Transforming Family Planning Programmes: Towards a Framework for Advancing the Reproductive Rights Agenda Author(s): Jodi L.

Jacobson Source: Reproductive Health Matters, Vol. 8, No. 15, Reproductive Rights, Human Rights and Ethics (May, 2000), pp. 21-32 Published by: Reproductive Health Matters (RHM) Stable URL: http://www.jstor.org/stable/3775186 . Accessed: 29/11/2013 01:08
Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp

.
JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org.

Reproductive Health Matters (RHM) is collaborating with JSTOR to digitize, preserve and extend access to Reproductive Health Matters.

http://www.jstor.org

This content downloaded from 14.139.62.114 on Fri, 29 Nov 2013 01:08:51 AM All use subject to JSTOR Terms and Conditions

rn

CX$LDCW1E g qa{
I ) O n

AXM{Mg
O

Features

0w?t S a amew0r i 3r08CXllllllmC$o

At yant:tng tae Re-9r0C^utt1Xt CUt

L Jacobson Jodi
from offamilyplanningprogrammes agreementscall forthetransformation Recentinternational practical the But objectives. rights and ofhealth a focus on demographicgoals to thepromotion programmesremainunclear.Publichealth and future ofthisagenda forcurrent implications ofdisease illnessand reducingtheprevalence and incidence resources are devoted topreventing individuals, of rights the methodologiesfocus on protecting across a population.Human rights and care. Both oftheseapproaches need tobe re-thought health and health to and on theright rights a Applying programmes. health reconciledon a practicallevel topromoterights-based focusingas much on healthprogrammesmeans, among otherthings, to reproductive framework power and gender to address the efforts theprocess as on theoutcome,incorporating and ofprogramme, everylevel and sexual decision-makinginto dimensionsofreproductive services. of providers the and seekers the among both focusingon buildinga sense ofentitlement to services clinic-based of quality technical the on It also means movingbeyonda focus only technical and institutional, perspectiveat everylevel. Political, incozporatetheethos ofa rights agenda includenationallevel rights and health reproductive ofthe barriersto therealisation actors. ofinstitutional civilsociety,and lack oftransparency politics,lack ofcapacitywithin planning,reproductive family reproductiverights, Keywords: public health,human rights, healthprogrammes

ofthesechangesfor theimplications Clearly, by NE of the centralchallengesposedand and even in the servicesalone are enormous, recent internationalagreements goals that will reflect of circumstances, women's advocacy movementsis the best the evengiven Yet realise. to years many require applicationof both public health and o in that suggests evidence challenges, health obvious to reproductive principles humanrights programmes to existing theapplication of Actionof the practice, The Programme programmes. lags farbehind principles rights reproductive of Population Conferenceon 1994 International calls on thetheory. (ICPD), forexample, and Development explorestheseissues and argues Thisarticle agencies donor international and governments have a health programmes reproductive that programmes, existing to expandand transform prothe in play to role unfulfilled servicesthat are comprehensive, pivotalbut and to offer equity. gender and health, accessibleand delivered motionof rights, universally integrated, 'reproducoftheterm withhealthand rights Despitetheproliferation in a mannerconsistent mandatesand rights'in the international tive objectives.
v Av {
21

This content downloaded from 14.139.62.114 on Fri, 29 Nov 2013 01:08:51 AM All use subject to JSTOR Terms and Conditions

Jacobson

nationalpoliciesof the past decadetthe trans- critiques of such programmes are well-known formative natureof the rightsframework for and have been extensively documentedelscexistingprogrammesremains relatively un- where.1 Theseprogrammes havegenerally been explored.Therefore, the articleexaminesthe characterised by poor qualityof care, limited political, institutional and ideological barriers to choiceofmethods offered, and lackofattention the transformation of existing family planning to critical issuessuchas sexualcoercionand the programmes and, by extension, the promotion riskof sexually transmitted infections thatare andprotection ofrights. fundamental towomen'shealth andrights.2 Obviously,health programmesalone are Many governments and donorstraditionally insufficient to achieve thesegoals.Multi-sectoral viewed contraceptive deliveryas a shortcut policies aimed at closing the gender gap in throughthe demographictransition. Family accessto education, employment, and other pro- planning programmes werecreated ina vacuum, ductive resources are essential to thefulfillmentisolated frombroader efforts to change the oftherights agenda,and to the achievement of cultural and economic conditions that contribute otherobjectives, such as slowingthe spread of to the subordination of womenand keep birth HIVand achieving population stabilisation. rateshigh.Such programmes have unquestionThe conclusionof this articlesuggeststhe ably filleda latentneed among women for parameters ofa framework intended to be used methodsof fertility control, but generally in a simultaneously to provideguidanceto govern- manner thatwas or is instrumental to thegoals ments and donor agencies on the practical of reducedfertility and not in the interest of implications forprogrammes of the healthand promoting rightst equity and empowerment. rights agenda,as wellas toevaluate thedegreeto Whilethe rhetorical emphasishas been on the need' forfertility regulation, in which specificprogrammespromote health, depthof 'unmet programmes have exhibited a tendency rights and equity, and thereby promote account- reality, to be selective in offering clients, and especially ability ofinstitutional actors. and methods,and have Forthepurposes ofthisanalysis, programmes women, information degreesofpersuasion and coercion are defined as the sumtotalof efforts aimedat usedvarious changingsocial normsand healthbehaviours as the means to reduce both unwantedand fertility.2 3 and providinghealth services,includingre- wanted In the last two decades,the global women's search,public educationand advocacy,behafundamentally changed the viour change interventions, social marketing, health movement clinical services and community-based distri- discourseofthepopulation and health fields by thatsocialjusticeand individual rights bution. (This definition recognises both the asserting importance and limitations of client-provider must be centralconcernsof policy and proRedefined along these lines,'populainteractions in promoting reproductive health gramme. ofmulti-sectoral and rights.) Reproductive rights include theright tionpolicies'are theaggregate ofindividuals to bodily integrity and security of strategiesaimed at achieving,among other the equitabledistribution of power beperson, therights of couplesand individuals to things, decide on the numberand spacing of their tweensocial groups and betweenwomen and services, including butnotlimited to children and to have access to the information, men.Health delivery, are essentialassets that educationand means necessaryto do so; the contraceptive right to attain thehighest standard ofsexualand peopleuseto meeta broadrangeofneeds. The rightsmovement recognisesthat the reproductive health; and the right to make ofwomenand mento fully exercise their decisions concerning reproductionfree of ability reproductive and sexual rights,to negotiate discrimination, coercion, andviolence. decisions about whetherand when to have childrent and to enjoy the highestattainable levelsofreproductive health is nota function of The rights and healthagenda health programmes, or ofaccessto The transformation of conventionalfamily reproductive perse, butis contingent uponthesocial planning programmes has been a majorgoal of services in which people live. Following women'shealthand rights movements forwell environment this, theICPD callsforintegrated efforts to over a decade. The historical limitations and from
22

