By Rosemary Okello and Terna Gyuse
BRUSSELS and CAPE TOWN, Jun 30 2009 (IPS)

The right to the highest attainable standard of health: not the most fashionable of human rights, but the limits on people’s enjoyment of their right to health often coincide with continuing inequalities behind claims of economic growth or political reform.

Women must gain greater involvement in shaping maternal health policies and practices. Credit: Ken Opprann/Norway/UNFPA

The quality of life of women and children – particularly poor women, rural women, and women from ethnic and indigenous minorities – is a strong measure of real change for the world’s most vulnerable people. During the month of June, women’s sexual and reproductive health rights received some welcome attention.

“Of the 500,000 maternal deaths that occur annually worldwide, more than 250,000 occur in Africa. Pregnant women in Africa are at grave risk,” Soyata Maiga told the 11th Session of the U.N. Human Rights Council. “Additionally, there are many countries at war in Africa, which compounds pregnant women’s risk, with hundreds of thousands of women dying every year.”

Maiga, U.N. special rapporteur on the rights of women in Africa, continued: “Socio-cultural practices such as early marriage, early pregnancy, violence, female genital mutilation, marginalisation in decision-making regarding issues that concern women, low status of women within the African family, and the fact that women are not enabled or permitted to plan their pregnancies – each of these factors leads to maternal mortality, an issue that can be addressed and prevented if we tackle it as a human rights issue.”

The ways in which sustained high levels of maternal mortality stem from a denial of rights was also the central focus of a conference held in Brussels at the end of May to review progress since the International Conference on Population and Development in Cairo. The 1994 conference was a watershed in terms of bringing a rights-based approach to population control and women’s sexual and reproductive health.

In Brussels, Indu Capoor, executive director of India’s Centre for Health Education, Training and Nutrition Awareness, shared the following anecdote, tracing how poverty sentences millions of women to a cascade of denials of their basic rights before maternal mortality brings impoverished lives to a full stop.

“What kind of human rights can you [speak of to] Lakshmi, a 13-year-old girl forced into marriage because her parents were poor? She was married off to a boy living in a nearby village. She got pregnant immediately, because she was expected to prove her fertility.”

Poor women are systematically denied their right to education, to adequate and accessible health care, or to make family planning choices and control their sexuality – multiple inequalities that too often narrow their future prospects to zero.

“Being both poor and young, she has no access to money, information or health services such as ante-natal check-ups. As she has been poor all her life, she was also severely anaemic. She had a premature delivery at five months,” Capoor continued, “and the baby did not survive. She herself suffered from excessive bleeding and due to her anaemic state, died soon after.”

On average, a woman somewhere on the planet dies in childbirth every minute. Three quarters of these deaths are preventable.

“Maternal mortality is a human rights issue. Underlying the systemic failure to prevent maternal death is, depending on specific circumstances, the denial of the right to health, to equality and non-discrimination, to reproductive self-determination and to the benefit of scientific progress,” said Ariel Frisancho of the International Initiative on Maternal Mortality as a Human Right.

The most recent global estimates of deaths in childbirth – 2005 figures released jointly by the World Health Organisation, UNICEF, the United Nations Population Fund and the World Bank – show limited progress.

From 1990 to 2005, maternal mortality declined by 26 percent in Latin America; in Asia the decline was 20 percent over the same period. In Africa, the decline was less than one percent, from 830 per 100,000 live births to 820 – an estimated 276,000 African women died from pregnancy-related complications in 2005.

Speaking on the same Human Rights Council panel of experts as Maiga, Frisancho explained that the majority of these deaths are a result of what activists describe as the Five Delays.

“One, the time it takes to recognise that a woman is facing a life or death health problem; two, the decision-making time to seek services; three, the travel time to receive services; four, the delay in receipt of services upon arriving at the health facility; and five, the political delay by governments and donors in effectively addressing the issue of maternal mortality.”

Some programmes that respond to this need are in place, but they require greater funding and support from governments.

In Frisancho’s native Peru, non-governmental organisations found that in addition to the familiar problems of distance, cost and staff shortages, indigenous women in the Ayacucho district did not trust state public health facilities.

Consultations with the community led to the adaptation of pre- and postnatal care and delivery in new – free – birthing centres to make them more culturally sensitive – including Quechua-speaking birth attendants, facilities for women to give birth in an upright position if they wished, and provision for a family member to receive the placenta in accordance with local traditions.

In West and Central Africa, a project run jointly by UNICEF and USAID in Ngaoundere, Cameroon and Kaedi, Mauritania trained several dozen doctors, midwives and assistants, and provided the towns’ clinics with new equipment.

