Features
Recent international agreements call for the transformation of familyplanningprogrammes
from
a focus on demographic goals to the promotion ofhealth and rights objectives. But thepractical
implications of this agenda for current and future programmes remain uncJear. Public health
resources are devoted to preventing illness and reducing the prevalence and incidence of disease
across a population. Human rights methodologies focus on protecting the rights ofindividuals,
and on the right to health and health care. Both of these approaches need to be re-thought and
reconciled on a practical level to promote rights-based health programmes. AppJying a rights
framework to reproductive health programmes means, among other things, focusing as much on
the process as on the outcome, incorporating efforts to address the gender and power
dimensions ofreproductive and sexual decision-makinginto
every level ofprogramme,
and
focusing on building a sense of entitJement among both the seekers and the providers of services.
It also means movingbeyond
a focus only on the technical quality of clinic-based services to
incorporate the ethos of a rightsperspective
at everylevel. Political, institutional, and technical
barriers to the realisation of the reproductive health and rights agenda include national level
politics, Jack of capacity within civil society, and Jack of transparency ofinstitutional actors.
Keywords: public health, human rights, reproductive
health programmes
NE of the central challenges posed by
recent
international
agreements
and
women’s
advocacy
movements
is the
application
of both public health and
human rights principles to reproductive health
programmes.
The Programme of Action of the
1994 International
Conference
on Population
and Development (ICPD), for example, calls on
governments
and international donor agencies
to expand and transform existing programmes,
and to offer services that are comprehensive,
integrated, universally accessible and delivered
in a manner consistent with health and rights
objectives.
rights, family planning, reproductive
Clearly, the implications of these changes for
services alone are enormous, and even in the
best of circumstances,
reflect goals that will
require many years to realise. Yet even given the
obvious challenges,
evidence suggests that in
practice, the application to existing programmes
of reproductive rights principles lags far behind
the theory.
This article explores these issues and argues
that reproductive
health programmes
have a
pivotal but unfulfilled role to play in the promotion of rights, health, and gender equity.
Despite the proliferation of the term ‘reproductive rights’ in the international mandates and
21
national policies of the past decade, the transformative nature of the rights framework for
existing programmes
remains
relatively unexplored. Therefore,
the article examines the
political, institutional and ideological barriers to
the transformation
of existing family planning
programmes
and, by extension, the promotion
and protection of rights.
Obviously,
health programmes
alone are
insufficient to achieve these goals. Multi-sectoral
policies aimed at closing the gender gap in
access to education, employment, and other productive resources are essential to the fulfillment
of the rights agenda, and to the achievement of
other objectives, such as slowing the spread of
HIV and achieving population stabilisation.
The conclusion of this article suggests the
parameters of a framework intended to be used
simultaneously to provide guidance to governments and donor agencies
on the practical
implications for programmes
of the health and
rights agenda, as well as to evaluate the degree to
which specific programmes
promote health,
rights and equity, and thereby promote accountability of institutional actors.
For the purposes of this analysis, programmes
are defined as the sum total of efforts aimed at
changing social norms and health behaviours
and providing health services, including research, public education and advocacy, behaviour change interventions,
social marketing,
clinical services and community-based
distribution. (This definition recognises
both the
importance
and limitations of client-provider
interactions
in promoting reproductive
health
and rights.) Reproductive rights include the right
of individuals to bodily integrity and security of
person, the rights of couples and individuals to
decide on the number and spacing of their
children and to have access to the information,
education and means necessary to do so; the
right to attain the highest standard of sexual and
reproductive
health; and the right to make
decisions
concerning
reproduction
free
of
discrimination, coercion, and violence.
The rights and health agenda
The transformation
of conventional
family
planning programmes has been a major goal of
women’s health and rights movements for well
over a decade. The historical limitations and
critiques of such programmes
are well-known
and have been extensively documented
elsewhere.l These programmes have generally been
characterised
by poor quality of care, limited
choice of methods offered, and lack of attention
to critical issues such as sexual coercion and the
risk of sexually transmitted infections that are
fundamental to women’s health and rights.*
Many governments
and donors traditionally
viewed contraceptive
delivery as a shortcut
through
the demographic
transition.
Family
planning programmes were created in a vacuum,
isolated from broader efforts to change the
cultural and economic conditions that contribute
to the subordination
of women and keep birth
rates high. Such programmes have unquestionably filled a latent need among women for
methods of fertility control, but generally in a
manner that was or is instrumental to the goals
of reduced fertility and not in the interest of
promoting
rights, equity and empowerment.
While the rhetorical emphasis has been on the
depth of ‘unmet need’ for fertility regulation, in
reality, programmes have exhibited a tendency
to be selective in offering clients, and especially
women, information
and methods, and have
used various degrees of persuasion and coercion
as the means to reduce both unwanted and
wanted fertility.2,3
In the last two decades, the global women’s
health movement fundamentally
changed the
discourse of the population and health fields by
asserting that social justice and individual rights
must be central concerns of policy and programme. Redefined along these lines, ‘population policies’ are the aggregate of multi-sectoral
strategies
aimed at achieving,
among other
things, the equitable distribution of power between social groups and between women and
men. Health services, including but not limited to
contraceptive deliver?, are essential assets that
people use to meet a broad range of needs.
