Last summer, UN Secretary-General Ban Ki-moon established the High-Level Panel (HLP), a group of 27 international government officials and civil society experts, to guide the development of the Post-2015 framework. The HLP recently convened in Bali for a meeting before they submit recommendations to Ban in May. Along with more than 100 youth delegates, I participated in a parallel youth multistakeholder meeting, which included an outreach event with key players such as High Level Panelist John Podesta of the Center for American Progress and Homi Kharas of the Brookings Institute.

In preparation for our meeting with the HLP, we were tasked with the impossible: to distill the vision and priorities of young people, all 3.5 billion of us, into a tidy presentation on what we hope to see in the next development framework. Compelled by this rare opportunity to provide direct inputs into what continues to be a frustratingly inaccessible process, we managed to catalog what matters most to young people, drawing on our own discussions as well as outcomes from prior and ongoing post-2015 youth meetings. Gender equality and sexual and reproductive health and rights (SRHR) emerged as areas of strong thematic consensus.

The Youth Communiqué, which documents the outcomes of the Bali youth meeting, calls for a transformative and transparent new development agenda, and includes strong language on inclusion and rights.  We also call for a number of commitments to gender equality and SRHR, including universal access to quality education (including Comprehensive Sexuality Education) and youth-friendly health services, a commitment to gender equality, the elimination of gender-based violence and the recognition of young people’s diverse sexual orientations and gender identities.

Inclusion was a striking theme of this meeting.  As we discussed the need for meaningful youth participation on the whole, we highlighted the challenge of ensuring that the most marginalized young people are included in the next development agenda.  Drawing heavily on commitments made during the 2012 Global Youth Forum, we demanded the recognition of young people with disabilities, sex workers, indigenous youth, and young people living with HIV/AIDS as valued stakeholders in the Post-2015 Development Agenda process.

Upcoming events throughout the summer (including another HLP meeting in mid-May and the ICPD Regional Reviews) present immediate opportunities for young people to mobilize yet again.  We must use these opportunities not only to further define our asks and non-negotiables, but also to continue challenging the limited and often superficial opportunities for meaningful youth participation. The fight is far from over. It’s crucial that we build on the momentum from Bali to claim this agenda as our own. 

After she left Planned Parenthood Indonesia, Ninuk worked independently and focused on training and supporting others to become counselors. She has done this work in Iran, Turkey, Azerbaijan, Ghana, South Africa, and other places as well. Among her trainees are many college students who were trained as volunteer peer educators who would talk to young people both in school and out of school about sexual and reproductive health.

Along the way, it became very clear that it was necessary to have a law in Indonesia that would protect women and make it possible for women to access abortion services. Eleven people–activists, psychologists, and ob-gyns–came together to create the YKP Womens’ Health Foundation. They decided to only focus on two things: fighting to have legal protections for reproductive health and especially access to safe and legal abortion services and empowering the community, especially the young generation, to access health services and information. When they first launched the organization, they realized that they needed to gather evidence to support their advocacy for better national policy and to understand the needs and demand for sexual and reproductive health services and information.

In 2009, a new health law was passed in Indonesia, with a section on reproductive health. The law says that abortion can only be accessed by women who are rape survivors or if there is a health risk for the woman. There are of course many shortcomings of the law, but it is big progress for Indonesia. Read our analysis of the law from just after it was passed. Today, YKP is working to ensure that the law is implemented in a useful way. Ninuk is currently working on implementing pre- and post-counseling support for women who need an abortion, to make sure that abortion care services are as comprehensive and woman-centered as possible under the current law.

After two weeks of fierce negotiations at the United Nations’ annual Commission on the Status of Women, on March 15 more than 130 governments committed to ending violence against women and girls, and reached strong agreements to promote gender equality and ensure access to sexual and reproductive health services.

The International Women’s Health Coalition and our amazing partners from around the world came out in force to the UN for the negotiations. Our agenda was clear: push governments to commit to concrete strategies to empower women and girls and end gender-based violence.