Training in better communication, management of labour and infection prevention improved maternal health, and community health workers were deployed to raise awareness on warning signs for complications in pregnancy, so that women and their relatives would not wait too long to seek emergency care.

In the Indian state of Uttar Pradesh, the rights NGO SAHAYOG has mobilised thousands of poor women to take issues of maternal care and other human rights violations to policy-makers. The women have formed the Mahila Swasthya Adhikar Manch (Women’s Health Rights Forum in Hindi), which aims to allow marginalised women to gain a voice in policy-making in order to curb high rates of maternal mortality in the state.

The vision of a rights-based approach to reducing maternal mortality has been around for 15 years and more; what is needed are diverse, wide-scale actions to put it into practice.

On Jun. 17, the United Nations Human Rights Council passed a resolution recognising that preventable maternal mortality is a violation of a woman’s rights to life, health, dignity, education and information. It is hoped this will be a tool allowing women to press for greater accountability.

“Sustainable, substantial change will only be achieved if poor people have greater involvement in shaping health policies and practices,” said Frisancho.

Excerpt:

In 1994, the International Conference on Population and Development (ICPD) proposed a groundbreaking shift in the approach to reproductive health: women’s reproductive capacity was to be transformed from an object of population control to a matter of women’s empowerment to exercise personal autonomy.

The ICPD’s Plan of Action set out several key action areas: education and literacy, reproductive health care and unmet need for contraception, maternal mortality reduction and HIV/AIDS.

But although reproductive health programmes enjoyed fresh attention and resources from donors and governments, the emergence of HIV/AIDS as a leading funding priority undermined progress.

The two became awkward bedfellows despite HIV/AIDS being a health issue that cannot be addressed effectively in isolation from sexual and reproductive health rights.

An emphasis on HIV/AIDS produced mixed results. A study published in 2008 by the International Treatment Preparedness Coalition (ITPC) – which included field research in Uganda, Zimbabwe and Zambia – indicates that while new investment in AIDS services had many positive impacts on health systems overall, it also exposed existing weaknesses, in some cases increasing the burden on limited human resources by increasing demand and shifting governments’ attention away from other health priorities.

As a result of this, many women were denied access to a full range of reproductive health services.

Says Jennifer Woodside of the International Planned Parenthood Federation (IPPF): “Those of us working in the area of reproductive health and rights missed the HIV/AIDS bus because of these hurdles where experts in the field of HIV/AIDS and us on the other hand did not make use of the linkages.”

According to Woodside, the debate around the morality of reproductive health rights as envisaged by the ICPD further complicated issues such as access to family planning and constrained funding for reproductive health. “Yet family planning was meant to provide a package on reproductive health care  as a way of achieving universal access to reproductive health.”

The ICPD Plan of Action calls for the achievement of universal access to basic reproductive health services by 2015 and for specific measures to foster human development, with particular attention to women. But its implementation has been hindered by governments in many countries focusing on HIV/AIDS programmes for which money was more easily be accessed.

The Plan of Action further underscores reproductive health as a right, which should strengthen women’s ability to take charge of their sexuality including sexual and reproductive health.

But efforts to improve access to contraception and safe abortion in line with the ICPD Plan of Action elicited international debate, with critics objecting on moral grounds to what they viewed as a licence for sexual behaviour.

In 2001, the George W. Bush administration in the United States reactivated the “gag rule” first formulated by the Reagan Administration in 1984. Also known as the Mexico City Policy the rule prevented U.S. funding for family planning that included abortion, abortion counselling and referrals services or abortion-related advocacy – even in countries where abortion is legal.

The enforcement of the rule – from 1984 until President Bill Clinton rescinded it in 1993, and again for eight years under the second President Bush – saw many family planning clinics and NGOs which provided comprehensive reproductive health care shut down.

The IPPF reported that it lost 100 million dollars in U.S funding during the latter Bush administration. Speaking during  the 2015 Countdown meeting in London in 2004, Steven Sindling, then director general of IPPF said that as a result of the ‘gag rule’ there was an increase of unwanted pregnancies around the world: “More deaths from pregnancy- related causes, more HIV infections and more unsafe abortions.”

President Obama again rescinded the gag rule in early 2009.

According to Marcela Howell, who directs communications and marketing for the non- profit sexual and reproductive health rights organisation Advocates for Youth, the more than 1.1 billion people between the ages of 15 and 24 are bombarded with ideologies of abstinence until marriage, but have little information on how to protect themselves from unwanted pregnancies and sexually transmitted infections, including HIV and AIDS.

But for youth like Rose (not her real name), an HIV-positive 18-year-old from the Kibera slum in Kenya, the information she receives from health providers is more frustrating than useful. She complains of impractical messages on abstinence directed towards her and her peers, most of whom are sexually active; and flatly incorrect information she was given about one day having a child, given her status.