This content downloaded from 14.139.62.114 on Fri, 29 Nov 2013 01:08:51 AM All use subject to JSTOR Terms and Conditions

Reproductive Health Matters, Vol. 8, No. 15, May 2000

to facerisksdue to individual increasewomen'seconomicand political clout, uals willcontinue challenge prevailing social norms around behaviour,environment, economicconditions, reproduction and sexuality, and combatgender and lack of access to healthcare, amongother It is understood thatresources are finite, violence- to create the 'enablingconditions' things. decisions needtobe madeto ensure that essentialto the realisation of reproductive and andthat yield thegreatest possiblereturn. sexualrights.4 In sum,the promotion of repro- investments ductive rights and health dependsfundamentally Human rightsconceptsand methodologies the rightsof individuals. and simultaneously on the conditions in which focus on protecting standardsare universal, indivispeople live,and on the tools - such as health Human rights ible and inalienable. Rights languagerefers to a services - that are attheir disposal. tohealth' and a 'right tohealth care'which, Health programmes oftenreflect, replicate 'right oflimited resources, can leavethe and reinforce the social climatein whichthey in thecontext health official at a loss. exist, and will thereforealso independently public theoretically either contribute to or detract from thefulfilment Althougha rightsframework of individual rights. Applying a rightslens to seeks to promoterightsas well as to protect from violations, thefocusformuch reproductive health programmes means such individuals programmes mustbe evaluated on theextent to ofthepast severaldecades has in factbeen on the documenting of violations. Duringmostof which they: the 20thcentury, the humanrights community * adopteffective meansormeasures topromote focusedon abuses ofindividual civiland politiand fulfill the reproductive healthand rights cal rightsby public actors - the state and its of womenand men,and address genderinrepresentatives. Only in the last two decades equitiesdirectly relevant to decisionsabout have rights advocates and legal scholars sex,pregnancy, childbirth, contraception, and established the basis for women's human infection prevention; rights,and following fromthis,reproductive * protect individuals from and immediately resand sexual rights. These rights are now pond to violations by institutional actorsor recognisedin a numberof conference docutheir surrogates. ments, including the1993WorldConference on Human Rights and the 1995 Fourth World Transforming discourseand practice Conference on Women,as well as the ICPD. Theintegration ofreproductive rights andhealth Violationsof women's rightsby governments objectives presents a number of conceptual are now documentedthrough a varietyof challengesthat need to be consideredat the formal means,e.g. through the Convention on outset. Traditionalpublic health and human the Elimination of All Formsof Discrimination rightsapproachesare based on different con- AgainstWomen (CEDAW) and the US State ceptualframeworks and use different method- Department's Country Reports on Human ologies, with seemingly different implications for Rights Practices. Non-governmental human programmes. Each oftheseapproaches has tobe rights organisations, including women'srights rethought and reconciled on a practical levelto groups, havealso successfully used thisfoundapromote rights-based health programmes. tionto document violations of women'sreproThe fieldof publichealthis concernedwith ductive rights bystatesand states'parties. improvingthe health status of populations. Traditional human rights documentation Success is measuredin termsof outcomes- relieson reports from and interviews withkey births averted, lives saved - and the goal is to informants in a givensetting. Byitsnature, such achievethegreatest good forthegreatest num- reporting is oftenbased on smallnumbersof ber. Public healthresourcesare allocated ac- discrete cases whichfrequently raise a red flag cordingto priorities thatreflect the ability to aboutproblems thataffect largernumbers, but prevent illness and deathon a largescale,and to do notprove thata givenproblemexistson a reducethe prevalence and incidence of disease large scale. As a result, humanrights findings acrossa population. Publichealth theory weighs oftenare not persuasiveto publichealthpracrelative risksand recognises thatin thequestto titioners who, in the absence of populationimprove thehealth ofpopulations, someindivid- based data,often remain unconvinced that these
23

This content downloaded from 14.139.62.114 on Fri, 29 Nov 2013 01:08:51 AM All use subject to JSTOR Terms and Conditions

