SA HEALTHCARE OP-ED
Improving access to sexual and reproductive health — a constitutional right in South Africa
The urgency for universal health care (UHC) has never been greater. However, progress towards UHC is conditional upon addressing inequities in health access, prioritising the health needs of women, adolescents, vulnerable and marginalised populations including their sexual and reproductive health rights (SRHRs). Stated simply, there is no UHC without a commitment to SRHR.
On 12 July this year, the World Health Organization launched its latest guidance “Critical considerations and actions for achieving universal access to sexual and reproductive health in the context of universal health coverage through a primary health care approach”. This document (also called a ‘handbook’) is intended for use by civil society organisations, researchers and policymakers. The key concepts (i.e. sexual and reproductive health, universal health coverage and primary health care) are defined.
Sexual and reproductive health and rights (SRHR) are defined as people’s ability “…to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so”.
Universal health coverage (UHC) is the ability of “all individuals and communities (to) receive the health services they need without suffering financial hardship”.
While the primary health care (PHC) approach is not explicitly defined in the document, it is defined by WHO as having three components: “meeting people’s health needs throughout their lives; addressing the broader determinants of health through multisectoral policy and action; and empowering individuals, families and communities to take charge of their own health”.
The launch of the WHO handbook is important and timely for several reasons. As the Covid-19 pandemic has, unfortunately, reminded us that in South Africa as in other parts of the world, in times of crisis, the SRHR of women, girls and marginalised populations are often side-lined. During the pandemic, this translated into SRH services including maternal health being deprioritised and considered non-essential; an increase in unintended pregnancies and unsafe abortions, especially amongst youth resulting from disruptions in family planning services and availability of contraception and equally disturbing, an increase in gender-based violence.
The impact was and continues to be hardest felt by those already under-served by health systems that are under-resourced, poorly functioning and lagging in progress towards UHC.
The urgency for UHC and in the context of South Africa, National Health Insurance (NHI) and safeguarding SRHRs, has never been greater. This is a key message of the handbook: progress towards UHC is conditional upon addressing inequities in health access, prioritising the health needs of women, adolescents, vulnerable and marginalised populations including their SRHRs. Stated simply, there is no UHC without a commitment to SRHR.
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As South African policymakers, technocrats and civil society organisations engage with the task of determining the design details and commence implementing UHC in the form of NHI in the context of the national SRHR policy, can use of the WHO handbook assist the process of expanding access to SRH service as part of UHC and using the PHC approach?
Encouragingly, the WHO handbook is well-aligned with South Africa’s national strategies and polices on SRHR and NHI and provides specific guidance on the following: the key policy actions to ensure SRH services are part of health benefit packages; on how health systems can deliver integrated SRH services; and how to ensure accountability in the design and delivery of SRH services. Here are a few select examples of ways in which the WHO handbook can support advancing SRHR within NHI design, policy development, programme implementation and monitoring.
First and most immediately needed is the translation for civil society, in particular women, of the key messages and popularising the key concepts in the WHO handbook (SRHR, UHC, PHC). This is important for participating in the design of programmes for advocacy, monitoring implementation as well as holding government accountable for their commitments. Involvement of civil society in SRHR programme design is as important as their involvement in the HIV response as noted during the recently held Aidsconference in Montreal.
Second, the handbook provides specific guidance on ensuring inclusion of comprehensive SRH services in nationally defined health benefit packages (or service benefits as known in South Africa). Defining service benefits is an essential key step in ensuring availability and access to quality SRH services and once defined, this information should be publicly available.
At the same time, paying attention to practices of good governance and especially in the priority-setting process for identifying and including services in health benefits packages is as important — but often neglected. Here, the handbook calls for transparent and inclusive engagement and participation of all stakeholders especially those who are often not reached (e.g. youth and women’s groups, marginalised groups, people with disabilities etc).
Linked to this, there are growing and strong calls for the involvement of young people in adolescent SRH and UHC policy design, legislation, programming and monitoring. However, for youth (and other groups typically excluded from the table) to fully and participate meaningfully, this must be enabled through investing in their technical capacity and knowledge to engage and advocate as equal partners in processes and platforms at national, sub-national and community levels.
Third, the handbook provides specific guidance to district health managers on delivering integrated SRH services within a primary care approach. This includes a checklist including, for example, the human resource implications of service delivery integration and joint planning between relevant programmes and departments such as basic education and social development.
Fourth, as reasoned in the handbook, a comprehensive approach to SHRH requires advancing gender equality and tackling social norms. This often entails action including ensuring an enabling legal and policy environment (e.g. legal minimum age at marriage, laws on domestic violence etc) and policies on gender, rights and equity that have implications for recognition and non-discrimination of one’s sexual orientation and recognition of different gender identities. In this regard, there are many policies in South Africa, but as many have argued, not many are fully implemented.
An overall key message of the handbook which holds true for South Africa and other countries committed to advancing universal access to SRHR is that progress requires moving from aspiration to policy action and implementation with accountability. This requires commitment, collective action of all stakeholders if South Africa is to ensure that all those who require sexual and reproductive health services receive them, that women are free from gender-based violence, are able to negotiate when and with whom to have sexual relations, and when to have children. DM/MC
Govender is Scientist in Department of Sexual and Reproductive Health and Research, World Health Organization.
Pillay is extraordinary professor, Division of Public Health and Health Systems, Stellenbosch University.