The rights movement recognises
that the
ability of women and men to fully exercise their
reproductive
and sexual rights, to negotiate
decisions about whether and when to have
children, and to enjoy the highest attainable
levels of reproductive health is not a function of
reproductive health programmes, or of access to
services per se, but is contingent upon the social
environment
in which people live. Following
from this, the I&PD calls for integrated efforts to
Reproductive Health Matters, Vol. 8, No. 15, May 2000
increase women’s economic and political clout,
challenge
prevailing
social
norms
around
reproduction and sexuality, and combat gender
violence - to create the ‘enabling conditions’
essential to the realisation of reproductive and
sexual rights4 In sum, the promotion of reproductive rights and health depends fundamentally
and simultaneously on the conditions in which
people live, and on the tools - such as health
services-that
are at their disposal.
Health programmes
often reflect, replicate
and reinforce the social climate in which they
exist, and will therefore
also independently
either contribute to or detract from the fulfilment
of individual rights. Applying a rights lens to
reproductive
health programmes
means such
programmes must be evaluated on the extent to
which they:
adopt effective means or measures to promote
and fulfill the reproductive health and rights
of women and men, and address gender inequities directly relevant to decisions about
sex, pregnancy, childbirth, contraception, and
infection prevention;
protect individuals from and immediately respond to violations by institutional actors or
their surrogates.
Transforming discourse and practice
The integration of reproductive rights and health
objectives
presents
a number of conceptual
challenges that need to be considered at the
outset. Traditional
public health and human
rights approaches are based on different conceptual frameworks and use different methodologies, with seemingly different implications for
programmes. Each of these approaches has to be
rethought and reconciled on a practical level to
promote rights-based health programmes.
The field of public health is concerned with
improving
the health status of populations.
Success is measured in terms of outcomes births averted, lives saved - and the goal is to
achieve the greatest good for the greatest number. Public health resources
are allocated according to priorities that reflect the ability to
prevent illness and death on a large scale, and to
reduce the prevalence and incidence of disease
across a population. Public health theory weighs
relative risks and recognises that in the quest to
improve the health of populations, some individ-
uals will continue to face risks due to individual
behaviour, environment,
economic conditions,
and lack of access to health care, among other
things. It is understood that resources are finite,
and that decisions need to be made to ensure that
investments yield the greatest possible return.
Human rights concepts and methodologies
focus on protecting the rights of individuals.
Human rights standards are universal, indivisible and inalienable. Rights language refers to a
‘right to health’ and a ‘right to health care’ which,
in the context of limited resources, can leave the
public health official at a loss.
Although a rights framework
theoretically
seeks to promote rights as well as to protect
individuals from violations, the focus for much
of the past several decades has in fact been on
the documenting of violations. During most of
the 20th century, the human rights community
focused on abuses of individual civil and political rights by public actors - the state and its
representatives.
Only in the last two decades
have rights
advocates
and legal scholars
established
the basis for women’s
human
rights, and following from this, reproductive
and sexual rights.
These
rights
are now
recognised
in. a number of conference
documents, including the 1993 World Conference on
Human Rights and the 1995 Fourth World
Conference
on Women, as well as the ICPD.
Violations of women’s rights by governments
are now documented
through
a variety of
formal means, e.g. through the Convention on
the Elimination of All Forms of Discrimination
Against Women (CEDAW) and the US State
Department’s
Country
Reports
on Human
Rights Practices.
Non-governmental
human
rights organisations,
including women’s rights
groups, have also successfully used this foundation to document violations of women’s reproductive rights by states and states’ parties.
Traditional
human
rights
documentation
relies on reports from and interviews with key
informants in a given setting. By its nature, such
reporting is often based on small numbers of
discrete cases which frequently raise a red flag
about problems that affect larger numbers, but
do not prove that a given problem exists on a
large scale. As a result, human rights findings
often are not persuasive to public health practitioners who, in the absence of populationbased data, often remain unconvinced that these
23
findings represent
more than a few isolated
cases, or a new priority to be addressed. For this
reason, proof of a small number of cases of
sterilisations without consent, for example, may
be viewed by public health institutions and programme managers
- especially those with a
vested interest in the reputation of a programme
_ as being more an aberration or an exception
than a rule, and therefore remedied through
palliative measures
focused
merely on the
individual case rather than the systemic problem.
In Mexico, for example, evidence gathered by
human rights organisations of government doctors performing sterilisations without the client’s
consent was largely dismissed by both the
government
and international
donor agencies
until large-scale surveys conducted in the 1980s
and 1990s by the government with the support of
donors showed the problem to be significant and
pervasive.5
On the other hand, by focusing only on blatant
violations, again, such as sterilisation without
consent, human rights methodologies
can also
miss subtler, but more widespread and persistent violations of rights. In Mexico, for example, a
1996 United Nations Population Fund analysis of
service delivery points throughout the country
revealed that only a limited number of contraceptive methods were offered, and that providers were required to strongly encourage and
persuade women with more than two children to
adopt IUDs or to undergo sterilisation.6 Since
most women were coming for and leaving with a
method, and since there appeared to be ‘consent,’ this type of practice might not be perceived
as a violation of rights. According to the interpretation of a rights approach, as posed by this
article, however, these are violations. A programme that offers limited methods in the
interest of reducing women’s fertility, takes
advantage
of their already limited sense of
entitlement in order to achieve externally posed
goals, and fails in any way to instill a sense of
broader choices and entitlement, does not meet
the test of contributing
to the promotion
of
reproductive rights.