Jacobson

findings represent more than a few isolated cases,or a newpriority to be addressed. Forthis reason, proofof a small numberof cases of sterilisations without consent, forexample, may be viewedbypublichealth institutions and programmemanagers- especiallythose with a vestedinterest inthereputation ofa programme - as beingmorean aberration or an exception than a rule, and therefore remediedthrough palliative measures focused merely on the individual case rather than thesystemic problem. In Mexico,forexample,evidencegatheredby humanrights organisations ofgovernment doctorsperforming sterilisations without theclient's consent was largely dismissed by both the government and international donor agencies until large-scale surveys conducted in the1980s and 1990sbythegovernment with thesupport of donorsshowedtheproblem to be significant and pervasive.5 On theother hand, byfocusing only on blatant violations, again, such as sterilisation without consent, humanrights methodologies can also misssubtler, butmorewidespreadand persistentviolations ofrights. In Mexico, for example, a 1996United Nations Population Fundanalysis of servicedelivery pointsthroughout the country revealedthatonlya limited numberof contraceptivemethodswere offered, and that providerswererequired to strongly encourageand persuadewomen with morethantwochildren to adopt IUDs or to undergosterilisation.6 Since mostwomenwerecoming forand leaving with a method, and since thereappeared to be 'consent,' this type ofpractice might notbe perceived as a violation ofrights. According to theinterpretation of a rights approach,as posed by this article,however,these are violations. A programme that offerslimitedmethods in the interestof reducing women's fertility, takes advantage of their already limitedsense of entitlement in orderto achieveexternally posed goals, and failsin anyway to instill a sense of broaderchoicesand entitlement, does notmeet the test of contributing to the promotion of reproductive rights. Applying a rights framework to reproductive health programmes meansfocusing as muchon the process as on the outcome, and opens the possibility oftransforming notonly programmes buttheessential discourseand practice ofboth public health andhuman rights.
24

A rightsapproach requires a fundamentally different analysis ofthecontent and intention of whatwe now callfamily planning programmes. To explorethe practicalmeaningof a rightsbased framework for current and future programmes, itmaybe helpful to start from theact of heterosexual intercourse. In the ideal world, sexualpartners decidetogether whether or not theywantto have children, and, ifnot,how to protect themselves fromunwanted pregnancy. They negotiatethe timingand frequency of sexualencounters. Ifone partner suffers from a sexuallytransmitted infection, they work together onwaystoprotect theother. The realworld, however, is still farfrom this ideal,and bothwomenand menare atrisk ofthe consequencesofunsafesex. Cultural and social normsmayinhibit partners from talking openly witheach otheraboutsex,sexuality, contraceptionand infection, thereby putting them atrisk of both unwanted pregnancy,and of disease. Taboos and traditional practicesmay prevent them fromseeking health care even in dire circumstances. Womenand menmayknowlittle abouttheir bodies and how they work.Women maybe particularly vulnerable becausethey face constraints posed by inequitablegender and power relations thatundermine theirability to negotiate sexual and reproductive decisions equally with their partners. Anindividual woman maysometimes - and sometimes frequently - be forced to engage in non-consensual sex, or she maybe rapedbyan intimate partner.7 Unwanted pregnancy maybe a persistent concern, either because a womancannotcontrol the timing of intercourse, and therefore protectherself, or because she lacksaccess to methods of fertility regulation that trulyfither particular needs. Accessto safeabortion is likely to be limited ifit is availableat all.Emergency obstetric care may be equallyscarce.Alloftheseconditions contributeto highratesofreproductive morbidity and mortality, especially among women. Byusingcontraception, womenofcoursemay be better ableto control someoftheoutcomes of unwanted sex,suchas unwanted pregnancy. They mayhowever still be forced to have sex against their willon a regular basis,perhapsevenmore frequently because the likelihood of unwanted pregnancy is diminished. These conditions and

From theoryto practice: minimum criteriaforrights-based programmes

This content downloaded from 14.139.62.114 on Fri, 29 Nov 2013 01:08:51 AM All use subject to JSTOR Terms and Conditions

Reprodllctive HealthMatters,Vol. 8, No. 15, May 2000

is contraceptive use and reduced the failureof programmes to adopt effective programming means to addressthemconstitute violations of fertility. A rights-based model, bycontrast, proand women's reproductive and sexual rights. videsa meanstestto measuretheintention achievement ofprogramme efforts Likewise, without simultaneous efforts or means progressive to behaviour to reduceSTIs,thesesamewomenremain at risk rangingfromresearchpriorities changecommunication to client-provider interofinfection - againa violation oftheir rights. reproductive choiceand Similarly, under this scenario, and in the actions- in advancing addressingwhat absenceofefforts to changethegenderdynam- rightswhile simultaneously bestbe calledtheproximate risks ofsexual ics of sex, encouraging mento use - or having might The rights modelis based on the inthemencouragetheirpartners to use - contra- relations. to bodilyintegrity, freedom of ception could yield higher rates of contra- divisiblerights freedom from coercion, ceptive use with littleor no change in the choice in childbearing, prevalence of sexual coercionand withlittle or and thehighest attainable standard of health. It risks of sexual no increasein positive communication between recognisesthat the proximate are integral to each act ofintercourse, couples, changes that would nonethelessbe relations deemeda successunderconventional measures and thereforeaddresses these risks programmatically in an integral, ratherthan an ofevaluation. A rights approachstarts from thisreality and additiveway. Because the proximate risksof asks: What can and should be done pro- sexual relationsare indivisible - any given grammatically to addresstheseissues?Instead of woman may simultaneously face the risks of offeringa limited range of contraceptive sexual coercion, unwanted pregnancy,and methods becausethey are effective or efficient in infection - theresponsemustbe indivisible too. meetingaggregategoals, a rights-based pro- Concernsabout sex, power,genderand rights gramme offersseveral, while constantly re- shouldtherefore be considered intrinsic to each affirming at every level the rightto choose aspect of programming - research,delivery, between these.Instead ofrelying on providers to education,communication and client-provider - and notbe compartmentalised. do all the work of informing and educating interactions clientsin the span of a few minutes, it offers In 1994,Jain and Bruce soughtto provide community-based reproductive health educa- concrete guidance on the transformation of tion, buildscommunity support forreproductive family planningprogrammes to policymakers health and rights, and uses a variety ofcommuni- and programme managers bysuggesting a shift cationstrategies to instill a sense ofentitlement froma focus on fertility objectives to 'helping among people and establishnew social norms individuals to achievetheirreproductive intenencouragingpartnership, communication and tions in a healthful manner.'8 To achieve this cooperation. Insteadofpretending thatunwant- goal,they argued, programmes must include the ed pregnancy is theonlypotentially problematic following elements: outcome ofsexualintercourse, itrecognises that * choiceofcontraceptive methods; theprevention of riskof infection and coercion * safeabortion; and efforts to deal with the consequencesof * diagnosisand treatment ofreproductive tract theseare,at a minimum, ofequal importance to infections and other preexisting conditions promoting reproductive and sexual healthand that would make the use of a particular are risks thatmany womenfaceeach and every contraceptive method unhealthful; time they engage in the act of intercourse, * diagnosis and treatment ofunhealthful effects whether ornotthey faceunwanted pregnancy. A ofcontraceptives. rights approachputsas muchemphasison the ethical and value-oriented aspects of a pro- They further note that the questionof which gramme as it does on technical skills. Finally, a servicesget priority dependson the local conrights approachacknowledges thathealthpro- ditions andfelt needsofclients. viders also are individuals with rights and needs, Takingthese steps would in itself represent and thatchanging thesystem is as important as a major advance in what is available to the changing theindividual. vast majority of women and men worldwide. Theprimary testofsuccessintheold modelof Applying a rights framework tothis constellation
25

