This intervention was originally published at the United Nations Department For Economic and Social Affairs – Sustainable Development.
The week of May 17, 2021, brought together a multi-stakeholder group of experts from academia, civil society, government experts participating in their own capacity, and UN system technical colleagues to inform the High Level Political Forum (HLPF) thematic reviews.
Sachini Perera presented the intervention on behalf of the Women’s Major Group and RESURJ. This intervention reiterates that states have a responsibility to uphold the right to health for all people. It is critical that member states fulfil their commitments to health rights under the 2030 Agenda, various other multilateral processes such as the CPD and UHC, and their human rights obligations including those emanating from CEDAW, CRPD and ICESCR.
Introduction
The Covid-19 pandemic has laid bare the urgent need for governments to prioritize policies and programs that guarantee universal access to the full spectrum of health services, including to vaccines and other essential medicines, and to rights-based sexual and reproductive health. The continuing and multiplying effects of colonialism and neoliberal patriarchy on the right to health and on access to health services are apparent given the inequity of vaccine distribution between the Global North and South and vaccine inaccessibility between and within countries. Under-resourcing and privatizing health systems and social protection are showing devastating results during the pandemic including innumerable preventable deaths around the world, especially but not only in the Global South.
Women and LGBTIQ people are already marginalized in our access to healthcare and we have seen this exacerbate during the pandemic, with groups like migrants, refugees, IDPs, stateless people, sex workers, domestic workers, workers empolyed in global value chains bearing the brunt of it. Gender-based violence, including online and ICT-facilitated violence, has increased during the COVID-19 pandemic, especially during lockdowns, with dire consequences for the physical and mental health and wellbeing of women, girls and LGBTIQ people.
We take this opportunity to reiterate that states have a responsibility to uphold the right to health for all people. It is critical that member states fulfil their commitments to health rights under the 2030 Agenda, various other multilateral processes such as the CPD and UHC, and their human rights obligations including those emanating from CEDAW, CRPD and ICESCR.
Structural challenges
Health for all remains our clarion call for SDG 3, now more urgent and relevant than ever before. Challenges in responding to Covid-19 have made it clear that there needs to be greater investment in strengthening health systems but that doing it through privatization or Public Private Partnerships (PPPs) that advantage profit over rights create health systems that follow a freemium model; the free and public health services are underfunded and underdeveloped, and you need to pay out of pocket if you want more and better options. To understand this in the context of the ongoing pandemic, a recent study found that a “10% increase in private health expenditure relates to a 4.3% increase in COVID-19 cases and a 4.9% increase in COVID-19 related mortality.” A link between privatization and mortality that we cannot ignore.
We call on states to halt and reverse the privatization of social protection and health systems to ensure they remain a public good and will reach those most in need. Private health schemes and service charges as well as financing models that only cover basic health interventions, are impeding women and girls living in poverty to access essential health services while leaving important economic and social costs to people and their families in the context of health care. The medicalized approaches continue to dominate the health responses, so principles such as civil society participation and human rights-based approaches must be put in place.
Poorly regulated financialized globalization and tax avoidance by the private sector further exacerbates inequities depriving us from resources essential for the provision of health services. States must initiate progressive tax systems, curb Illicit financial flows, address tax evasions by the private sector and resist trade agreements that impact access to medicines and commodities, pushing out low-cost generic producers, increasing the financial burden on marginalized groups.
Other challenges impeding progress on SDG 3 include populist nationalism, weakening of multilateralism, conservative backlash against ‘gender ideology’, corporatization of food systems, lack of meaningful access to the internet and ICTs, and environmental degradation and the climate crisis that affect social and environmental determinants of health.
In many of our countries we’ve also seen a criminal justice approach to a public health crisis, with fines, penalties and imprisonment being introduced through the use of criminal law related to public health as well as by activating emergency laws that have increased police and military power; “implementing fines, court summons, and arresting those who do not comply with them, from mandatory mask wearing to quarantine.”
Vaccine justice
While the privatization and cost of healthcare and medicine remain a key concern for the right to health, vaccines occupy a liminal space in this landscape because while essential, they are not profitable given that in most instances a person needs only one or two doses in their lifetime. Therefore, the incentives and funding/subsidies for discovering and producing vaccines are led by governments so that pharmaceutical companies can maintain a satisfactory profit margin, including by securing copyrights and patents. This means vaccines are usually produced through public private partnerships (PPP’s) and often result in extremely inequitable distribution and access. As noted by the World Health Organization (WHO) Director General, “Even as they speak the language of equitable access, some countries and companies continue to prioritize bilateral deals, going around COVAX, driving up prices and attempting to jump to the front of the queue. This is wrong.”
The Committee on Economic, Social and Cultural Rights (CESCR) recently clarified the duty of states in relation to vaccines; “States have therefore a duty of international cooperation and assistance to ensure access to vaccines for COVID-19 wherever needed, including by using their voting rights as members of different international institutions or organizations, including regional integration organizations such as the European Union.” We reiterate the need for more countries to co-sponsor the proposal for a TRIPS waiver on the Covid-19 vaccine patent, and extend their cooperation and assistance to the transfer of technology, know-how and skills in line with their commitments under SDG 17.
Health services
Accessibility, affordability, acceptability and inequity remain key core challenges in delivering and receiving health services. These challenges have further exacerbated during the pandemic.