Applying a rights framework to reproductive
health programmes means focusing as much on
the process as on the outcome, and opens the
possibility of transforming not only programmes
but the essential discourse and practice of both
public health and human rights.
24
From theory to practice: minimum
criteria for rights-based programmes
A rights approach requires a fundamentally
different analysis of the content and intention of
what we now call family planning programmes.
To explore the practical meaning of a rightsbased framework for current and future programmes, it may be helpful to start from the act
of heterosexual intercourse. In the ideal world,
sexual partners decide together whether or not
they want to have children, and, if not, how to
protect themselves from unwanted pregnancy.
They negotiate the timing and frequency
of
sexual encounters. If one partner suffers from a
sexually transmitted
infection, they work together on ways to protect the other.
The real world, however, is still far from this
ideal, and both women and men are at risk of the
consequences
of unsafe sex. Cultural and social
norms may inhibit partners from talking openly
with each other about sex, sexuality, contraception and infection, thereby putting them at risk of
both unwanted
pregnancy,
and of disease.
Taboos and traditional practices may prevent
them from seeking health care even in dire
circumstances. Women and men may know little
about their bodies and how they work. Women
may be particularly vulnerable because they face
constraints
posed by inequitable
gender and
power relations that undermine their ability to
negotiate
sexual and reproductive
decisions
equally with their partners. An individual woman
may sometimes - and sometimes frequently -be
forced to engage in non-consensual
sex, or she
may be raped by an intimate partner.’ Unwanted
pregnancy may be a persistent concern, either
because a woman cannot control the timing of
intercourse,
and therefore protect herself, or
because she lacks access to *methods of fertility
regulation that truly fit her particular needs.
Access to safe abortion is likely to be limited if it
is available at all. Emergency obstetric care may
be equally scarce. All of these conditions contribute to high rates of reproductive morbidity and
mortality, especially among women.
By using contraception, women of course may
be better able to control some of the outcomes of
unwanted sex, such as unwanted pregnancy. They
may however still be forced to have sex against
their will on a regular basis, perhaps even more
frequently because the likelihood of unwanted
pregnancy is diminished. These conditions and
Reproductive
the failure of programmes
to adopt effective
means to address them constitute violations of
reproductive
and
sexual
rights.
women’s
Likewise, without simultaneous efforts or means
to reduce STIs, these same women remain at risk
of infection - again a violation of their rights.
Similarly, under this scenario,
and in the
absence of efforts to change the gender dynamics of sex, encouraging men to use - or having
them encourage their partners to use - contraception could yield higher rates of contraceptive use with little or no change in the
prevalence of sexual coercion and with-little or
no increase in positive communication between
couples, changes that would nonetheless
be
deemed a success under conventional measures
of evaluation.
A rights approach starts from this reality and
asks: What can and should be done programmatically to address these issues? Instead of
offering
a limited range
of contraceptive
methods because they are effective or efficient in
meeting aggregate
goals, a rights-based
programme offers several, while constantly
reaffirming at every level the right to choose
between these. Instead of relying on providers to
do all the work of informing
and educating
clients in the span of a few minutes, it offers
community-based
reproductive
health education, builds community support for reproductive
health and rights, and uses a variety of communication strategies to instill a sense of entitlement
among people and establish new social norms
encouraging
partnership,
communication
and
cooperation. Instead of pretending that unwanted pregnancy is the only potentially problematic
outcome of sexual intercourse, it recognises that
the prevention of risk of infection and coercion
and efforts to deal with the consequences
of
these are, at a minimum, of equal importance to
promoting reproductive and sexual health and
are risks that many women face each and every
time they engage in the act of intercourse,
whether or not they face unwanted pregnancy. A
rights approach puts as much emphasis on the
ethical and value-oriented
aspects of a programme as it does on technical skills. Finally, a
rights approach acknowledges that health providers also are individuals with rights and needs,
and that changing the system is as important as
changing the individual.
The primary test of success in the old mode1 of
Health
Matters,
Vol. 8, NO. 1.5, May 2000
programming is contraceptive use and reduced
fertility. A rights-based model, by contrast, provides a means test to measure the intention and
progressive achievement of programme efforts ranging from research priorities to behaviour
change communication to client-provider interactions - in advancing reproductive choice and
rights while simultaneously
addressing
what
might best be called the proximate risks of sexual
relations. The rights model is based on the indivisible rights to bodily integrity, freedom of
choice in childbearing, freedom from coercion,
and the highest attainable standard of health. It
recognises
that the proximate risks of sexual
relations are integral to each act of intercourse,
and therefore
addresses
these
risks
programmatically
in an integral, rather than an
additive way. Because the proximate risks of
sexual relations
are indivisible - any given
woman may simultaneously
face the risks of
sexual coercion,
unwanted
pregnancy,
and
infection - the response must be indivisible too.
Concerns about sex, power, gender and rights
should therefore be considered intrinsic to each
aspect of programming
- research,
delivery,
education, communication
and client-provider
interactions - and not be compartmentalised.
In 1994, Jain and Bruce sought to provide
concrete
guidance on the transformation
of
family planning programmes
to policymakers
and programme managers by suggesting a shift
from a focus on fertility objectives to ‘helping
individuals to achieve their reproductive intentions in a healthful manner.‘8 To achieve this
goal, they argued, programmes must include the
following elements:
??
??
??