We met with instant opposition from conservative governments. Countries such as Iran, Russia, Egypt, and Syria joined with the Vatican in what The New York Times called “an unholy alliance.” IWHC staff and our women’s rights caucus of more than 100 activists worked around the clock to support progressive delegations to stand strong and not to cave in to pressure. We would not let a small but vocal minority use culture and religion as excuses to deny women their rights.

Our efforts prevailed and consensus was finally reached to loud applause from supportive governments such as Argentina, Brazil, Denmark, Mexico, Norway, the Philippines, South Africa, Switzerland, Turkey, United States, Uruguay, and even the small island of Tonga! As the “agreed conclusions” document was adopted, hundreds of women’s rights activists streamed into the negotiating room to join in the cheers.

For the first time at the UN, governments reached consensus that survivors of rape are entitled to emergency contraception to prevent unwanted pregnancy, and to timely and respectful forensic exams to support prosecution. They called for an end to child marriages. They agreed women’s right to control their sexuality is essential to preventing further violence. And they recognized the role that evidence-based sexuality education can play in reducing the harmful gender stereotypes that lead to violence.

In a sign of just how much was at stake, this year’s meeting received an unprecedented amount of media coverage after the Muslim Brotherhood condemned (and mischaracterized) the negotiations. IWHC featured prominently in many news articles, including in The Washington Post, The Guardian, Associated Press, ABC News, The Globe and Mail, Radio Free Europe, O Estado de S. Paulo, and Reuters.

Once again, we women have shown we’re an irresistible force. But our work is far from over. Now we must be vigilant to ensure that the agreements made at the UN are put into practice in local communities worldwide.

For that to happen, we must continue to support women’s groups to hold their own leaders to account.

Best regards,

But an equally important weakness of universal health coverage as a concept is that it fails to address the non-economic factors that play a significant role in determining whether women and young people can access and use the health services they need. These factors include:

• Laws and policies that restrict access, such as policies requiring parental or spousal consent or couples treatment, or laws that restrict the provision of and access to certain services, such as safe abortion.
• Social and cultural norms and practices that embody persistent gender inequalities. This can result in, for example, low immunization rates for girls or stigma and discrimination when unmarried women seek sexual health services. These norms and practices can keep women and girls from using services that are otherwise available.
• Lack of individual empowerment, information, and education, which impede women’s and adolescents’ knowledge about health and health-seeking behaviors.
• Weaknesses in health systems that may result in poor quality of care or inaccessible, inadequate, and inappropriate services. These range from resource issues such as the inequitable distribution of services between urban and rural areas and insufficient numbers of trained health care workers to systemic problems like discrimination and abuse of marginalized patients, including women, adolescents, and people who are lesbian, gay, bisexual, and transgender.
• Other social determinants of health, such as food and nutrition, security, water and sanitation, and other environmental and occupational factors that can have specific negative health consequences for women and girls, including for their sexual and reproductive health.

A draft discussion paper prepared for next week’s Global Leadership Meeting on Health acknowledges the critical gap of universal health coverage in addressing the social determinants of health and other barriers to health care. Indeed, this gap might even make universal health coverage something of a pipe dream when sexual and reproductive health is on the line. Without concomitant efforts to address these and the economic factors outlined in my previous blog, women and girls will continue to face challenges accessing and using sexual and reproductive and other critical health services and exercising their rights. The government and civil society leaders meeting next week would do well to discuss the full range of factors that can facilitate or impede people’s ability to achieve the highest attainable standard of health.

We at the International Women’s Health Coalition hope that global leaders agree to take a more holistic approach to improving health care by recommending development goals specifically for women and adolescents—two population groups who face the biggest barriers to care and whose health is critical for overall development. Such an approach would allow for focus on the particular health challenges faced by women and young people, the contextual factors that can jeopardize their health and erect barriers to care, and the specific interventions needed for both prevention and treatment of health conditions.

Universal health coverage is important, but it alone is not enough to guarantee access to health services and improve health. We need specific goals that address the diversity of barriers to care faced by women and adolescents, along with a dose of political will and resources adequate to meeting these goals.

