Opinion: SRHR puts the 'universal' in universal health coverage

2019 is the year of universal health coverage, the year when the global community will step up to ensure that all people have access to quality, affordable health services. Momentum is already building — with the executive board meeting of the World Health Organization in Geneva this week — for September’s United Nations High-level Meeting on UHC, where governments will renew and strengthen commitments to achieve this lofty goal by 2030.

The focus on UHC in 2019 is commendable, but it will be fruitless if discussions do not include a meaningful consideration of sexual and reproductive health and rights, or SRHR, and the inter-related aspects of gender equality and human rights. A few sexual and reproductive health services, such as antenatal care and family planning, are included in WHO’s tracer indicators for monitoring UHC, but the Guttmacher-Lancet Commission calls for a broader interpretation of SRHR in the essential package services for UHC.

SRHR goes beyond antenatal care and family planning. It includes reproductive health, sexually transmitted infections, access to safe abortion, cancers of the reproductive organs, and infertility. It includes determinants of health and well-being such as sexual consent, gender relations, intimate partner violence, comprehensive sexuality education, and the human right of girls and women to make decisions over their own bodies and fertility.

It is not a single issue, but an important, cross-cutting theme that touches all aspects of health, at all ages, for all genders. We cannot achieve UHC and the Sustainable Development Goals without addressing these integrated needs that universally impact the health and well-being of everyone.

For example, ending the HIV/AIDs epidemic will not be possible without addressing sexual and mother-to-child transition of the virus, and the disproportionate burden on HIV/AIDS on young women tied to unequal power dynamics between men and women. Likewise, progress in ending preventable maternal and child deaths will stall without ensuring that girls and women have information and access to modern contraception, alongside access to safe and legal abortion.

Despite the strong connection between SRHR and other health issues, essential services are often underprioritized and underfunded, sometimes due to political and cultural pressures. According to the Guttmacher-Lancet Commission, most of the 4.3 billion people who are of reproductive age worldwide will lack access to at least one essential sexual or reproductive health service over the course of their reproductive life. As of 2017, more than 350 million people needed treatment for one of four curable sexually transmitted infections. In 2018, 214 million women in developing countries had an unmet need for modern contraception, contributing to 67 million unintended pregnancies, 23 million unplanned births, and 36 million abortions.

Investing in SRHR isn’t just an essential component of UHC, it’s a cost-effective solution. Research has found that providing a comprehensive SRHR package would cost only $9 per person, per year. For just 2.5 cents a day, we could potentially reduce unintended pregnancies by 75 percent, induced abortions by 74 percent, maternal deaths by 73 percent, and newborn deaths by 80 percent.

If the world’s leaders really want to get serious about achieving UHC and truly providing health for all, then investing in a more comprehensive approach to SRHR is nonnegotiable.

Making this aspiration a reality

We need to develop aligned and concerted advocacy at three levels.

First, at the global level, we must raise our collective voices to help ensure that SRHR in UHC is on the agenda at influential meetings that guide the adoption of UHC principles and service packages — such as the WHO Executive Board meeting happening now in Geneva. We must rally together to show the linkages between gender equality, human rights, and SRHR as we advocate for the inclusion of SRHR in UHC dialogues and policy, through shared initiatives such as the call to action led by the Partnership for Maternal, Newborn & Child Health as well as the civil society engagement mechanism of UHC2030. And we must keep up the momentum, and build a steady drumbeat to highlight the centrality of SRHR in UHC at key moments throughout the year, such as the Commission on the Status of Women, Commission on Population and Development, World Health Assembly, Women Deliver 2019 Conference, High-level Meeting on UHC, and Nairobi Summit for ICPD 25.

Second, in-country advocates must directly engage with governments to foster political will and commitment to SRHR in UHC. We need to highlight the sound evidence base that shows the cost and life-saving benefits of SRHR to push for greater integration of SRHR into primary care. We can engage at a technical level and work with leaders to define essential SRHR services, and the related gender equality and human rights provisions, as part of country-level UHC packages.

Third, we should mobilize at the point-of-care and community level to track and spotlight how integrated UHC programming is working for accountability purposes. Are services truly comprehensive? Are they equitable? We should monitor how comprehensive health services are functioning and pinpoint where efforts must be adjusted in order to bring fidelity to UHC’s principles of promotive, protective, preventive, curative, rehabilitative, and palliative care that leaves no one behind.

At all levels, advocates and health professionals can play a powerful role to ensure that SRHR, gender equality, and human rights are not shortchanged in UHC conversations, and that strong, comprehensive UHC policy trumps political expediency. This will take vigilance, but advocates must be united and strong behind a common evidence-based position that there is no UHC without SRHR.