??
choice of contraceptive methods;
safe abortion;
diagnosis and treatment of reproductive tract
infections and other preexisting
conditions
that would make the use of a particular
contraceptive method unhealthful;
diagnosis and treatment of unhealthful effects
of contraceptives.
They further note that the question of which
services get priority depends on the local conditions and felt needs of clients.
Taking these steps would in itself represent
a major advance in what is available to the
vast majority of women and men worldwide.
Applying a rights framework to this constellation
25
of services, however, takes us several steps
further, and at a minimum includes efforts at
every level of programming to:
address sexual violence and coercion, especially as it relates to restricting
women’s
choices, and exposes women and girls to
higher risks of morbidity and mortality;
incorporate multi-source reproductive health
and rights education strategies, and seek to
instill a sense of entitlement among people
and a rights-based ethos within programmes;
incorporate
communication
and behavior
change interventions
encouraging
the prevention of disease, the practice of safe sex, and
changes in social norms that encourage equitable partnerships;
establish means of ensuring the accountability
of programmes to the population and means
of redress for violations of rights.
Obstacles to change
On the face of it, the rights agenda is now mainstream. Today, a majority of governments (and by
extension other public institutions, such as donor
agencies), are signatories to international agreements that recognise reproductive and sexual
rights as human rights. The terms ‘health,’
‘rights,’ and ‘gender,’ are now ubiquitous in the
rhetoric and the policy statements of the population and health fields, suggesting that institutional actors at least nominally support this vision.
But evidence suggests that on the whole,
progress in making the fundamental changes in
family planning programmes
required by a
rights framework is uneven at best. There are a
number of obstacles to the transformation
of
family planning programmes, some of which are
explored briefly below.
Social, economic, and political conditions
undermine rights and entitlement
The most important obstacles to the realisation
of the reproductive rights and health agenda are
the continued lack of attention to enabling conditions, and the absence of institutional and
political environments
that support, promote,
and protect rights. Poverty, lack of social investment and the dislocation caused by rapid globalisation and privatisation
worldwide,
among
other things, continue to undermine individuals’
rights and sense of entitlement. Fundamentalist
26
religious and political movements pose particularly profound threats to women’s health and
rights.g
Lack of transparency
of institutional actors
also severely undercuts the ability of civil society
to monitor progress and ensure accountability
on the rights agenda. Governments and donor
agencies have their own political agendas and
institutional imperatives, and their internal systems often are set up to protect these, making it
difficult for civil actors to gain access to information on programmes or spending.
Support for a rights agenda at the national
level may be weak
National politics plays a pivotal role in the reproductive rights agenda. The USA, for example,
remains among the leading contributors to international family planning programmes
in both
financial and technical terms. The strong influence of political ideologies that come from opposite ends of the spectrum around the issue of
population stabilisation and reproductive rights
have impeded both conceptual
and practical
progress toward a rights-based
agenda within
US international assistance. On the one hand,
traditional supporters within the US Congress of
international family planning programmes back
these efforts largely because of their concerns
with population
growth
and demographic
threats to the environment, economy and international security. While the need to achieve
population stabilisation is a legitimate concern,
support for international family planning programmes has been sold to policymakers and the
USA largely on the basis that such programmes
‘achieve results’ and are the ‘most effective’ route
to reducing birth rates.
On the other hand, a quite small but powerful
counter-constituency
seeks to eliminate programmes altogether. Ih the US House of Representatives, right-wing politicians have made the
gutting of family planning programmes
one of
their main priorities. Efforts to curtail or eliminate spending on contraceptive delivery - an area
in which the USA has historically played a
leadership role - have taken many forms. Since
the 198Os, the far right has persistently worked to
diminish the capacity of organisations receiving
US international assistance to work on expanding access to safe abortion overseas, even in
countries where abortion is legal and even in
Reproductive
instances where funds for work on safe abortion
were obtained from other sources. In the mid199Os, Congress
imposed a harsh system of
metering of funds on international family planning programmes in a failed attempt to eliminate
the overall programme. More recently, Congress
passed a new global gag rule, requiring USfunded organisations to sign pledges renouncing
any and all work on safe abortion - including the
collection of data or the dissemination
of information
on unsafe abortion - to continue
receiving funds. It is clear that the objective of
this assault is to undermine access to all means of
preventing
or ending unwanted pregnancies,
ranging from contraception
through abortion
services.
In recent years, the far right also has used the
human rights agenda to its own ends. In 1999,
leaders of the conservative right crafted a law
mandating
monitoring
of US-funded
programmes for violations of informed consent, and
requiring that funding be withdrawn from any
programme in which such violations are found.
This poses a critical problem for women’s right
of access to services, and to meaningful choices,
because instead of making a commitment to
funding and improving programmes
in which
governments
or donors are taking pro-active
steps to expand choice and infuse their programmes with a rights agenda, the ultimate
effect of this legislation is to diminish choices
altogether. In effect, it is the wrong means test
for anyone concerned with expanding women’s
rights generally
and reproductive
rights in
particular, and strongly underscores
the real
intentions of the far right in promulgating these
rules. These efforts have had far greater success
than otherwise might be the case because of the
absence of an organised, vocal and truly rightsoriented constituency base in the USA.