One proposal on the table would group all these concerns under the objective of “universal health coverage.” In my two-part blog series, I will discuss why this proposal falls short when it comes to women and adolescents.

Universal health coverage is defined in the draft discussion paper for Botswana as “two inter-related components: coverage with needed health services (prevention, promotion, treatment, and rehabilitation) and coverage with financial risk protection, for everyone.” Universal health insurance is considered critical to achieving universal health coverage because of the protection it can provide against catastrophic health costs and its contribution to sustainable financing. But is it enough?

Economic barriers (“financial risk”) certainly pose formidable obstacles to women and adolescents seeking sexual and reproductive health care; universal health insurance can help to address this.  But alone, it is not sufficient. In fact, health insurance schemes may contain their own barriers to care, particularly for marginalized women and adolescents.

For example, core sexual and reproductive health services, such as family planning counseling and contraceptives and maternity care, are often excluded from benefits packages that determine what is and is not covered by insurance schemes.

Abortion services are largely excluded from coverage, despite the fact that abortion is legal (on one or more grounds) in a majority of countries worldwide. Coverage of contraceptives and sexual health services for adolescents may be likewise constrained due to political sensitivities.

The level of financial protection provided by health insurance can also vary and may not be sufficient to insulate women against economic hardship.  Women consistently experience a higher burden of out-of-pocket costs for health care services than men who have similar levels of insurance coverage, largely due to non-coverage or limits on coverage for sexual and reproductive health services. Even nominal co-pays, common in many insurance programs, may pose a significant barrier if women do not have access to or control over cash.

Concerns about confidentiality and privacy may also impede access for adolescents and women when their own insurance coverage is tied to their parents’ or spouse’s coverage.  In the United States, adolescents and young women and men enrolled as dependents under their parents’ health insurance policies often choose not to use their insurance coverage to pay for sexual and reproductive health services, for fear that their parents will receive notification that they sought such care. Women covered as dependents under their husbands’ insurance policies may likewise be hesitant to seek much-needed care, such as contraceptives or treatment for violence.

Finally, the most marginalized women often fall through the cracks of so-called “universal” health insurance schemes for a number of reasons including lack of autonomy and decision-making power, or lack of information.  Women who are employed in the informal sector, women living in poverty, adolescent girls, and older women are often those least able to obtain good quality health insurance.

How do we make sure what is recommended at the Botswana meeting addresses these concerns?

I suggest a way forward in my next post.

Despite the highly gendered nature of the HIV/AIDS pandemic (women represent well over half of all people living with HIV worldwide), most prevention and treatment programming fails to account for the social determinants—violence against women, limited access to sexual and reproductive health (SRH) services, early and forced marriage, etc.—which make women and girls particularly vulnerable to the virus.

The International Women’s Health Coalition believes that effectively curbing the spread of HIV/AIDS relies fundamentally on the integration of sexual and reproductive health and rights (SRHR) with HIV/AIDS programming. The post-2015 development agenda must address the particular susceptibility of women and girls to HIV as well as the fundamental role that gender inequality plays in the spread of the virus.

Integrating SRH and HIV/AIDS services is a proven strategy for reducing new infections.   When men and women have access to HIV testing and treatment in the same spaces they seek out family planning and maternal health services, they are more likely to find out their status, learn about prevention methods, and explore treatment options.

Research has also shown that the availability of HIV services alongside other SRH services can reduce the stigma typically associated with HIV-specific programs.  Because the availability of treatment services for other STIs has been proven to reduce new HIV infections, expanding access to all forms of contraception and sexual health services through voluntary, rights-based, client-centered, and cost-effective programming is imperative.

Comprehensive Sexuality Education (CSE) should equip young people with protective sexual behaviors, the skills to effectively use condoms and other contraceptive methods, and should address gender and power, human rights and healthy relationships.  While male and female condom use is proven to reduce new HIV infections, the distribution of condoms alone is not a sufficient prevention method.  CSE should ensure that young people know how to use condoms correctly and should equip girls in particular with the tools to negotiate condom use and refuse unwanted sex.

