UNFPAState of World Population 2002
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CHAPTER 5:
Challenges and Needs


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"Eradication of poverty based on sustained economic growth, social development, environmental protection and social justice requires the involvement of women in economic and social development, equal opportunities and the full and equal participation of women and men as agents and beneficiaries of people-centred sustainable development."

— Paragraph 16, Beijing Declaration, Fourth World Conference on Women, 1995

Action is especially needed in two areas: first, to establish the broad human rights which enable sexual and reproductive rights, and create the conditions for their exercise; and second, to put in place information and services that meet the full range of requirements for sexual and reproductive health.

Greater attention has to be paid to broader human rights issues, especially to those that promote gender equality and the empowerment of women. Laws and procedures must be reformed, and existing rights protections better enforced. Procedures to document human rights violations are needed. Both government and civil institutions must become more accountable for protecting rights. Education about human rights should be undertaken, and alliances developed among institutions concerned with rights. Internationally, human rights goals must be given greater priority in assistance programmes.

Poverty is the defining factor preventing both women and men, especially in developing countries, from exercising their sexual and reproductive rights. The actions advocated in this report will have a powerful impact on poverty, but specific action is needed to increase women’s access to credit and economic resources.

Education, both general education and specific education on sexual and reproductive health, is needed at all levels. After primary health care, the most valuable investment a country can make is in closing the gender gap in education for girls and women. Boys and men have specific educational needs, notably in the area of gender relations, so that they can take their proper place as equal partners with women in family, community and national life. Domestic and sexual violence will not end while inequality exists between men and women.

Health services need to be restructured to meet the reproductive and sexual health needs of clients, including currently underserved groups. Guidelines, standards of conduct and evaluation methods need to be developed. All the institutions of civil society— governments, non-governmental organizations and the private sector—must be involved in designing, implementing and monitoring programmes. Priority for sexual and reproductive health is needed when resources are allocated.

Enabling Rights

Population and development strategy. In countries all over the world, policy frameworks for population and development programmes are being reviewed and revised to reflect the international consensus reached at development conferences, including the ICPD’s commitment to reproductive health and rights. This process must continue.

Gender equality and equity. The international conferences of this decade drew unprecedented global attention to social development, and in particular to what it means, or should mean, for women. This awareness should grow as countries continue to implement the conference agreements. The United Nations system is integrating gender concerns in programmes and procedures; producing gender-differentiated data and offering assistance for national efforts to develop culturally sensitive education programmes.2 United Nations bodies are working for the withdrawal of national reservations to the Convention on the Elimination of All Forms of Discrimination Against Women, and for the adoption of its draft optional protocol adding an enforcement mechanism.

Methods to monitor progress. Within the United Nations system, the Inter-agency Task Force on Basic Social Services for All is working on a set of indicators measuring gender differentials in educational attainment, access to basic health services, access to family planning services and levels of morbidity and mortality (including maternal mortality). Efforts have begun to reconcile the diverse methodologies of human rights organizations, the public health community, specialized agencies of the United Nations and national recording systems.

Multinational and bilateral assistance agencies are cooperating to develop indicators for measuring the performance of reproductive health programmes.3 UNFPA is developing indicators to measure national reproductive health conditions (relating to family planning, maternal health, reproductive tract infections and STDs, abortion and post-abortion care, infertility and harmful traditional practices) and the impact of policies and programmes. Complementary demographic, social and economic data will provide the context for interpreting these indicators.

Human rights activists, UNFPA, UNICEF, WHO, the UN Division for the Advancement of Women and the human rights treaty bodies have begun consultations on mechanisms for monitoring reproductive and sexual rights within the context of human rights treaty mechanisms. Relevant public health indicators could be incorporated into national procedures for reporting to the treaty bodies.

Documenting violations. Just as civil and political rights monitoring identifies specific violations such as arbitrary arrest or detention, so must there be mechanisms to identify and seek redress for violations of reproductive and sexual rights such as unauthorized medical procedures. This should extend to gender issues such as differential inheritance and property rights.

Enforcing rights protections. Existing legal safeguards of civil, economic and social rights must be effectively implemented and fairly applied. Officials need to be trained to review complaints fairly and to enforce laws (for example, laws against domestic violence, sexual harassment and rape) which protect rights to gender equality and reproductive and sexual health. Advocacy efforts can mobilize community concern and ensure that policy makers and civil institutions give priority to these concerns.

Legal and procedural reforms. Rights for sexual and reproductive health need to be reinforced by legal and institutional frameworks. Some national constitutions (notably in Chile, Mexico and South Africa) explicitly guarantee reproductive rights. Many other countries have reformed laws and procedures relating to families, inheritance, credit access, schooling, domestic violence and non-discrimination. In some countries medical codes of ethics and guidelines have been revised to incorporate standards of care consistent with rights guarantees. The scope of recent changes reveals an intensification of the review of national laws and procedures following the international conferences.

Accountability. Measures to hold programmes accountable for both performance and rights transgressions must be institutionalized. Communities and service providers should encourage the appointment of independent observers to receive and evaluate complaints.