In a sense, US assistance
confronts three
competing paradigms - the demographic approach and the reproductive rights approach both of which seek to expand services but for
different reasons and with different implications
for services - and the anti-choice/anti-rights
paradigm, which seeks to eliminate them altogether. These competing agendas, and the constant sense on the part of USAID that it is under
siege, have paralysed the Agency. As a result of
these and other constraints, including internal
resistance within the Agency, changes in the
Health Matters,
Vol. 8, No. 15, May 2000
structure, design and evaluation of the majority
of family planning
programmes
funded by
USAID have tended to be at the margin. New
indicators - such as levels of client awareness of
reproductive
function
and measures
of the
number of counselling sessions held with clients
and their partners - have been added in some
programmes, but these remain subsidiary rather
than equivalent to contraceptive prevalence and
reduced fertility in their importance
for programme success, and often are not viewed as
critical benchmarks on which either reporting is
required or decisions about disbursements
are
made.1° While there are notable examples of
innovative projects, such as ReproSalud in Peru,
these remain the exception rather than the rule.
Similar situations exist in many countries. In
Mexico, for example, national level reproductive
health policies extol the ICPD agenda. Yet while
data now confirm that problems with both
informed
choice and informed
consent
are
deeply embedded in the public sector family
planning programme, the government and key
donor agencies have taken only superficial steps
toward resolving these issues. These include the
development of new forms to be signed by clients
and a series
of trainings
for programme
managers. Yet providers report that though they
are told to obtain consent and promote choices
of methods, they are nonetheless still subject to
the same evaluation
criteria for delivering
methods. The efforts to promote informed choice
in Mexico, therefore fall far short of addressing
the fundamental barriers to choice presented by
continued numerical targets for the delivery of
particular methods, provider bias, and other
concerns
characteristic
of the government’s
programme.
Programmes remain focused on narrow
objectives
Reduced fertility remains the central objective
and contraceptive
prevalence rates (CPR) the
primary indicator used in many programmes,
with limited consideration
evident in most
programmes
of the contextual
factors
that
influence fertility decisions or put women at risk.
Indeed, USAID’s own policy documents reiterate
the importance, efficiency and effectiveness of
contraceptive
delivery for achieving reduced
fertility and population stabilisation, statements
that stand in direct contrast to the spirit of the
27
Jacobson
ICPD in its recognition of the critical importance
of multi-sectoral approaches and its intention to
de-link
family planning
programmes
from
demographic goals.ll
Today, several initiatives intended to incorporate concern for gender issues into USAIDfunded family planning programmes are underway, but it remains unclear how these will
advance the fundamental changes called for by a
rights perspective.
For example, in 1997 the
Office of Population formalised an Inter-Agency
Gender Working
Group to explore the incorporation of gender issues into programmes
funded by the Agency. The group, comprised
almost entirely of USAID-funded
cooperating
agencies, has done important work in reviewing
the Agency’s strategic objectives and exploring
the practical implications of male involvement,
and is now preparing guidelines for the incorporation of gender-sensitive
indicators into the
Agency’s ‘requests for proposal.’ The long-term
impact of the IGWG is unclear, however, in view
of the fact that neither the central office nor the
missions are committed to incorporating
the
findings or recommendations
of the group into
actual programmes.1°
Key concepts remain ill-defined
Key concepts,
such as ‘comprehensive’
and
‘integrated,’ on which rhetorical agreements on
reproductive and sexual health programmes are
based, remain ill-defined. The failure to go beyond the level of rhetoric to clearly articulate the
meaning of these terms, and to demonstrate
understanding of the financial and technological
limitations
to creating
comprehensive
programmes in the short run, has hampered progress on many fronts.
Lacking guidance on what to do and how to do
it, many in the public health community feel
unclear about how to proceed toward a rightsbased reproductive health programme, or how to
respond to frequently used terms like ‘comprehensive’ and ‘integrated’.12 The lack of clarity can
result in institutional paralysis on the part of
governments and donors who perceive that they
are being asked to provide everything to everybody simultaneously. Faced with pressure to do
something, some institutional actors make superficial changes in programmes; others just go on
with business-as-usual. For example, the ICPD +5
objective calling for reductions in unmet need for
28
contraception
implies that reproductive rights
are divisible into neat categories, such as ‘access
to contraception’,
reinforcing the sense among
those for whom contraceptive delivery is a priority that they need do no more than this.13 The oftrepeated ‘right to choose freely’ is seen by many
institutional actors as being fulfilled if an individual woman with an ‘unmet need’ receives a contraceptive - irrespective of any risks of infection
or sexual coercion she may have, or her lack of
knowledge about reproductive functioning.
The sense of being overwhelmed
appears
even greater among those politically or otherwise disinclined to support the overall objectives
of the ICPD. Adherents of conventional family
planning programmes,
for example, argue that
their programmes
are efficient and cost-effective, and that the public health impacts are easily
measured. This group, which is in many instances still represented
at high levels in both
governments
and donor agencies,
often dismisses the call for comprehensive,
integrated
services as grossly unrealistic, arguing that a
public health approach demands priority actions
in the interests of increasing
general health.
Many in this group view ‘gender’, ‘empowerment’ and ‘rights’ concerns
as add-ons to
programmes that can be costly, may dilute programme effectiveness and compromise results.14
In fact, the rights framework does allow for
progressive realisation of goals. However, neither the principle of progressive realisation nor the
interim steps needed to achieve priority goals in
particular settings have as yet been deeply
enough
explored by the rights and health
communities in specific settings to provide sufficient guidance to even the strongest supporters
within government and donor agencies on how
1
to move forward.