In addition to equipping young people with scientifically sound and culturally appropriate information about sexuality, health, and rights, CSE should introduce empowering life skills to help young people navigate healthy and rewarding relationships, influence leaders in their community, and exercise their rights.

It is critical to invest in prevention efforts that target the most at-risk and overlooked populations of women and girls—adolescent girls, married girls and women, sex workers and women who use drugs. We must also ensure that treatment options are available and accessible to those living with HIV/AIDS, and that prevention and treatment efforts do not infringe on the rights of women living with the virus.

Women living with HIV/AIDS have a number of unique needs, and are particularly vulnerable to coercive sterilization practices, violence and discrimination.  They still often provide the bulk of care and support for their families, they face unmet need for contraception, and they need support to prevent vertical transmission.

Prevention of Mother to Child Transmission efforts play an important role in reducing new HIV infections, but these programs tend to focus far more attention on the infant than the mother.  The rights of HIV positive mothers must be fully protected and realized, including the right to informed consent and to choose the treatment regimens that best meet their needs.

The post-2015 development agenda must commit to addressing HIV/AIDS through targeted evidence-based prevention and treatment methods that account for the unique needs of women and girls.  Curbing the spread of HIV hinges on the transformation of discriminatory gender norms and practices, and the expansion of SRHR programming and policies. When women are able to refuse sex, live free from violence, insist on condom use, and avoid early marriage, they are able to reduce their risk of HIV infection (not to mention attend school, participate in civic affairs, and engage in healthy and respectful relationships).

Like so many of our development priorities, addressing the HIV/AIDS pandemic is inherently linked to issues of gender equality.  We must focus not only on the direct determinants of HIV infection, but also the profound gender inequalities and resulting discriminatory practices which make women more vulnerable to the virus and which stand squarely in the way of addressing its spread.

Young people all over the world face a range of unique challenges to exercising their rights.  Barriers to age-appropriate health services, meaningful education, and viable livelihoods opportunities are among the most pressing impediments to youth empowerment.

The International Women’s Health Coalition is centrally concerned with the sexual and reproductive health and rights of young people.  We believe that working with both young men and women is critical to ensuring that the rights of all young people, particularly girls, are universally protected and realized. The following contribution focuses specifically on the challenges facing girls, who continue to experience systematic social, economic and political marginalization in every part of the world.

Given the global persistence of gender inequality, many of the issues disproportionately affecting young people also tend to disproportionately affect girls. In 1997, UNAIDS reported that 60% of new HIV infections in sub-Saharan Africa were among young people (aged 15-24), with a 2:1 ratio of infected girls to infected boys.  This ratio continues to grow increasingly lopsided, with girls representing 74% of new infections among young people in 2009.

Additionally, girls face extraordinarily high rates of violence.  The experience of violence, the perceived threat of violence, or the stigma associated with being a victim of violence hinder access to entitlements, opportunities for social participation, and employment.

In developing countries, 40% of girls have their first child before the age of twenty, many before the age of 18. Not only does this mean that more girls are dropping out of school, but girls are also more likely than adults to die, experience complications, or suffer chronic injuries related to childbirth. Because they have less access to contraceptives and are less sexually experienced, adolescents are more likely than adults to seek out unsafe (often late-term) abortions.  Each year, it is estimated that 2 million to 4.4 million adolescents in developing countries have abortions, 70,000 unsafe abortions are carried out, and 13% of all maternal deaths occur as a result of unsafe abortion.

Early pregnancy is often associated with child marriage, a practice which also puts girls at increased risk of HIV infection.  Female genital mutilation, infanticide, nutritional bias—these and other harmful traditional practices disproportionately affect girls, infringing on their fundamental rights and opportunities for development.