This content downloaded from 14.139.62.114 on Fri, 29 Nov 2013 01:08:51 AM All use subject to JSTOR Terms and Conditions

Jacobson

of services,however,takes us several steps further, and at a minimum includesefforts at every levelofprogramming to: * addresssexualviolenceand coercion, especially as it relates to restricting women's choices, and exposes women and girls to higher risks ofmorbidity andmortality; * incorporate multi-source reproductive health and rights educationstrategies, and seek to instill a sense of entitlement among people and a rights-based ethoswithin programmes; * incorporatecommunication and behavior change interventions encouraging the prevention ofdisease, thepractice ofsafesex,and changesinsocialnorms that encourage equitablepartnerships; * establish meansofensuring theaccountability of programmes to thepopulation and means ofredress for violations ofrights.

religious and political movements pose particularlyprofound threats to women's healthand rights.9 Lack of transparency of institutional actors also severely undercuts theability ofcivil society to monitor progressand ensureaccountability on the rights agenda. Governments and donor agencieshave theirown political agendas and institutional imperatives, and their internal systems often are setup to protect these,making it difficult forcivil actors to gainaccess to information on programmes orspending. Supportfora rightsagenda at the national levelmay be weak National politics playsa pivotal roleinthereproductive rightsagenda. The USA, for example, remains amongtheleading contributors tointernational family planningprogrammes in both financial and technical terms. The strong influence ofpolitical ideologies that comefrom opposite ends of the spectrum aroundthe issue of population stabilisation and reproductive rights haveimpeded both conceptualand practical progress towarda rights-based agenda within USinternational assistance.On the one hand, traditional supporters within theUS Congress of international family planning programmes back these efforts largely because of theirconcerns with population growth and demographic threats to theenvironment, economy and international security. While the need to achieve population stabilisation is a legitimate concern, support forinternational family planningprogrammes has been soldto policymakers and the USA largely on thebasis thatsuchprogrammes 'achieve results' andarethe'mosteffective' route to reducing birth rates. On theother hand,a quitesmallbutpowerful counter-constituency seeks to eliminateprogrammes altogether. In theUS House ofRepresentatives, right-wing politicians have made the gutting of family planning programmes one of their mainpriorities. Efforts to curtail or eliminate spending on contraceptive deliveryan area in which the USA has historically played a leadership role- have takenmanyforms. Since the 1980s, thefarright has persistently worked to diminish thecapacity oforganisations receiving US international assistance to workon expanding access to safe abortionoverseas,even in countries where abortionis legal and even in

Obstacles to change

On thefaceofit,therights agendais now mainstream. Today, a majority ofgovernments (andby extension other public institutions, suchas donor agencies), are signatories to international agreements that recognisereproductive and sexual rights as human rights.The terms 'health,' 'rights,' and 'gender,' are now ubiquitous in the rhetoric and thepolicy statements ofthepopulation and healthfields, suggesting thatinstitutional actors atleastnominally support this vision. But evidence suggests that on the whole, progress in making thefundamental changesin family planning programmesrequired by a rights framework is unevenat best.Thereare a number of obstaclesto the transformation of family planning programmes, someofwhichare explored briefly below.

Social, economic, and political conditions undermine rights and entitlement

The mostimportant obstaclesto therealisation of the reproductive rights and health agendaare the continued lackof attention to enabling conditions, and the absence of institutional and political environments that support,promote, and protect rights. Poverty, lackofsocialinvestment andthedislocation causedbyrapidglobalisation and privatisation worldwide,among other things, continue to undermine individuals' rights and sense of entitlement. Fundamentalist
26

This content downloaded from 14.139.62.114 on Fri, 29 Nov 2013 01:08:51 AM All use subject to JSTOR Terms and Conditions

Reproductive Health Matters, Vol. 8, No. 15, May 2000

instances wherefunds forworkon safeabortion were obtainedfrom othersources.In the midl990s, Congress imposed a harsh systemof metering of fundson international family planningprogrammes in a failed attempt to eliminate theoverall programme. Morerecently, Congress passed a new global gag rule, requiring USfunded organisations tosignpledgesrenouncing anyand allworkon safeabortion - including the collectionof data or the dissemination of information on unsafe abortion- to continue receiving funds. It is clear thatthe objective of thisassaultis to undermine accessto allmeansof preventing or ending unwantedpregnancies, rangingfromcontraception throughabortion
services.