Realising this, women’s rights and health
advocates are taking” on these issues. For example, a groundbreaking
article by Alicia Ely
Yamin and Deborah Maine in 1999 suggests a
methodology
for marrying human rights and
public health standards in efforts to measure
progress
in reducing maternal mortality and
morbidity.15 The article examines in detail how
international human rights principles, concrete
data collection, and measurable
indicators of
progress can be used simultaneously to analyse
the scope of a problem, i.e. maternal mortality,
set achievable,goals and mark progress.
Reproductive
Still, much more needs to be done to identify
priority issues in particular settings and to ensure
the collection and analysis of data essential to
identifying and understanding the dimensions of
other key reproductive
health
and rights
concerns, such as STIs and unsafe abortion.
These findings then need to be used to inform the
development of reproductive health programmes
and service delivery.
Limitations of technology,
and of technical
and human resource capacity, also act as limiting
factors in the transformation
of programmes.
For example, ICPD and other agreements call for
integrated reproductive health services. O’Reilly
and colleagues rightfully suggest that integration
of efforts to prevent, diagnose, and treat STIs
into existing programmes (at various levels) is an
important first step, and crucial to addressing the
proximate risks of sex. l2 Without question, much
more can and must be done within existing
programmes to develop and carry out ST1 prevention strategies that address the fundamental
issues of gender, power and sexuality, and to
offer women and men true access to existing
barrier methods and the means of dual protection from pregnancy
and infection. These
efforts may soon receive a boost as female
condoms and new technologies such as microbicides become available.
What are the existing barriers to diagnosis
and treatment?
There are, for example, unanswered questions about whether existing ST1
diagnostics are too expensive or too technologically complex to be useful in low-resource
settings. Costing studies examining the balance
between the higher costs of technologies
and
lower labour and laboratory costs in developing
countries are now underway.16 Further information is needed on the real costs of these tools so
that they can be used as widely as possible as the
development of lower-cost diagnostics proceeds.
And work is needed at the international level to
ensure that donors and governments are putting
sufficient funding into the development
and
dissemination of these diagnostic tools, so that
the pace of dissemination is accelerated.
Reforms are rapidly changing
of health care
the face
While the proximate risks of unsafe sex and the.
gender dimensions of sexual and reproductive
Health
Matters,
Vol. 8, No. 15, May 2000
negotiation are indivisible, setting priorities to
address them progressively will nonetheless be
necessary in light of the fact that the situation
both internationally and within the majority of
countries is one of limited and often static or
declining expenditure on health care. Setting
specific priorities and indicators of success for
the progressive
incorporation
within
programmes of a rights approach is even more
urgent, given the rapid changes underway as a
result of health sector reforms.17 There is very
little concrete evidence on how sector reforms
are affecting access to and the quality of care,
whether positively or negatively. We need to
know much more about the implications for
reproductive
health
and rights
in various
settings of efforts to decentralise, redistribute
staff resources, institute user fees, privatise services and overhaul drug management systems.
And we need to actively engage in these efforts
to ensure that they advance, rather than undermine the ICPD agenda.
Lack of capacity and lack of
transparency
Finally, lack of capacity in the women’s movement and lack of transparency
on the part of
institutional
actors are constraining
factors.
Over the past two decades, the capacity of the
international women’s movement to influence
rhetoric and policy, lobby, use the media, and use
international bodies to advance women’s rights
has expanded dramatically. As I have argued
above, however, now that we have won globally,
we have to act locally. The transformation
of
programmes has to occur at the national, state,
and district levels. In fact, in many countries
undergoing
health sector reforms, decentralisation and privatisation of health care is occurring at a rapid pace.
Meanwhile, the ability of civil society actors to
monitor progress and ensure accountability on
the rights agenda is constrained in several ways.
Lack of transparency of institutional actors is a
critical obstacle. Governments and donor agencies have their own political agendas and institutional imperatives,
and their internal systems
often are set up to protect these, making it difficult for civil actors to gain access to information
on programmes or spending, or to be meaningfully engaged in developing programmes.
29
Jacobson
In fact, severe resource constraints,
among
other things, strongly limit the capacity of state
and local-level civil society groups concerned
with reproductive health and rights - to shape
debates, conduct research, engage with institutional actors in setting priorities, monitor programmes,
and engage with communities.
In
some cases, such as the devolution of power to
district and village-level bodies under the Panchayati Raj Act in India, the authority to shape
and implement health programmes
is being
vested in groups whose understanding
of and
willingness to address reproductive health and
rights issues is limited at best.‘* Ironically, the
urgent need to build capacity at the local level
comes at a time when it appears that some of the
private foundations that helped create the ICPD
agenda may be reducing their overall support to
the field, and others have re-focused on more
traditional approaches to family planning.
Towards a framework for advancing
the reproductive rights agenda
To ensure progress toward the goals of the
reproductive
rights agenda, a framework
is
needed that encompasses the technical aspects
of quality of care, but goes beyond it in several
ways. First, the framework must ask: In what
ways must existing family planning programmes
be transformed so that these can help ensure that
women and men can engage in sexual intercourse free from the fear of unwanted pregnancy, infection and sexual coercion, and with
equal negotiating power with their partners?