Non-governmental alliances. Organizations focused on human rights, women’s empowerment, health and reproductive rights have been forging alliances to promote their shared concerns. The historic consensus on reproductive and sexual rights reached at the ICPD and extended at Beijing was achieved with the active participation of hundreds of international, national and local organizations, facilitated by governments’ increasing acceptance of NGO inputs. Networks have formed to influence conference outcomes and to take part in and monitor national follow-up efforts. International and local human rights organizations are documenting and publicizing women’s rights issues including reproductive rights in a wide variety of countries.4 International and national news media help to raise awareness of gender-related issues such as sexual violence, discrimination and reproductive freedom. International meetings have helped ensure prominent attention to these concerns.5

Mobilization of communities is the best guarantee of reproductive and sexual rights. The women and men seeking to exercise these rights know the social, legal and institutional obstacles they face. Women, especially, are aware of gender inequality with regard to participating in and benefiting from social and economic development; they know when decisions and actions are being forced on them. Mobilizing the public to monitor human rights issues will require better education about these issues and the procedures required to obtain redress. Materials for this purpose have been developed for use in school curricula at various levels.6

International assistance programmes, both multilateral and bilateral, need to ensure that programmes they support work to advance human rights. The United Nations system, in collaboration with governments and NGOs, should work to strengthen programme monitoring in order to prevent rights violations. UNFPA is committed to reproductive rights, gender equality and male responsibility, and to the autonomy and empowerment of women everywhere; it recognizes that safeguarding and promoting these rights, and promoting the well-being of children, especially girls, are development goals in themselves. The Fund gives the highest priority to programmes supporting the advancement of reproductive and sexual rights, and includes such considerations in its evaluation of programme and project design and implementation.

Towards Better Sexual and Reproductive Health

The ICPD Programme of Action calls for eliminating programme-related barriers to information and services for reproductive health, including family planning and sexual health, by 20057 and attaining universal access to services by 2015. The function of service delivery programmes should assist men and women in meeting their reproductive goals.

Capacity building. Provision of high-quality services requires improved staff training and supervision, supported by regular and thorough monitoring of performance including provider-client interactions. To work with their staff and clients in reviewing and improving services, managers need to understand evaluation methodologies and to allocate the relatively small resources needed to apply them.8 Self-assessment tools can help managers identify clinic problems including staff and supply shortages, inadequate equipment, gaps in keeping and retrieving records, and deficiencies in counselling and outreach.

Improving the quality of care and reorienting services to address the full range of reproductive health concerns may require additional investments in both infrastructure (including equipment as well as water and electrical supplies) and personnel (including training of managers and service staff). Facilities and personnel need to be used more efficiently. Managers need feedback to identify and correct shortcomings including uneven quality, efficiency and effectiveness in serving different delivery sites and different client groups.

Serving underserved groups. National-level indicators of progress in addressing reproductive health concerns should include information on specific groups (e.g., the poor, women, rural dwellers, adolescents, indigenous people, the disabled, migrants and refugees) that are often underserved by programmes and left out of information systems and research. The perspectives of underserved groups need to be reflected in the design, implementation and monitoring of programmes.

Geography, language and cultural barriers all limit indigenous people’s access to health services. At public health facilities service providers sometimes fail to respond to indigenous women’s complaints. Language differences may limit indigenous clients’ understanding of the examination process. Indigenous groups have criticized the use in their communities of sterilization and provider-controlled contraceptive methods (especially injectables and implants). Some NGOs have reported cases of medical experimentation without informed consent, and use of unapproved or inappropriate drugs. In Ecuador, with UNFPA’s support, the Indigenous Federation of Imbabura provides indigenous communities with integrated health services, including vaccination, family planning, emergency referrals and nutrition education, provided by indigenous physicians and traditional healers. Close attention is paid to service quality and follow-up.

Partnership with civil society. The ICPD and other conferences have stressed the importance of involving civil society—non-governmental and community organizations as well as individual women and men—in designing, implementing and monitoring reproductive health programmes so they respond to the felt and stated needs of those they serve. This is true both in public enterprises serving those too poor to afford private services and in programmes with substantial private sector involvement. Programmes can also benefit from qualitative research (such as focus groups, group interviews and rapid assessment procedures9) on the dynamics of social change supporting the expansion of sexual and reproductive rights.

Partnerships between government programmes and NGOs have been developed in many countries, recognizing the comparative advantages of the different actors. Non-governmental organizations have helped test new methods of service delivery, including outreach to the poor and to adolescents, and collaborated in training government service providers and in advocacy for national programme expansion.

Guidelines and standards of conduct for health systems need to incorporate a reproductive rights perspective. WHO (in collaboration with UNFPA, UNICEF, the World Bank, UNAIDS and other experts) is developing standards that stress informed consent, attention to the quality of care and client-centred participatory approaches in reproductive health care, including family planning, sexuality, safe motherhood and STD/HIV/AIDS prevention and management. Staff members need training in the protection of clients’ rights, along with information materials on procedural safeguards for use with clients.