In recent years, thefarright also has used the humanrights agenda to its own ends. In 1999, leaders of the conservative rightcrafted a law mandating monitoringof US-funded programmes for violations ofinformed consent, and requiring thatfunding be withdrawn from any programme in whichsuchviolations are found. Thisposes a critical problem forwomen'sright ofaccess to services, and to meaningful choices, because instead of makinga commitment to funding and improving programmes in which governments or donors are takingpro-active steps to expand choice and infusetheirprogrammeswith a rightsagenda, the ultimate effect of thislegislation is to diminish choices altogether. In effect, it is the wrongmeanstest foranyoneconcerned withexpanding women's rights generallyand reproductive rights in particular, and strongly underscoresthe real intentions ofthefarright in promulgating these rules.Theseefforts havehad fargreater success thanotherwise might be thecase because ofthe absenceof an organised, vocal and truly rightsoriented constituency base intheUSA. Programmes remain focused on narrow In a sense, US assistance confronts three objectives competing paradigms- the demographic app- Reduced fertility remainsthe centralobjective roach and the reproductive rightsapproach- and contraceptive prevalencerates (CPR) the both of whichseek to expand servicesbut for primary indicator used in manyprogrammes, different reasonsand withdifferent implications with limited considerationevident in most for services - and the anti-choice/anti-rights programmesof the contextualfactors that paradigm, whichseeks to eliminate themalto- influence fertility decisions orputwomenat risk. gether. These competing agendas,and thecon- Indeed, USAID's ownpolicy documents reiterate stant sense on thepartofUSAID thatitis under the importance, efficiency and effectiveness of siege,have paralysed theAgency. As a result of contraceptive deliveryfor achievingreduced these and otherconstraints, including internal fertility and population stabilisation, statements resistancewithinthe Agency,changes in the thatstandin directcontrast to the spirit of the
27

structure, designand evaluation ofthemajority of familyplanning programmesfunded by USAID have tendedto be at the margin.New indicators - suchas levelsofclient awarenessof reproductive functionand measures of the number ofcounselling sessionsheldwithclients and theirpartners - have been added in some programmes, buttheseremain subsidiary rather thanequivalent to contraceptive prevalence and reduced fertility in theirimportance for programmesuccess, and oftenare not viewed as critical benchmarks on whicheither reporting is requiredor decisionsabout disbursements are made.10While there are notable examplesof innovative projects, suchas ReproSalud in Peru, theseremain theexception rather thantherule. Similar situations existin manycountries. In Mexico, forexample, national levelreproductive health policiesextoltheICPD agenda.Yetwhile data now confirm that problems with both informedchoice and informedconsent are deeply embedded in the public sector family planning programme, the government and key donoragencieshavetakenonlysuperficial steps towardresolving theseissues.Theseinclude the development ofnewforms tobe signed byclients and a series of trainingsfor programme managers. Yetproviders report that though they are toldto obtainconsentand promote choices of methods, theyare nonetheless stillsubjectto the same evaluation criteria for delivering methods. Theefforts topromote informed choice in Mexico,therefore fallfarshortof addressing thefundamental barriers to choicepresented by continued numerical targets forthe delivery of particular methods,providerbias, and other concerns characteristic of the government's programme.5

This content downloaded from 14.139.62.114 on Fri, 29 Nov 2013 01:08:51 AM All use subject to JSTOR Terms and Conditions

Jacobson

ICPD in itsrecognition ofthecritical importance contraception impliesthat reproductive rights ofmulti-sectoral approachesand itsintention to are divisible intoneatcategories, suchas 'access de-link family planning programmes from to contraception', reinforcing the sense among demographic goals.ll thosefor whomcontraceptive delivery is a priorToday, several initiatives intendedto in- ity that they needdo no morethanthis.l3 Theoftcorporate concern for gender issuesinto USAID- repeated 'right to choosefreely' is seen bymany funded family planning programmes are under- institutional actorsas beingfulfilled ifan individway, but it remains unclear how these will ual womanwithan 'unmet need' receives a conadvancethefundamental changescalledforbya traceptive - irrespective of anyrisksofinfection rightsperspective. For example,in 1997 the or sexualcoercion she mayhave,or herlack of aboutreproductive functioning. Office ofPopulation formalised an Inter-Agency knowledge The sense of being overwhelmed appears Gender WorkingGroup to explore the incorporation of genderissues intoprogrammes even greateramongthose politically or otherfundedby the Agency.The group,comprised wisedisinclined to support theoverall objectives almost entirely of USAID-funded cooperating of the ICPD. Adherents of conventional family programmes, forexample, arguethat agencies, has doneimportant workin reviewing planning theAgency'sstrategic objectives and exploring theirprogrammes are efficient and cost-effectimpacts are easily the practical implications of male involvement, ive,and thatthepublichealth Thisgroup, whichis in manyinstanand is now preparing guidelines fortheincorp- measured. orationof gender-sensitive indicators into the ces still representedat high levels in both Agency's 'requestsforproposal.'The long-term governments and donor agencies, oftendisintegrated impact oftheIGWGis unclear, however, inview misses the call for comprehensive, ofthefactthatneither thecentral office northe servicesas grosslyunrealistic, arguingthat a approachdemands priority actions missionsare committed to incorporating the publichealth findings or recommendations ofthe groupinto in the interests of increasinggeneral health. Many in this group view 'gender','empoweractualprogrammes.10 ment' and 'rights' concerns as add-ons to programmes thatcan be costly,maydilute proKey concepts remain ill-defined effectiveness and compromise results.l4 Key concepts, such as 'comprehensive' and gramme 'integrated,' on whichrhetorical agreements on In fact, the rights framework does allow for reproductive and sexualhealth programmes are progressive realisation ofgoals.However, neithbased, remainill-defined. The failure to go be- ertheprinciple ofprogressive realisation northe stepsneededto achievepriority goals in yondthelevelofrhetoric to clearly articulate the interim meaningof these terms,and to demonstrate particularsettingshave as yet been deeply understanding ofthefinancial andtechnological enough explored by the rights and health limitationsto creating comprehensivepro- communities inspecific settings to provide sufficsupporters grammes in the shortrun,has hampered pro- ientguidanceto even the strongest within government and donoragencieson how gresson many fronts. Lacking guidance on what todo andhowtodo tomoveforward. Realisingthis, women's rightsand health it, many in the public healthcommunity feel unclearabouthow to proceedtowarda rights- advocates are takingon these issues. For exbasedreproductive health programme, orhowto ample,a groundbreaking articleby Alicia Ely respondto frequently used terms like'compre- Yaminand Deborah Maine in 1999 suggestsa for marrying human rightsand hensive' and 'integrated'.l2 Thelackofclarity can methodology to measure resultin institutional paralysison the part of public healthstandardsin efforts and governments and donorswho perceive that they progressin reducingmaternalmortality The article examines in detailhow are beingaskedto provide everything to every- morbidity.15 humanrights principleso concrete bodysimultaneously. Faced withpressure to do international something, someinstitutional actors makesuper- data collection, and measurableindicators of to analyse ficial changesin programmes; others just go on progresscan be used simultaneously with business-as-usual. Forexample, theICPD +5 the scope of a problem, i.e. maternal mortality, objective calling for reductions inunmet needfor setachievable goalsandmark progress.
28