Second, it must take a ‘systems’ approach to
programme development, and provide guidance
on the integration of both public health and human
rights principles at each stage of programme
development and execution, ranging from the
conceptualisation of programmes and the conduct
of research to gather baseline data, through programme execution and service delivery, and onto
evaluation and measurement. It must be used to
develop an overall plan for the evolution of programmes that can act simultaneously as a guidepost for institutional actors and as a means of
holding them accountable for moving forward.
Third, it must be universally relevant but specifically applicable. It must be used to transform
existing programmes in a manner consistent with
broad goals, such as integration and gender
equity, but in a manner that is step-wise and
progressive, based on specific and clearly articulated objectives that meet local needs -aimed at
addressing a core set of priority issues and the
achievement of measurable changes in a given
setting over a discrete period of time. Understanding what must be done in absolute terms and
what can be done relative to a given situation is
crucial to recognising good faith efforts and the
progressive
realisation of a rights framework
within programmes.
Fourth, the framework must include but extend
beyond the purely technical aspects of training for
clinic-based service delivery and technical quality
to incorporate means for infusing programmes
and the people that run them with the ethos of a
rights perspective at every level. This means developing approaches to problems that are integral,
not additive, e.g. by taking into account in the provision of methods, the potential interplay between
contraceptive use, sexual coercion, and risk of infection. It means working with providers in recognising the gender, class and other constraints that
not only affect their relationships with clients, but
are also likely to influence their own lives and
health. It means examining the rights of providers
as actors and potential agents of change within
institutions as much as it does the rights of clients.
The rights agenda requires a fundamentally
different perspective on reproductive health programmes and service delivery, as well as fundamentally different approaches to the development
of programme goals and objectives, strategies,
and evaluation. While the vision of the rights
agenda is broad and encompassing, the means to
get there can be incremental and achievable.
What is needed are long-term commitments by
institutional actors to working with civil society to
achieve these goals, and a reciprocal commitment
by civil society actors to engage with institutions
proactively, while maintaining their independence and ability to advocate for change from
outside the health system.
Acknowledgements
The analysis presented here is based largely on
work conducted by the Center for Health and
Gender Equity (CHANGE) over the past several
years in monitoring implementation of the health
and rights agenda by international donor agencies supported by the United States government
in various country settings. As such, it is inffu-
Reproductive
enced
by
m’duals,
the
thinking
including
whose
unwavering
health
and
emotional
rights
and
those
work
within
commitment
I have
drawn
support.
of many
CHANCE,
HeaJtJl Matters,
indi-
Correspondence
from
Jodi
L Jacobson,
Center
to reproductive
Equity,
6930
Carroll
intellectual
20912,
USA.
Phone:
and
270-2052.
E-mail:
8, No.
for Health
Avenue,
l-301
Vol.
Takoma
270-1182.
1.5, &Jay
and
Gender
Park,
Fax:
2000
Md.
l-301
jjacobson@genderhealth.org
References and Notes
1. Germain A et al, 1994. Setting a
new agenda: sexual and
reproductive health and rights.
In: Population Policies
Reconsidered: Health,
Empowerment, and Rights. G
Sen et al (eds). Harvard School
of Public Health, Cambridge
MA.
2. See, for example: Bruce J, 1989.
Fundamental Elements of the
Quality of Care: A Simple
Framework. Population Council,
New York; Germain A, Ordway
J, 1989. Population Control and
Women’s Health: Balancing the
Scales. International Women’s
Health Coalition, New York.
3. Jain A, 1995. Implementing the
ICPD’s message. Studies in
FamilyPlanning. 26(5):296-g&
4. Correa S, Petchesky R, 1994.
Reproductive and sexual rights:
a feminist perspective. In:
Population Policies
Reconsidered: Health,
Empowerment, and Rights. G
Sen et al (eds). Harvard School
of Public Health, Cambridge
MA.
5. These observations are based
on research conducted in
Mexico by myself and others
between 1997 and 2000 for the
Center for Health and Gender
Equity (CHANGE), and by our
partners in Mexico, including
Monica Jasis, co-director,
Centro Mujeres, Baja California
Sur. During this period, we have
been involved in conducting
research on constraints to
informed choice and consent in
Mexico, and in monitoring the
activities of both the
government and donor agencies
in addressing these issues.
Unpublished data collected by
CONAPO and funded by several
external donor agencies
(presented in a meeting with
CONAPO officials at which
CHANGE representatives
were
present) reveal that problems
with choice and consent are
widespread in the Mexican
programme, and are
particularly entrenched within
particular segments of the
public sector programme.
Qualitative research and
programme analyses indicate
that the problems of choice and
consent are most obvious in
clinical settings, but have deep
roots in cultural, economic, and
class-based constraints on
women’s lives. These issues are
to be explored more fully in a
forthcoming case study of
reproductive health
programmes in Mexico to be
published by CHANGE in 2000.
United Nations Population
Fund, 1996. Evaluation Repoti:
Quality of Family Planning
Services. No. 8. New York.
Johns Hopkins University and
the Center for Health and
Gender Equity, 1999. Ending
violence against women.
Population Reports. 24(4).
Jain A, Bruce J, 1994. A
reproductive health approach to
the objectives and assessment of
family planning programs. In:
Population Policies
Reconsidered: Health,
Empowerment, andRights. G
Sen et al (eds). Harvard School
of Public Health, Cambridge
MA.
Freedman L, 1996. The
challenge of fundamentalisms.
Reproductive Health Matters.
4(8): 55-69.
10. Observations based on
documents reviewed during
meetings and participation by
CHANGE in the Inter-Agency
Gender Working Group, 1997 to
the present.
