systems: Gender and rights in
RH (WHO)
 Two-week regional short course offered at Ahfad
University for Women in Sudan
 Focuses on integrating gender and rights into RH
services.
 The course, which is taught in English, is open to up to 25
regional participants with backgrounds in gender, rights,
policy and health.
 Information is not available about graduates of these
programs and any evaluation of the program is not
published on the websites.
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University programs
Much of the impetus for reform of medical
education to pay greater attention to gender
issues and SRH has originated by external
agencies
 Most public health programs are within medical
schools, a biomedical approach, focused on
disease
 Reproductive Health Working Group (1988):
annual meeting, valuable opportunity for
capacity-building and networking in a region
with many political divisions
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Increasing debate and awareness about the need for a
“public health workforce” in the region and
discussion of what competencies such a workforce
should command
 Attention to the social determinants of health and to
a rights perspective has been central to some of
those larger debates - may be a new funding area,
perhaps superseding reproductive health.
 Need for a critical assessment in this region, joined
with global initiatives, to reinvigorate the SRH field as
an integrated field, not a collection of separate issues
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Case study 2: Sexual and Reproductive Health Education
in South Africa – a perspective from University of
Witwatersrand
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The School of Public Health, University of Witwatersrand in
Johannesburg South Africa has a more than 20-year history of
working in reproductive health. Post-apartheid transition
By 1997, a three week curriculum, entitled Transforming
Health Systems: Gender and Rights in Reproductive Health, had
been developed and field-tested in South Africa.
Tensions between a long history of programme specific,
vertical, interventions – necessary because of the sheer
enormity of health crises – and a focus on general health care
system that start at a very low base.
The success of the program was recognised by the World
Health Organization (WHO) and from among competitive
applicants, four regional training centres were selected to
adapt and host the training.
 A 500 page step by step manual was published by WHO in
2001
 In the world, over 1,300 participants directly, and thousands
on programs derived from that curriculum
 Longevity and impact: WSPH offered this course for over 10
years and now parts of the course are incorporated into the
teaching of Wits medical doctors, in the Masters of Public
Health degree and the MSc in Epidemiology and Biostatistics.
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However the focus of training currently undertaken
in the Master of Public Health remains that of
health systems development.
 Gender equity is clearly evident as a theme, short
courses periodically still offer a focus on women’s
health.
 However a review of the degree as seen from a
more traditional stance – that of looking for a
programmatic approach to maternal health or
family planning would find it lacking.
 The School of Public Health has chosen to define
and defend the line of a systems approach
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Case study 3: Sexual and Reproductive
Health in PH Education in Brazil
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In the 70 and 80s, as part of the political resistance to the
military dictatorship (1964-1984) there was of a a strong
movement for health rights (health party)
Most PH education programs come from this period, and the
Brazilian association of these programs (Abrasco) was created
in 1979.
As a result of the activism, health was defined in the 1988
Brazilian Constitution as “a right of every citizen and a State
duty”, and the Brazilian public, universal health system (SUS)
was created
Private sector (23%) little regulation, + SUS
Gender and Health working group in Abrasco (1994).
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Boom in Gender studies, 2/3 production in SRHR.
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Among the 23 most important programs, SRH is under
“Gender and Health”
1984 (pre-SUS) Women’s Comprehensive Health
Program, a broad agenda (RH, SH, mental health,
occupational health, violence etc)
Short courses in coalitions of several PH teaching
institutions helped mainstreaming the field
Teaching reflects the limits of the political and legal
context. Brazilian public health training is very SUS-
oriented
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SUS: universal access: fertility rate 1.8, high
contraceptive use, condom use, abortion is very
restrictive (provided in the private sector).
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The use of the concept of gender in health varies and is
sometimes just a descriptive substitution of the word “sex”
for “gender” (especially in epidemiology).
Many of the most innovative training and service provision
are ignited by activism (funding very scarce now).
Transgender care: PH training?
Formal higher education follows it, often years later.
Women’s health, HIV/AIDS, violence against women are
examples
SRH dissociated from maternal health
High medicalization and depolitization of maternal health
(“maternal-infantilism”), heteronormative, specially on
Family Health Program, main PH strategy
Training PH X training service providers in SRH
Random reflections from the Brazilian case
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The right to not have and to have children (1980s) –
reproductive as part of sexual
SRHR separated from maternal care – the most depoliticized part of all (church, Family Health Program,
maternal-infantilism) PPP and IUDs and abortion, condoms
Integrality (comprehensiveness) Bio, social, psycho
health/prevention and treatment/all ages/ SUS principle
Men’s comprehensive health program (2008) chronic
diseases, sexual health, violence
De-politization – power relations – women x men, women x
health providers, women x institutions etc
Skilled birth care: episiotomy 80%, c-section 45% (85% in
private), oxytocin 80%, alone (law?). Effective, safe, humane
We need to generate the evidence we need – and teach it - a
political and scientific challenge / alliances
Complexities in SRHR education
Challenges
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The extent to which the content of sexual and reproductive health
education can be politicized clearly depends largely on the context
There are however some global trends.
Recent advocacy has attempted to forge stronger links between
traditional public health education and the approach driven by social
justice, equity and human rights
Objection to any move away from the technocratic approach
Erosion of academic freedom is also a real threat in some countries
and a real danger in others
Current global health debates strongly favour programmatic foci
(maternal health, family planning, abortion services) as these are
perhaps more resilient and are clearly preferred by funding agencies
A number of issues remain open to
discussion:
Is there an ideal qualification to work in
SRHR?
 What are the problems in our current
approaches to SRHR education?
 Does the technocratic, competency based
model produce a ‘competent’ SRHR
professional?
 Do we need a shift in our approaches to
SRHR education?
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