This content downloaded from 14.139.62.114 on Fri, 29 Nov 2013 01:08:51 AM All use subject to JSTOR Terms and Conditions

Reproductive Health Matters, Vol. 8, No. 15, May 2000

Still, muchmoreneeds to be done to identify priority issuesinparticular settings andtoensure the collection and analysisof data essentialto identifying and understanding thedimensions of other key reproductivehealth and rights concerns,such as STIs and unsafe abortion. Thesefindings then needtobe usedtoinform the development ofreproductive health programmes andservice delivery. Limitations of technology, and of technical and human resource capacity, also actas limiting factorsin the transformation of programmes. Forexample, ICPD and other agreements callfor integrated reproductive health services. O'Reilly andcolleagues rightfully suggest that integration of efforts to prevent, diagnose,and treatSTIs intoexisting programmes (atvarious levels) is an important first step, and crucial to addressing the proximate risks ofsex.12 Without question, much more can and must be done withinexisting programmes to developand carryout STI prevention strategies thataddressthefundamental issues of gender,power and sexuality, and to offer women and men true access to existing barriermethodsand the means of dual protectionfrompregnancyand infection. These efforts may soon receive a boost as female condomsand new technologies such as microbicidesbecomeavailable. What are the existing barriers to diagnosis and treatment? There are, for example,unansweredquestionsaboutwhether existing STI diagnostics aretooexpensive ortootechnologicallycomplexto be usefulin low-resource settings. Costing studies examiningthe balance betweenthe highercosts of technologies and lowerlabourand laboratory costsin developing countries are now underway.16 Further informationis neededon thereal costsofthesetoolsso that they can be used as widely as possibleas the development oflower-cost diagnostics proceeds. And workis neededat theinternational levelto ensure thatdonorsand governments areputting sufficient fundinginto the development and dissemination of thesediagnostic tools,so that thepace ofdissemination is accelerated.

negotiation are indivisible, setting priorities to addressthemprogressively willnonetheless be necessary in lightof the factthatthe situation bothinternationally and within the majority of countries is one of limited and oftenstaticor decliningexpenditure on health care. Setting specific priorities and indicators of success for the progressive incorporationwithin programmesof a rightsapproach is even more urgent, giventherapidchangesunderway as a resultof healthsectorreforms.17 Thereis very little concrete evidenceon how sectorreforms are affecting access to and the quality of care, whetherpositively or negatively. We need to know much more about the implications for reproductivehealth and rights in various settings of efforts to decentralise, redistribute staff resources, institute userfees,privatise services and overhauldrugmanagement systems. And we need to actively engagein theseefforts to ensurethattheyadvance,rather thanundermine theICPD agenda.

Finally, lack of capacityin the women'smovementand 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 andpolicy, lobby, use themedia, anduse international bodies to advancewomen'srights has expanded dramatically. As I have argued above,however, nowthat we havewon globally, we have to act locally.The transformation of programmes has to occurat thenational, state, and district levels. In fact,in manycountries undergoing health sector reforms, decentralisationand privatisation of healthcare is occurringata rapidpace. Meanwhile, theability ofcivil society actors to monitor progressand ensureaccountability on therights agendais constrained in several ways. Lack of transparency of institutional actorsis a critical obstacle. Governments and donoragencies havetheir ownpolitical agendasand institutional imperatives, and their internalsystems Reforms are rapidly changing theface often are set up to protect these,making itdiffiofhealthcare cultforcivilactorsto gainaccess to information Whiletheproximate risksofunsafesex and the on programmes or spending, or to be meaninggenderdimensions of sexual and reproductive fully engagedindeveloping programmes.
29

Lack of capacity and lack of transparency

This content downloaded from 14.139.62.114 on Fri, 29 Nov 2013 01:08:51 AM All use subject to JSTOR Terms and Conditions

Jacobson

In fact,severe resourceconstraints, among otherthings, strongly limit thecapacity of state and local-level civil societygroups concerned withreproductive healthand rights - to shape debates, conduct research, engagewithinstitutional actorsin setting priorities, monitor programmes,and engage with communities. In some cases, such as thedevolution of powerto district and village-level bodies underthe Panchayati Raj Act in India,the authority to shape and implement health programmesis being vestedin groupswhose understanding of and willingness to addressreproductive healthand rights issues is limited at best.18 Ironically, the urgent need to buildcapacityat the local level comesat a time whenitappearsthatsomeofthe private foundations thathelpedcreatetheICPD agendamaybe reducing their overall support to the field, and othershave re-focused on more traditional approaches tofamily planning.

