1. Sexual and reproductive health and rights as an essential part of the health goal: tackling inequities and disparities
Health cannot be ensured without ensuring sexual and reproductive health and rights (SRHR). We therefore support the inputs into this report that propose that SRHR should be at the centre of any health goal in the post-2015 development framework. It is time to reflect on and act upon the lessons learned from the MDGs, which overlooked the broad SRHR agenda established at the 1994 International Conference on Population and Development to focus primarily on HIV and reducing maternal and child mortality. Crucial issues, seen by some to be “sensitive”, were ignored, and as a result have been sidelined in programming, policy and funding. This new development framework must support and galvanize efforts to achieve universal and equitable access to comprehensive sexual and reproductive health services and, especially, to increase reproductive autonomy and human rights, including in relation to sexuality.
The report calls for a “hierarchy of goals […] to capture the increasing complexity of priority health challenges” (p.32). We recommend that any hierarchy must not be used to exclude priority health issues that have been neglected or inadequately addressed because they were left out of the MDGs. These include many other serious health problems that are subject to inequities and disparities affecting millions of people worldwide, which are central to achieving the right to health.
While we agree that the post-2015 development agenda should be relevant for all people in all countries (p.32), we suggest that the reduction of health inequities should be a primary focus of the development agenda. Furthermore, the needs of the poor, marginalized and those whom the efforts based on the MDGs have not reached should also be prioritised throughout.
In response to the paragraph “Universal access to sexual and reproductive health…” on p.24, it is important to emphasise that neither maternal health nor family planning, while extremely important, should be seen as the only important components of SRHR nor as separate services for attention. This would perpetuate the undermining of a holistic notion of SRHR that occurred as a result of MDG 5.
2. Universal health coverage
We question the assertion that UHC is considered to be one of the three goals that “appear to have the most support” (p.21), and we disagree that “universal health coverage”, as currently defined and outlined by WHO, is acceptable as the basis of a health goal for the future. Health services alone are not enough, and the financing issues are fraught with controversies and difficulties that must be debated further before they are set in stone. We have shown in SRHR that the right to health, equity, universal access, reduction of disparities, and the external determinants of health are all undermined by private ownership of health services, private financing and private control (RHM journal 2009-2012). It is crucial to address where financing should come from, who has responsibility for health systems, and public vs. private ownership, control and provision of health care. We support the strengthening of public health systems above all and would argue that the increase in private medicine has not helped public systems to become stronger, to the detriment of the poorest socioeconomic quintiles, rural populations, women and young people above all.
3. Health and human rights
The right to the highest attainable standard of health, as enshrined in international law and the WHO constitution, and other human rights that are inextricably linked to health, must be at the core of any health goal. This goes further than the “strong relationship” between health and human rights cited in the report (p.14). Specific components of this right, as elaborated by UN and regional human rights bodies, must be captured and reflected throughout the goals, targets and indicators of the new development framework. These components – based on legal norms binding on States that have ratified the relevant treaties (1) – must serve as the bottom line for actions expected of States. Measurement of a health goal requires a public health and human rights approach. Understanding of the relevance of legal norms to technical approaches and ways of capturing human rights considerations through measurement tools has been developed considerably since the MDGs were conceived, and must directly inform this agenda
4. Using indicators to monitor progress in line with commitments
The document focuses on the need for indicators to measure impact, coverage and health systems (p.32). It is essential that the indicators are designed to capture health inequities. Putting inequities at the heart of the global development agenda can only be achieved if the measurement tools used are designed with this specific purpose.
In relation to the indicators for monitoring progress listed in the paragraph “Universal access to sexual and reproductive health…”(p.24), we would like to emphasise that any indicators on SRHR must be carefully designed to implement key components of the rights to sexual and reproductive health, and framed in such a way that they do not promote or encourage vertical approaches to programming.
The report cites the example of the UN Commission on Information and Accountability for Women’s and Children’s Health in accelerating progress towards MDGs 4 and 5 (p.30) and setting a long-term foundation for accountability for health as being of “significant benefit for the post-2015 development framework”. Yet it has been acknowledged that MDG5 has been one of the least achieved goals to date, especially “universal access to reproductive health”. In order to ensure full accountability for a progressive development agenda, the scope and mandate of all accountability mechanisms must be expansive enough to address all issues that are relevant to achieving the new goals, be designed to ensure accountability at different levels (international, national and local) and cooperate with the range of existing accountability mechanisms in operation under UN and regional human rights frameworks.