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.

The fall is in full swing and so are we at the International Women’s Health Coalition!

We continue to push the U.S. Government to take greater, concerted, and strategic action to prevent the early and forced marriage of millions of girls in key countries and to support the more than 60 million girls who are already married. It goes without saying that global development goals will not be achieved without women and girls, and that women and girls cannot thrive when they are married off as children, against their will, and often to much older men. Yet in a number of countries around the globe today, more than 40% of girls are married before the age of 18. Our colleagues at the Ford Foundation put together a fascinating report on the situation around the world.

On October 11, 2012, the world marked the first International Day of the Girl with many events around the world, including Too Young to Wed, a haunting exhibition by photographer Stephanie Sinclair. IWHC, as co-chair of the U.S. chapter of Girls Not Brides: the Global Partnership to End Child Marriage, collaborated with organizations around the world to raise the profile of this issue.

A day before, on October 10, I participated in a small closed door meeting at the State Department in Washington, DC that included Secretary of State Hillary Clinton, Archbishop Desmond Tutu of the Elders, Dr. Babatunde Osotimehin, Executive Director of the UN Population Fund (UNFPA), and Luis Ubiñas, President of the Ford Foundation. It was a special thrill to meet Tutu – such a humble and inspiring man! Shortly thereafter, Secretary Clinton announced some welcomed steps, such as a USAID-funded project to get girls into schools in Bangladesh and a one-year program to keep girls in schools in the Democratic Republic of the Congo. Still, we had hoped for quicker and more decisive action from the U.S. Government – these girls should not and cannot wait! Other commitments were also announced on that day – $25 million from the Ford Foundation and $20 million from UNFPA to prevent child marriage, and $39 million from the MacArthur and Mastercard Foundation for girls’ education. There is still time for the U.S. government to do its part. We will keep pressing the Administration to provide the leadership and resources these girls needs to live healthy and just lives.

We’ve also received positive news from our partner and grantee MYSU – Mujer y Salud en Uruguay (Woman and Health in Uruguay). After a 12-year battle, the Uruguayan Congress passed a bill last week that will allow abortions on any ground in the first trimester of pregnancy, and President Mujica just signed it into law. True, the law continues to stigmatize abortion and contains odious provisions that will force women to “explain the circumstances that surrounded the conception…”(!) to their doctor, go before a hospital committee to hear about “alternatives to abortion,” and endure a five-day waiting period. Nevertheless, this is a very significant step in Latin America, where women still face severe legal restrictions to safe abortion except in Mexico City, Guyana, Cuba, and Puerto Rico. IWHC first gave a grant to MYSU for this work in 1999, and we have supported them steadfastly through the many twists and turns along the way. Two years ago, for example, a more liberal law passed the Uruguayan Senate, only to be vetoed at the last minute by then President Tabare. MYSU and their allies have their work cut out for them to make certain the new law is implemented in such a way that barriers to safe abortion are removed, not reinforced. Social and policy change does require patience and staying the course!

For more news, follow IWHC and me on Twitter at @IntlWomen and @francoisegirard, or go to our website www.iwhc.org

Best regards,

Thirty years later, I am coaching Mozambican reporters doing stories on illegal abortion in Mozambique.

Africa in 2012 is a world apart from Latin America in 1982 – but I find similarities between the stories of women here now, and there, then.

Now, as then, women who don’t want a pregnancy will do anything to interrupt it – even dangerous procedures. I just returned from Inhambane province, 500 kms North of Maputo. We interviewed a primary school teacher who introduced an 8 centimeter long root into her vagina, perforated the uterus, developed sepsis and required a hysterectomy. See her story here.

Now, as then, middle-class women can interrupt their pregnancies safely and discreetly. Poor women resort to gruesome methods and unscrupulous individuals perform atrocities on their bodies.

One big difference is Misoprostol. The pills, sold in Mozambican pharmacies as Cytotec with a prescription, or under the counter without one, have made pregnancy interruption much safer. That is, for urban, informed women who know about it and live near well-stocked pharmacies in the anonymity of towns.

For rural women like the teacher, there are virtually no safe options.

Every day, an average of six women are admitted in the clinics of Inhambane province, with complications from unsafe illegal abortion. In 2011, there were 2,300 cases, resulting in seven deaths. The numbers are similar in Mozambique’s other provinces. In 2011, hospitals in Maputo province admitted 9,400 women with complications from unsafe abortions. Of these, eight died.

These cases are just the tip of the iceberg.

In the rural areas, where 17 million of the 22 million population live, and only 7% of women use modern contraception, women with botched abortions have little chance of reaching a hospital in time to be saved. They die without being counted, the collateral cost of the country’s antiquated legislation from 1886.

This is about to change – as it recently changed in my home country, Uruguay. In September, a new law passed authorizing abortion in the first 12 weeks, although flawed and restrictive due to political compromises with conservative representatives.

In Mozambique, before the end of the year, the National Assembly should discuss a new law decriminalizing abortion, already approved by the Council of Ministers.