To ensure progresstoward the goals of the reproductive rights agenda, a framework is needed thatencompassesthe technical aspects of quality of care,butgoes beyondit in several ways. First,the framework mustask: In what waysmust existing family planning programmes be transformed so that thesecan helpensure that women and men can engage in sexual intercourse freefromthe fear of unwantedpregnancy,infection and sexual coercion, and with equalnegotiating powerwith their partners? Second,it musttakea 'systems' approachto programme development, and provide guidance ontheintegration ofboth public health andhuman rightsprinciples at each stage of programme development and execution, rangingfromthe conceptualisation ofprogrammes andtheconduct ofresearch to gather baseline data,through programme execution and service delivery, and onto evaluation and measurement. It mustbe used to developan overall planfortheevolution of pro- Acknowledgements presented hereis based largely on grammes thatcan act simultaneously as a guide- The analysis by the CenterforHealthand post forinstitutional actorsand as a means of workconducted GenderEquity (CHANGE)overthepast several holding them accountable for moving forward. implementation ofthehealth Thirdr itmust be universally relevant butspec- yearsin monitoring agenda by international donoragenifically applicable. It mustbe used to transform and rights by theUnited Statesgovernment existing programmes ina manner consistent with cies supported settings. As such,it is influbroad goals such as integration and gender in variouscountry
30

Towardsa framework foradvancing thereproductive rights agenda

equity, but in a manner that is step-wise and progressive,based on specificand clearlyarticulated objectives that meet local needs -aimed at addressing a core set of priority issues and the achievementof measurable changes in a given setting over a discrete period of time. Understandingwhat mustbe done in absolutetermsand what can be done relativeto a given situationis crucial to recognisinggood faithefforts and the progressive realisation of a rights framework within programmes. Fourth, theframework mustincludebut extend beyondthe purelytechnicalaspects oftraining for clinic-basedservice delivery and technicalquality to incorporate means for infilsingprogrammes and the people thatrun themwiththe ethos of a rights perspective at everylevel.This means developing approaches to problems that are integral, not additive, e.g. bytakingintoaccountin theprovisionofmethods,the potential interplay between contraceptive use, sexual coercion,and riskof infection. Itmeans working withprovidersin recognisingthe gender,class and otherconstraints that not onlyaffect theirrelationships withclients, but are also likelyto influencetheir own lives and health.It means examining the rightsofproviders as actors and potentialagents of change within institutions as muchas itdoes therights ofclients. The rights agenda requires a fUndamentaIly different perspectiveon reproductive healthprogrammes and service delivery, as well as fundamentally different approaches to the development of programme goals and objectives, strategiest 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-termcommitments by institutional actorsto workingwithcivilsocietyto achieve these goals, and a reciprocalcommitment by civilsocietyactors to engage withinstitutions proactively,while maintainingtheir independence and abilityto advocate for change from outsidethehealthsystem.

This content downloaded from 14.139.62.114 on Fri, 29 Nov 2013 01:08:51 AM All use subject to JSTOR Terms and Conditions

Reproductive HealthMatters,Vol. 8, No. 15,May 2000

enced by the thinking and workof manyindividuals, including those within CHANGE,from whose unwavering commitment to reproductive healthand rights I have drawninte11ectual and emotional support. Referencesand Notes
1. GermainA et al, 1994. Settinga new agenda: sexual and reproductive healthand rights. In: PopulationPolicies Reconsidered:Health, Empowerment, and Rights.G Sen et al (eds). Harvard School of Public Health,Cambridge MA. 2. See, forexample: Bruce J,1989. FundamentalElementsof the Qualityof Care: A Simple Framework. PopulationCouncil, New York;GermainA, Ordway J,1989. PopulationControland Women's Health:Balancingthe Scales. International Women's Health Coalition,New York. 3. JainA, 1995. Implementing the ICPD's message. Studies in FamilyPlanning.26(5):296-98. 4. Correa S, Petchesky R, 1994. Reproductiveand sexual rights: a feminist perspective.In: PopulationPolicies Reconsidered:Health, Empowerment, and Rights.G Sen et al (eds). Harvard School of Public Health,Cambridge MA. 5. These observationsare based on research conducted in Mexico bymyself and others between 1997 and 2000 forthe CenterforHealth and Gender Equity(CHANGE), and byour partnersin Mexico, including Monica Jasis,co-director, Centro Mujeres, Baja California Sur. During thisperiod,we have been involvedin 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. Unpublisheddata collected by

Jodi L Jacobson, Center for Health and Gender Equity, 6930 Carroll Avenue, Takoma Park, Md. 20912, USA. Phone: 1-301 270-1182. Fax: 1-301 270-2052. E-mail: iiacobson@genderhealth. org

Correspondence

6.

7.

8.

9.

CONAPO and fundedby several externaldonor agencies (presentedin a meetingwith CONAPO officials at which CHANGE representatives were present)reveal thatproblems withchoice and consent are widespread in the Mexican programme,and are particularly entrenchedwithin particularsegmentsofthe public sector programme. Qualitativeresearch and programmeanalyses indicate thatthe problemsof choice and consent are mostobvious in clinicalsettings, buthave 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 studyof reproductive health programmesin Mexico to be published by CHANGE in 2000. UnitedNations Population Fund, 1996. EvaluationReport: QualityofFamilyPlanning Services. No. 8. New York. JohnsHopkins University and the CenterforHealthand Gender Equity,1999. Ending violence against women. PopulationReports.24(4). JainA, Bruce J,1994. A reproductive healthapproach to the objectivesand assessment of family planningprograms.In: PopulationPolicies Reconsidered:Health, Empowerment, and Rights. G Sen et al (eds). Harvard School of Public Health,Cambridge MA. Freedman L, 1996. The challenge of fundamentalisms. Reproductive HealthMatters. 4(8): 55-69.

