Q&A: How to integrate sexual and reproductive health services into broader health agendas

A district health center that provides reproductive health services in Ethiopia. Photo by: Mulugeta Ayene / UNICEF Ethiopia / CC BY-NC-ND

Target 3.7 in the Sustainable Development Goals details the need to ensure universal access to sexual and reproductive health services, “including for family planning, information and education, and the integration of reproductive health into national strategies and programs.”

Currently, there are 214 million women of reproductive age living in developing countries who don’t have access to modern contraceptive methods, yet want to avoid pregnancy. That means there’s a big gap to fill between now and 2030 in terms of family planning alone, without considering the other areas of sexual and reproductive health and rights that cover the full spectrum of physical, mental, and social health.

Rather than 3.7 being treated as a standalone target, Dr. Mengistu Asnake, Ethiopia senior country director at Pathfinder International, said that it needs to be addressed in the wider context of achieving primary health care and universal health coverage.

“If we really want to have universal access across whole countries and socio-economic groups, for me there should be a renewed commitment within primary health care addressing the SRH and rights issue,” he said, adding that without this, health programs won’t see success.

However, the Guttmacher-Lancet Commission’s latest report on sexual and reproductive health and rights states that many countries are not prepared to provide the full spectrum of services, but still recommends “that governments commit to achieving universal access to sexual and reproductive health services and to making continual and steady progress, regardless of their starting point.”

Considering the 4.3 billion people who are within the reproductive age and their huge impact on sustainable development, any development agenda not considering this group and the issues related to SRHR will fall short of its targets.”

— Dr. Mengistu Asnake, Ethiopia senior country director, Pathfinder International

When countries aren’t on board with providing all services within sexual and reproductive health — antenatal, perinatal, postpartum, and newborn care; family planning services; abortion care; combating sexually transmitted infections, cervical cancer, and other gynecological needs; and promoting healthy sexuality, how can the global health community expect the target to be achieved — is the integration of sexual and reproductive health and rights into broader health systems the answer?

Sitting down with Devex, Asnake shares his insights.

This conversation has been edited for length and clarity.

Why is it important to ensure comprehensive sexual and reproductive health and rights is part of a renewed commitment to primary health care and the movement toward health for all?

One of the most important things when we consider sexual and reproductive health and rights is to look at the three pillars of sustainable development: social, economic, and environmental issues. In order to achieve these pillars, we need to address the 4.3 billion people in the world at reproductive age, otherwise, we will not be successful. They can contribute a lot in terms of sustainable development and for me, it's a very essential requirement in terms of achieving the SDGs.

Even though much has been achieved in the past few decades in terms of most health services — including sexual and reproductive health and rights — looking at the gains in the different parts of the world, there is huge variation among countries and among the different socio-demographic groups.

In a lot of places, access to sexual and reproductive health services is very limited. There may be access to a single component, such as family planning or adolescent services, abortion services or maternal health services, without having all the components of sexual and reproductive health. Within the renewed commitment of primary health care, we need to look at the intersection with sexual and reproductive health and rights and bring it in an integrated way to help increase access to comprehensive services, and also integrate with other sectors to achieve the SDGs.

Considering the huge share of funding for sexual and reproductive health and rights from external sources, what needs to be done to ensure the sustainability of programs in line with the principles of primary health care?

Looking at the whole issue in terms of the basic principles of primary health care, the first thing we need to do is to create demand for those services. We do this by raising awareness and creating the opportunities for people to ask for them. When people are aware and are demanding services, they can also contribute to their development.

3 things that need to happen to integrate sexual and reproductive health and rights into country plans

1. Strengthen primary health care system to deliver quality integrated and comprehensive sexual and reproductive health services.

2. Ensure domestic financing for sexual and reproductive health supplies: no supplies, no program; including health insurance for financial access.

3. Invest in a strong frontline health workforce to reach even those falling off the safety net.

Then there is the issue of “can we really do local and domestic financing?” In the African setting, there were several declarations like the Abuja Declaration — which decided governments should put at least 15 percent of their annual budget into the health sector — and then the Maputo Plan of Action — which emphasized integration of sexual and reproductive health and rights with STI/HIV/AIDS programs within maternal, newborn, and child health programs, youth sexual and reproductive health programs, addressing inequalities in service delivery, and increasing resources for sexual and reproductive health and rights, in alignment with the Abuja Declaration.

In reality, these are ambitious plans very few countries have reached, but are there mechanisms for accountability? That's something where global commitments need to be made. Unless there is an accountability mechanism, how can we reach that level of financing?

In line with this, the whole issue of public-private partnerships is very important. Even though in primary health care, the government should take responsibility to ensure the basic rights of the people, public-private partnerships are another way resources can be mobilized.

In terms of local, domestic financial resource generation we also need to see the whole list of insurers. Insurance is a way of having financial risk protection, specifically helping the community — those who are in most need of the services — to protect them from catastrophic out-of-pocket payments. That's another area that needs a wilful way of looking at it.

Do you have a call to action for development practitioners when it comes to improving primary health care and sexual and reproductive health and rights in low- and middle-income countries?

Sexual and reproductive health and rights need to be considered as an essential requirement for achieving the SDGs. Considering the 4.3 billion people who are within the reproductive age and their huge impact on sustainable development, any development agenda not considering this group and the issues related to sexual and reproductive health and rights will fall short of its targets. Local governments should include the whole sexual and reproductive health package in their universal health care agendas by specifically focusing on those who are in need.

At the global level, donors, implementing partners, and advocacy groups — including the media — should continue the dialogue, using evidence to foster greater national commitments on the whole issue of health financing and the workforce. When we talk about sexual and reproductive health and rights and also the implementation of primary health care, these are only two out of the many issues that need to be considered.

While it is clearly included in the principles of primary health care, a multisectoral approach is still an important priority for countries. Comprehensive sexual and reproductive health and rights is not only a health issue: we must link it to financial and social determinants. Just like the rest of the SDGs, the need for multisectoral and intersectoral approaches and collaboration is very important.

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