In fact, Mozambican central hospitals already provides safe abortion in some cases. Concerned with the number of deaths from unsafe abortion, Dr. Pascoal Mocumbi, a former health Minister and Prime Minister, allowed central hospitals to provide safe abortion in the mid-1990s.  But, because abortion is illegal according to the Penal Code, the Ministry of Health cannot inform women openly about this safe option.

Inhambane’s provincial hospital provides such services but few women know and uptake is very low.

I hope Mozambican women do not have to wait 30 years, like Uruguayans, for a law to protect their autonomy and their right to make a safe choice. A luta continua!

Mercedes Sayagues, a Uruguayan journalist, is a Knight Health Fellow in Mozambique.

Working on the funding bill for the State Department and U.S. foreign assistance programs, today the Senate Appropriations Committee repudiated the negative action recently taken in the House.  The overall funding levels in the Senate bill for family planning and reproductive health programs were set at $700 million (an increase of about $125 million from last year’s levels – in an attempt to make up for disproportionate cuts in the past).  And, rather than seeking to defund UNFPA, as the House bill does, the Senate committee included $44.5 million for reproductive health services in more than 140 countries.

In direct opposition to House action, the Senate Committee included a provision to prohibit a futurePresident from unilaterally imposing the Global Gag Rule. The amendment was offered by Senator Frank Lautenberg (D-NJ) – a stalwart supporter of reproductive rights – and passed by a vote of 18-12. Committee Democrats (with the exception of Senator Ben Nelson (D-NE), supported it and were joined by Republicans Susan Collins, Lisa Murkowski and Mark Kirk (by proxy, as he is absent from the Senate due to health issues). Please take a moment to call or email Senator Frank Lautenberg and thank him for his continued commitment to women and girls’ basic human right to access the information and services they need to promote their health and well-being.

Additional good news: the bill contains language to allow abortion services for Peace Corps volunteers in cases of rape, incest, and life endangerment of the woman.  This is progress of sorts – and if enacted would give Peace Corps volunteers the same right federal employees already have in other federal programs.

Next step is action by the full Senate – and then the House and Senate will need to work out differences between the two versions of their bills before sending to the President for signature into law.

But as important as it is to teach others this valuable skill, it’s just as important for us to make sure that every single person in our own organization is exposed to these vital tools.

That’s why this past Monday and Tuesday we held the first ever IWHC Staff AiP training right here in our NYC headquarters! During the training, just like in past AiP’s, we discussed key international agreements and why they matter, advocacy strategies, and messaging around the themes of comprehensive sexuality education and sexual and reproductive rights and health. There was a lot of information for staff to absorb and consider, but we also did some exercises and role plays to helps us think through various aspects of the work.

Akimbo contributors Lori Adelman and Audacia Ray at the United Nations Commission on the Status of Women:   

I personally was grateful to be able to attend the training, which until now I had helped provide support for, but never attended in full. I found it to be extremely useful for gaining a better understanding of the work of my colleague in International Policy (IP). I was fascinated by the intricate details of the UN infrastructure, and floored to find out that, althought the UN technically operates on consensus, countries often participate in negotiations via blocks, or groups of aligned countries. I was also pleased to spend time with my co-workers in such a setting, and felt it brought all of us a bit closer. Below, I’ve shared some of my colleague’s impressions as well.

Audacia Ray, Program Officer for Online Communications and Campaigns, said the following about her experience:

“Having provided support for the AiP trainings and meetings at the UN during the last couple of years at IWHC, it was really interesting to get a deeper perspective on how advocacy at the UN functions. Though the UN seems like a very large, very bureaucratic entity with many agencies and acronyms, most of the advocacy for our issues actually happens one-on-one and is very much about building relationships and knowledge.”

Kelly Castagnaro, Director of the IWHC Communications Program, said: “It was fascinating to learn about the different UN agreements related to women and how they can be used by advocates to forge change on the national level.  The UN is a big place and while governments have busy schedules and many agendas, advocating with government delegates on how they can support the health and rights of women and girls is within our reach.  In this type of advocacy, a thorough knowledge of relevant precedent language is essential, as are excellent communications skills.  At the end of the training, I felt that I had learned a lot but still had much to learn, particularly related to how UN agencies operate and carry forth the content of these agreements with national governments.  Mostly, I left with tremendous respect for and admiration of the many talented advocates around the world who spend countless days and nights at the UN on behalf of women and girls.”

Reporter Corinna Barnard scoured over 200 of the Wikileaked cables and found “nothing about political participation of women, their role in civil society or efforts to empower women and facilitate access to justice.” Although it’s true that there are still vast quantities of cables yet to read through, and although we definitely have proof that our governments do think about and act in the name of women’s rights—it’s clear that women and girls are not always given the priority they deserve on the world stage.

We can shift this conversation, but only if we use our voices to talk about women and girls in a meaningful way—which we have a chance to do right now. The International Protecting Girls by Preventing Child Marriage Bill was recently passed unanimously by the U.S. Senate, and now it’s on its way to the  House of Representatives for a vote. Now is the time to urge your Congressperson to stand up for women and girls by passing this bill to help end the devastating practice of child marriage. It’s simple to send a note to your representative, or you can sign an online petition here to show your support.