10. Observationsbased on documentsreviewedduring meetingsand participation by CHANGE in the Inter-Agency Gender WorkingGroup, 1997 to thepresent. 11. UnitedStates Agencyfor International Development, 1999. From Commitment to Action:MeetingtheChallengeof ICPD. WashingtonDC. 12. See, forexample,O'ReillyK, Dehne K, Snow R, 1999. Should managementof sexually transmitted infections be integrated intofamily planning services:evidence and challenges. Reproductive Health Matters7(14):49-59. 13. GirardF, 1999. Cairo + Five: . . n revlewlngprogress torwomen fiveyears after the International Conferenceon Populationand Development.Journalof Women's Healthand Law.
1(1 ):1 -14.

14. Based on experienceof CHANGE staff and drawn from numerousdiscussions and meetingsin the period 19972000. 15. Yamin A, Maine D, 1999. Maternalmortality as a human rightsissue: measuring compliance withinternational treaty obligations.Human RightsQuarterly. 21(3):565-607. 16. O'Reilly,K. Personal communication, March 2000. 17. CenterforHealthand Gender Equity,PopulationCouncil, 1999. The Implications ofHealth Sector Reforms forReproductive Rightsand Health.Reportfrom a meetingof theWorking Group on ReproductiveHealth and FamilyPlanning.World Bank, 14-15December,
31

This content downloaded from 14.139.62.114 on Fri, 29 Nov 2013 01:08:51 AM All use subject to JSTOR Terms and Conditions

Jacobson

WashingtonDC. 18. Sethi G, 1997. Administrative decentralization as a strategy to improvethe qualityand responsivenessofsocial

services:the PanchayatiRaj and reproductive healthin India. Paper presentedat Accountability Mechanisms: MarkingProgress in the

Implementation ofICPD, WorkingGroup on ReproductiveHealth and Family Planning,Ford Foundation, New York,9-10 April.

Resume Resumen De recents accordsinternationaux demandent de Recientesacuerdos internacionales hacen un faire passer les programmes de planification llamado a la transformacion de los programas familiale d'objectifs demographiques a la pro- de planificacion familiar desdeun enfoque en las motiond'objectifs de sante et de droits.Les metasdemograficas a la promocion de los objeconsequences pratiques de l'association de tivosde salud y los derechos.Sin embargo, no principes de santeet de droits de lthomme dans estan claras las consecuenciasque tendrlala les programmes actuels et futursdemeurent unionde los principios de salud y los derechos neanmoins peu claires.Les ressources de sante humanosen los programasactualesy futuros. publique sont allouees selon les priorites qui Los recursos de la saludpublicason distribuidos refletent la capacitede prevenir la maladieet de de acuerdocon prioridades que reflejan la capareduire sa prevalence et son incidence dans une cidad de prevenir enfermedades y disminuir la population.Les methodologies des droits de prevalencia e incidencia de enfermedades en la lthomme portent surla protection des droits des poblacion. Las metodologiasde derechoshuindividus, et le droita la sante et aux soins de manos estan enfocadosen la proteccion de los sante. Les plus importantsobstacles a la derechos de las personas, y el derechoa la salud realisation d'unprogramme en faveur des droits y la atencion en salud. Los obstaculos sont la pauvrete,le manque de conditions principales a la realizacionde una agenda de propiceset dtinvestissement social,et l'absence derechosson la pobreza,la faltade condiciones d'environnements institutionnels et politiques habilitantes yla inversion social,yla ausenciade pouvantsoutenir, promouvoir et protegerles ambientes institucionalesy politicos que droits. Ces dernieresannees, des politiciens apoyan, promuevan yprotegen los derechos. En d'extreme droite aux USA ont utilise les anos recientes, los politicosde la ultraderecha programmes des droits de lthomme a leurs en los EE.UU. han usado la agenda de derechos propresfinset ont fixecommel'une de leurs humanos para sus propiosfines y han hechodel priorites de vider de sens les programmes de desfin anci amiento de los programas de planification familiale. Appliquerun cadre de planificacionfamiliaruna de sus mayores droits aux programmesde sante genesique prioridades. Aplicar un marcode derechosa los signifie se centrer autant surle processus que sur programas de salud reproductivasignifica le resultat, ctesta-dire qut enplusde proposer des enfocar tanto en el proceso como en los methodescontraceptives, cette approchepeut resultados, i.e. ademasde ofrecer metodosantioffrir une education en santegenesiquea assise conceptivos, este enfoque podria tambien communautaire, un appui communautaire pour ofrecer educacionen salud reproductiva a nivel la santeetles droits genesiques, etltemploi d'une comunitarioZ construir apoyo comunitario para varietede strategies de communication pour la saludylos derechos reproductivos, yusaruna transmettre un sentiment de legitimite dans la variedadde estrategias comunicacionales para population etetablir de nouvelles normes sociales infundir un sentidode derechopropioentrela encourageant le partenariat, la communication et gentey establecer nuevasnormassociales que la cooperation. Elledoitassurer nonseulement la fomenten las asociaciones, la comunicacion y la qualite technique des services proposes en cooperacion. Debe incluir no solamente la dispensaire, maisaussiintroduire ltethique d'une calidad tecnicade la provision de los servicios perspective de droits a tousles niveaux. clinicos sinoincorporar ademasuna perspectiva de derechoa todonivel.

32

This content downloaded from 14.139.62.114 on Fri, 29 Nov 2013 01:08:51 AM All use subject to JSTOR Terms and Conditions