11. United States Agency for
International Development,
1999. From Commitment to
Action: Meeting the Challenge of
ICPD. Washington DC.
12. See, for example, O’Reilly K,
Dehne K, Snow R, 1999. Should
management of sexually
transmitted infections be
integrated into family planning
services: evidence and
challenges. Reproductive Health
Matters 7(14):49-59.
13. Girard F, 1999. Cairo + Five:
reviewing progress for women
five years after the International
Conference on Population and
Development. Journal of
Women’s Health and Law.
l(l):l-14.
14. Based on experience of
CHANGE staff and drawn from
numerous discussions and
meetings in the period 1997.
2000.
15. Yamin A, Maine D, 1999.
Maternal mortality as a human
rights issue: measuring
compliance with international
treaty obligations. Human
Rights Quarterly. 21(3):565-607.
16. O’Reilly, K. Personal
communication, March 2000.
17. Center for Health and Gender
Equity, Population Council,
1999. The Implications ofHealth
Sector Reforms for Reproductive
Rights and Health. Report from
a meeting of the Working
Group on Reproductive Health
and Family Planning. World
Bank, 14-15 December,
31
Jacobson
Washington DC.
18. Sethi G, 1997. Administrative
decentralization as a strategy to
improve the quality and
responsiveness
of social
services: the Panchayati Raj and
reproductive health in India.
Paper presented at
Accountability Mechanisms:
Marking Progress in the
R&urn6
De recents accords internationaux demandent de
faire passer les programmes
de planification
familiale d’objectifs demographiques
a la promotion d’objectifs de Sante et de droits. Les
consequences
pratiques
de l’association
de
principes de Sante et de droits de l’homme dans
les programmes
actuels et futurs demeurent
neanmoins peu claires. Les ressources de Sante
publique sont allouees selon les priori&
qui
refletent la capacite de prevenir la maladie et de
reduire sa prevalence et son incidence dans une
population. Les methodologies
des droits de
l’homme portent sur la protection des droits des
individus, et le droit a la Sante et aux soins de
Sante. Les plus importants
obstacles
a la
realisation dun programme en faveur des droits
sont la pauvrete, le manque de conditions
propices et d’investissement social, et l’absence
d’environnements
institutionnels
et politiques
pouvant soutenir, promouvoir et proteger les
droits. Ces dernieres
annees, des politiciens
d’extreme
droite
aux USA ont utilise les
programmes
des droits de l’homme a leurs
propres fins et ont fix6 comme l’une de leurs
priorites de vider de sens les programmes
de
planification familiale. Appliquer un cadre de
droits aux programmes
de Sante genesique
signifie se centrer autant sur le processus que sur
le resultat, c’est-a-dire qu’en plus de proposer des
methodes contraceptives,
cette approche peut
offrir une education en Sante genesique a assise
communautaire,
un appui communautaire pour
la Sante et les droits genesiques, et l’emploi dune
variete de strategies
de communication
pour
transmettre un sentiment de legitimite dans la
population et etablir de nouvelles normes sociales
encourageant le partenariat, la communication et
la cooperation. Elle doit assurer non seulement la
qualite technique
des services proposes
en
dispensaire, mais aussi introduire l’ethique dune
perspective de droits a tous les niveaux.
Implementation of ICPD,
Working Group on
Reproductive Health and Family
Planning, Ford Foundation,
New York, 9-10 April.
Resumen
Recientes
acuerdos internacionales
hacen un
llamado a la transformacidn
de 10s programas
de planificacion familiar desde un enfoque en las
metas demograficas a la promotion de 10s objetivos de salud y 10s derechos. Sin embargo, no
estan claras las consecuencias
que tendria la
union de 10s principios de salud y 10s derechos
humanos en 10s programas actuales y futuros.
Los recursos de la salud publica son distribuidos
de acuerdo con prioridades que reflejan la capacidad de prevenir enfermedades
y disminuir la
prevalencia e incidencia de enfermedades en la
poblacibn. Las metodologias
de derechos humanos estan enfocados en la protection
de 10s
derechos de las personas, y el derecho a la salud
Los
obstticulos
y la atencion
en salud.
principales a la realization de una agenda de
derechos son la pobreza, la falta de condiciones
habilitantes y la inversion social, y la ausencia de
institucionales
y politicos
que
ambientes
apoyan, promuevan y protegen 10s derechos. En
adios recientes, 10s politicos de la ultraderecha
en 10s EE.UU. han usado la agenda de derechos
humanos para sus propios fines y han hecho de1
desfinanciamiento
de
10s programas
de
planificacion
familiar una de sus mayores
prioridades. Aplicar un marco de derechos a 10s
programas
de salud reproductiva
significa
enfocar
tanto en el proceso
corn0 en 10s
resultados, i.e. ademas de ofrecer metodos antieste enfoque
podria
tambien
conceptivos,
ofrecer education en salud reproductiva a nivel
comunitario, construil- apoyo comunitario para
la salud y 10s derechos reproductivos, y usar una
variedad de estrategias comunicacionales
para
infundir un sentido de derecho propio entre la
gente y establecer nuevas normas sociales que
fomenten las asociaciones, la comunicacion y la
cooperation.
Debe incluir no solamente
la
calidad tecnica de la provision de 10s servicios
clinicos sino incorporar ademas una perspectiva
de derecho a todo nivel.