Let’s not be hypocrites. If we want our leaders to act, we need to act, too. Raise your voice to encourage more talk—and action!—toward a just and healthy life for every woman and girl.

While we hear a lot about the prevalence of violence against women, we hear little about the consequences.  Beyond being a gross violation of human rights, violence has demonstrable impacts on a woman’s health and her ability to meaningfully participate in her community.  Gender inequality and violence against women are also associated with a substantial number of new HIV infections among women. In Swaziland, which has one of the highest prevalence rates of HIV globally, one-third of girls have been subjected to sexual violence, with nearly half experiencing violence prior to the age of 18.  

IWHC’s  Board Chair, Brian Brink, published a piece in Friday’s  Mail and Guardian about how gender inequality and violence has helped to fuel the HIV/AIDS pandemic.  Despite rising infections in women and exemplary local programs, the world has a ways to go before the realities of women’s lives become the centerpiece of programs and policies. 

To find out more about policy responses to violence against women, read Seven Things the World Can Do to End Violence Against Women, published in collaboration with Women Won’t Wait, the World AIDS Campaign and the International AIDS Women’s Caucus. 

We have, of course, been in touch with our Pakistani partners at Aahung, and wanted to let you know that they are doing alright. Sheena Hadi, Aahung’s director, wrote this morning saying, “The last month has brought even more hardship to people in the country who were already facing far too much violence and poverty.  We are trying to do our best to support the flood relief efforts wherever possible through networks and personal donations.  I will definitely let you know if there is something IWHC can do, but your ongoing support is valued by the entire staff at Aahung.”

She also emphasized that, as in many disasters, the protection of women and girls has been pushed aside in favor of other needs—but that we need to continue working to protect and promote them, especially as flood waters continue to rise. Two UN organizations have stepped up to assist women and girls: The UNFPA has provided kits of reproductive health medicines and other vital tools to thousands of women, and UNICEF has prioritized the distribution of clean water kits to women-run households.

We will keep you updated on our friends at Aahung and on what you might be able to do to help the women of girls of Pakistan.

In recent years, the transition from girlhood to womanhood  has seemed to come faster, and has had everyone from gossip columnists to politicians abuzz. From sexualized kindergarteners on TLC’s “Toddlers and Tiaras” to horrific images and tragic stories of child brides in the news, the sexual maturity of young girls is in the spotlight. A new study out today complicates the issue: girls—at least in America—are hitting puberty earlier and earlier—some as young as seven years old. In the spirit of “protecting girlhood,” there’s been a lot of brouhaha over naming the culprit of early physical maturation of girls, with both obesity and environmental factors under scrutiny. But instead of pointing fingers, we need to face the facts and focus on the changing needs of girls in our lives and around the world. The New York Times briefly touched on this, saying, “Socially and emotionally, life can be difficult for a girl who has a child’s mind in a woman’s body and is not ready to deal with sexual advances from men and boys, or cope with her own hormone-spiked emotions and sexual impulses,” but neither the writer nor the experts interviewed suggested how we could prepare potentially confused girls to deal with these realities.

One of the most obvious things we need to offer to girls is early, age-appropriate, and comprehensive sexuality education. Regardless of when they hit puberty, children should know about their bodies and their rights. The urgency for such information is far greater when a girl is already menstruating and could be at risk for early pregnancy, or is having to negotiate sexual pressures, often from members of her family or community. The Netherlands is doing a fantastic job of educating youth on their bodies and sexual rights, and there are several other blueprints for how age-appropriate sexuality education can be achieved—but it’s becoming more apparent that the U.S. and countries around the world need to follow suit and make this an even greater priority.

Further, early puberty illuminates the crucial need to fight child marriage on a global scale. In Yemen, a man can legally have sex with a girl once she is “suitable for sexual intercourse” or—in other words—once she has reached puberty. While the latest study confirms that girls are hitting this benchmark earlier and earlier, it does not confirm their readiness to engage in sexual activity. IWHC’s fact sheet on child marriage explains how girls ages 14 and younger are especially vulnerable  to violations of their health and rights, rarely have capacity to give or withhold their consent, and are also more at-risk of contracting sexually transmitted infections (STIs), including HIV/AIDS. In light of this, I hope you’ll urge your Senator and State Representatives to support the Protecting Girls by Preventing Child Marriage Act.

People might not like the idea that little girls are, physically speaking, growing up faster—but that doesn’t mean we can afford to simply stick our heads in the ground, or focus only on how to stop early maturation. Puberty is scary and confusing at any age—and as girls face it earlier and earlier, it’s our responsibility to offer them any help we can.

Spain vs. Netherlands

Under a new law, teenage girls aged 16 and 17 can access abortion services in Spain without parental consent.

It’s been reported that the Netherlands has the lowest HIV transmission rate from sex and drug use in the world.