The short answer to why these inequalities exist is that girls, especially the most vulnerable girls, continue to remain invisible. Despite the aforementioned figures, policymakers have consistently masked the specific needs of girls within “male-focused and male-dominated community-based activities and generic ‘youth’ prevention initiatives, all of which widely miss the mark” (Bruce, Temin, & Hallman, 2012).  This generic youth programming disproportionately benefits boys over girls overall, but it also favors unmarried to married girls, well-connected to socially marginalized girls, urban to rural girls, girls belonging to an ethnic majority to migrant or indigenous girls, and so on.

Girls also remain invisible because of how we measure progress.  Primary education enrollment figures, for example, are based on one day of the school year; even if there were genuine parity on this particular day, these figures fail to account for the reality that girls often miss multiple days of school each week because their domestic and reproductive responsibilities take priority.  Moreover, data on young people is rarely disaggregated, resulting in measures of participation which fail to report gender, age, marital status, and other critical factors.

The disproportionate burden that girls share for maternal morbidity and mortality, the time burdens that girls shoulder, the staggering inequalities in girls’ educational outcomes—these are all reversible realities. To tackle these disparities, we need to begin by making girls visible.  We must call for the post-2015 agenda to pay particular attention to girls and the challenges that they face.  The risks facing girls are well documented and the next step is to match the research with the necessary resources.

We need to make girls visible.

Making girls visible begins with how we count them.  By properly counting girls and disaggregating data by age and gender, we can target youth programming at specific subsets of youth—like adolescent girls.  We can also measure whether programs are actually reaching the girls who are most at risk.

We need to invest in girls.

We must invest in programming aimed specifically at girls, with an emphasis on the most at-risk populations of girls—those who engage in transactional sex, those who are forced into early marriage, those who fluently speak their native language but cannot communicate in their national language, and so on.  These programs must include the following features.

• Comprehensive Sexuality Education (CSE) must be thorough, scientifically sound, and culturally appropriate.  It should take place in a safe and healthy learning environment and it should explicitly address gender norms and gender equality.  When young people are educated about human rights, gender equality, and the role of power in relationships, they are not only equipped with the tools to negotiate their own health relationships, but they are also able to educate and influence power-brokers in their communities.
• Comprehensive services must be universally available and accessible.  This means, access to high quality sexual and reproductive health care, all forms of safe and effective contraception, safe abortion and post abortion care, maternity care, and prevention and treatment of sexually transmitted infections including HIV.
• Education is foundational to girls’ empowerment. We must ensure that all girls, no matter how poor, isolated or disadvantaged, are able to attend school regularly and without the interruption of early pregnancy, forced marriage, etc.  Education—for both girls and boys—must go beyond academics and equip young people with life skills so that they are prepared to think critically and challenge discriminatory and repressive policies and practices.
• Empowering spaces ensure girls have the opportunity to feel secure, be themselves, and plan for their safety and development.  Even if only for a few hours a week, accessing safe spaces allows girls to frame their own agendas, receive training on sexual and reproductive health and rights, and develop their social and economic capital. These participatory social spaces also foster opportunities for community-building and networking, mitigating the isolation that many girls experience.

We need to support young leaders.

We must continue to support both young women and young men to be advocates for change. Ensuring that reproductive rights are protected and promoted rests in the hands of young women and men, particularly young people throughout the global South.  Young people should be involved in all types of decision making on sexual and reproductive health and rights.  Seasoned advocates must be willing to pass the torch, share best practices, and work alongside—sometimes even be led by—a new generation of SRHR leaders.

As advocates, we can listen to one another and work in tandem to repeal legislation that legitimizes discrimination against girls and press for new protections that ensure equality of access to health services, jobs and earnings, education, property and all the rest.  Addressing the profoundly complex root causes of gender inequality (and accordingly the inequalities experienced by girls) is not a simple challenge.

As we begin to develop a tangible action plan for the post-2015 development framework, we must remain mindful that shifting the social and cultural norms that permit and promote discrimination against girls is not a simple box-ticking task. We cannot continue to view gender equality as a singular aim, but rather as both an explicit goal and an issue that needs to be mainstreamed throughout the post-2015 development agenda.