Experts warn that providing Rose and billions of women like her with access to affordable reproductive health care as well as empowering her with education about – and protection for – her rights to sexual health is necessary if the much-talked about millennium goals of reducing poverty, maternal and child mortality and attaining gender equality are to become a reality.

Many hope that the spirit of the ICPD will rise again, and women access a holistic approach to reproductive health care.

Significant new investments in the fight against the AIDS pandemic could have positive impacts on broader health systems in Africa if governments handle them right.

A study of six countries – Argentina, Brazil, Dominican Republic, Zimbabwe, Kenya and Uganda – by the International Treatment Preparedness Coalition (ITPC), titled “Missing the Target 6 – The HIV/AIDS Response and Health Systems” indicates that new investment in AIDS services has exposed existing fragilities in health systems. In some cases it has placed increasing burdens on these systems by expanding demand and stretchied already overextended human resources.

The report, which provides some of the first on-the-ground research documenting the impacts of the AIDS service scale up, shows that the AIDS response has attracted the biggest share of health financing, increased the number of trained medical personnel, improved the management of people living with the virus, and supported the establishment of HIV clinics that treat TB and other opportunistic infections.

The pandemic has spurred the mobilisation of activists and health care consumers themselves and forced global and national leaders to a more vigorous sense of accountability and urgency.

The research also examined claims that the international response to HIV/AIDS has also weakened the primary care in many instances, distorting health systems, and diverting funding and health care personnel.

“To the degree the response to AIDS ‘distorted’ health systems, it did so by increasing the accessibility and quality of services for one devastating disease,” the authors write.

“Before AIDS, health systems suffered from decades of disinvestment due to structural adjustment policies and chronic under-funding, which damaged the entire infrastructure for primary care. Today’s debates about AIDS versus health systems would not have happened 10 or 20 years ago. AIDS has opened up a sense of possibility for change, for progress in providing health care to all who need it.”

The ITPC report shows that HIV and AIDS has placed extra pressure on health systems in each of the countries studied, which is manifested in increased workload for the health workers, whose numbers have not increased in tandem with increasing demands. In Uganda, for example, staff in public health facilities have moved to HIV clinics where they are paid better, creating a deficit in the institutions they are departing from.

Yet the scale-up of AIDS services has also led to improvements in several aspects of health care, including how services were delivered and who received care. In the Wakiso district, community health workers who carry out HIV/AIDS sensitisation also give out anti-malaria medicines, mosquito nets, and treat minor illnesses, such as obvious malaria, and diarrhoea. The Mengo and Rubaga hospitals have outreach programs that focus on HIV testing alongside immunisation, family planning, and prevention and treatment of common diseases.

The report recommends that the donor community should channel more resources into improving infrastructure, with particular focus on increasing the number of laboratory facilities for diagnostic tests. It also calls for the governments in Africa to streamline the supply and logistics chain to ensure a more consistent and uninterrupted supply of ARVs and other essential medicines.

The challenges facing health care systems in Africa are compounded by a shortage of personnel. According to a senior lecturer at Makerere University’s School of Health, Professor Fred Nuwaha, the shortage can only be solved through the regional medical body that should also front for serious research against communicable diseases and the latest disease of the affluent such as heart, high blood pressure and cancer.

“This will also help tame the migration of doctors to Europe and America, a move that is fast derailing the health sector in Uganda and other African countries,” he adds.

Nuwaha reveals that 20 percent of 200 medical doctors that are trained at the university each year end up leaving the country due to the poor working conditions in the country. “As these medics relocate, people in hard to reach rural areas are most affected as the few doctors available find themselves in urban areas,” he notes.

Zimbabwe also faces severe shortages of healthcare workers, aggravated by the economic collapse and political stalemate.

“What we found was that HIV/AIDS services, particularly provision of antiretrovirals, have become a lifeline for the health care system in Zimbabwe,” said Matilda Moyo, who co-authored the report’s chapter on Zimbabwe.

“In the midst of the economic and political crises, a consistent focus on HIV health services has been an oasis in a whole desert of the collapsing health delivery system.”

But another person involved in producing the report cautioned against the diffusion of AIDS funding to support the general public health system.

“The AIDS response in Zimbabwe, Brazil and other countries shows that new investments in health can have dramatic impact,” said Chris Collins, one of the report’s coordinators. “But a simple reshuffling of health resources toward more generalized health functions at the expense of effective disease-specific programs, such as HIV/AIDS, would jeopardize the remarkable advances that have been made and leave the more than six million people who urgently need AIDS treatment without this care.”

*This feature is a joint production with the African Woman and Child Feature Service.