As I reported previously, the ICPD Global Youth Forum in Bali earlier this month brought passionate engagement by young people committed to securing a healthy and just life for youth worldwide. The Forum closed on December 6 with a celebratory reading of the key recommendations from the various multi-stakeholder consultations that took place related to five themes: Staying Healthy, Education, Decent Work, Youth Leadership and Participation, and Families, Rights, and Sexuality.

The key recommendations are included in a public declaration. Please take a look and share your thoughts with us. We here at the International Women’s Health Coalition are thrilled that young people and adult allies from governments, civil society, the private sector, multilateral agencies, and other stakeholders from around the world spoke out in support of a bold and progressive vision for what the global community must do in partnership with youth to achieve the largest generation ever of educated, empowered, safe, and healthy young people.

Only by working together as a global community and as individuals can we realize this bold and achievable vision of what young people want, need, and deserve. UNFPA Executive Director Dr. Babatunde Osotimehin rightly described the process of meeting the sexual and reproductive health and human rights of young people as “a journey of 1,000 miles [that] starts with the first step.”

We look forward to working with and on behalf of young people to realize the key recommendations contained in the Bali Declaration, including with UNFPA which did an exemplary job ensuring that the process remained youth-led and youth-driven. We simply cannot progress as communities and nations without continuing to make these important leaps forward on our collective journey of 1,000 miles to secure an educated, empowered, safe, and healthy future for all.

Will you join us?

Researchers estimate that 35,000 pregnancies occur every year in Peru as a result of rape. Women and girls in this situation are faced with two options: seek an illegal abortion and risk going to jail or carry the pregnancy to term and suffer the psychological and physical trauma that go along with giving birth to your rapist’s child. Women who can prove that a pregnancy is the result of rape receive a “reduced” sentence of three months in jail (the standard prison sentence for illegal abortions in Peru is two years). Perversely, this reduced sentence does not apply to married women who are raped by their husbands, even though marital rape is a crime under Peruvian law. Doctors who perform abortions in cases of rape face up to six years in prison.

On September 28, 2012, a coalition of women’s rights groups launched a campaign to challenge this cruel violation of human rights. The campaign, Dejala Decidir (“Let her decide”), seeks to introduce a new law that decriminalizes abortion in cases of rape (currently, abortion is only permitted when the woman’s life or health is at risk). The groups, led by partners of the International Women’s Health Coalition—PROMSEX, Demus, Catholics for the Right to Decide-Peru, Manuela Ramos, CLADEM-Peru, and Flora Tristán—need to collect 60,000 valid signatures to petition Congress to consider the bill.

Photo courtesy of PROMSEX

This is no small challenge. The requirement for valid signatures means that people must be willing to provide their government ID numbers to verify their identities. This may be intimidating to many people in a country where the Catholic Church exerts a great deal of influence in the government and within communities. Consider also that many people in rural and indigenous communities—especially poor women who are disproportionately impacted by the abortion ban—do not have government IDs. Even if the campaign succeeds in obtaining 60,000 valid signatures, there is no guarantee that Congress members will risk controversy or the ire of the Catholic Church and support a change in the law.

The groups see the Dejala Decidir campaign as an opportunity to build a powerful and active movement on two important but neglected issues: abortion and rape. Every signature represents at least one more person informed about the harsh realities faced by rape victims in Peru, and mobilized to change the current abortion law.

George Liendo, Director of PROMSEX, says the time is ripe for a national dialogue. “It’s not always easy to build a coalition in Peru, but there is real energy for this campaign. People across the country want to put this on the political agenda.”

Peru is not the only country in the region rethinking its draconian approach to abortion. In October 2012, the Uruguayan congress voted to decriminalize abortion in the first twelve weeks of pregnancy.

Activists in Peru have until October 2013 to collect enough signatures to ask their own Congress to act. In the meantime, we can expect a rich and lively dialogue on rape and abortion. It’s about time.

This blog was cross-posted on RH Reality Check at http://www.rhrealitycheck.org/article/2012/12/19/double-jeopardy-rape-victims-in-peru.