As of April 2021, approximately 90% of countries have reported some type of disruption to their health services as a result of the COVID-19 pandemic. At the start of the pandemic, UNFPA predicted the impact Covid-19 could have on sexual and reproductive health, including that a possible 47 million women in low- and middle-income countries would not be able to access modern contraceptives as well as the possibility of an additional 7 million unintended pregnancies. In the past year we’ve witnessed and experienced this impact on health services. Critical health services for women, including mental health care, and sexual and reproductive services including safe abortion care and contraceptive provision, treatment for malnutrition, and HIV treatment, care and support, being among the most heavily impacted. We also note with concern that in many countries, what is identified to be “essential” in terms of healthcare and services during Covid-19 do not include those critical for women, LGBTIQ people and key populations, such as abortion, condoms, or harm reduction treatment.
At the most recent Commission on Population Development, the negotiated outcome reconfirmed that sexual and reproductive health is central to the realization of social justice, to the achievement of global, regional and national commitments for sustainable development, and that universal access to sexual and reproductive health and reproductive rights and services must be part of an effective public health response to the COVID-19 pandemic. We support and uplift this while flagging that sexual rights should not be excluded or subsumed.
As noted by the Women’s Major Group, “sexual and reproductive health and reproductive rights are integral to the realization of the right of everyone to the enjoyment of the highest attainable standard of physical and mental health and comprehensive sexual and reproductive health-care services must have the interrelated and essential elements of availability, accessibility, acceptability, equity, efficacy, and quality”.
Challenges to women and girls accessing safe abortion:
- Lack of it in general, due to criminalization, stigmatization and other reasons
- Being excluded from UHC packages
- Shortage of trained healthcare providers
- Biased, judgmental and unwilling service providers
- Privatization of abortion and post-abortion care
- Unsafe abortion continues to be a major contributor to maternal mortality.
Adolescent pregnancy
According to UNFPA, 20,000 girls under the age of 18 give birth every day in developing countries. In developing regions, nearly half of pregnancies among adolescent girls and women aged 15-19 are unintended. Adolescent pregnancy poses grave risks including the risk of dying in childbirth, premature labor, complications during delivery, low birthweight, and infant mortality, as well as morbidities, especially vesico-vaginal fistula.
The pandemic could increase this rate given school closures, increased rates of gbv and dv, lack of access to SRH commodities like contraception, lack of access to CSE.
Impacts of adolescent pregnancy and early childbearing include:
- Disruptions to and ending of education
- Limiting opportunities for employment, forced to do precarious and/or low-paid work
Recommendations
We have the following recommendations for governments at the national and sub-national levels:
COVID-19
- Treat COVID-19 vaccines as a global public good. Abandon vaccine nationalism, the stockpiling of vaccines, and support the TRIPS COVID-19 waiver.
- Apply an intersectional, gender-responsive and human rights-based approach to address the impacts of COVID-19
- Ensure that people living in communities affected by armed conflict, refugees, internally displaced peoples, migrants, or stateless people get speedy access to COVID-19 vaccines, testing, and treatment.
- Take measure/action to address the negative impact that the COVID-19 pandemic has had in the educational sector, and more specifically in access to comprehensive sexuality education, and consider this in response and recovery plans by ensuring that all adolescents, in particular adolescent girls have access to CSE to be better equipped to make informed decisions over their bodies, relationships, and life course.
Universal Health Coverage (UHC) and Health Systems
- Deliver UHC through public health systems ending and reversing privatization of health systems, as well as public-private-partnerships to deliver health services.
- Provide adequate financial, human, and infrastructure resources towards achieving UHC and integrate sexual and reproductive health care services into the provision of primary healthcare and UHC packages.
- Commit to coordinated, sustainable, long-term funding for health systems strengthening that applies a gender lens to disease detection, prevention, and treatment.
- Address the significant barriers that prevent women, girls, and non-binary people from accessing health care, including user fees, out-of-pocket payments, physical distance, stigma, and legal restrictions.
- Guarantee the labor rights of health workers at all levels, including community health workers, and ensure their safety through the provision of personal protective equipment and safe working environments.
- Cease targeting healthcare facilities in the context of armed conflicts, per the obligations of all states under international human rights and humanitarian law. Cease all activities that prevent people in conflict-affected areas from accessing their rights to health.
Sexual and Reproductive Health and Rights
- Ensure the availability and provision of sexual and reproductive health-care services, incorporate them as essential services, and prioritize these services for all women and girls within recovery plans as well as contingency planning for future pandemics.
- Safeguard essential sexual and reproductive health and rights (SRHR), including access to services, supplies, and information. Critical care includes contraceptives, safe abortion and post-abortion care antiretroviral therapy, diagnosis and treatment of sexually transmitted infections, pre-and post-exposure prophylaxis, emergency obstetric care, and newborn and maternal care. Do not let emergency responses be used to divert resources or justify targeted restrictions or regulations that limit access to SRHR.
- Challenge harmful norms and gender inequality which hinder fulfilment of the sexual and reproductive health and rights of adolescents, young people, women, LBTI+ women, and gender non-conforming people.
- Ensure that all survivors of sexual and gender-based violence have access to a comprehensive package of sexual and reproductive health care services, including post-exposure prophylaxis, emergency contraception, abortion, and mental health services. Ensure that these services are considered essential services in times of crisis.
- Recognize abortion as a human right and remove all punitive laws and measures, including those for healthcare providers. Ensure the accessibility of abortion services, including through the provision of services, facilities and personnel trained on safe abortion and post-abortion care and self-managed medical abortion. In times of crisis, declare abortion as an essential service and implement telemedicine and other online tools to fulfill the human right to abortion.
- Guarantee access to comprehensive sexuality education and youth-responsive sexual and reproductive health information and services to ensure that adolescents and young people can make informed choices free from discrimination, coercion or violence.
- Recognize and work to eliminate period poverty, through removal of taxes from menstrual products, as well as providing these products free of charge to women and adolescent girls who do not have access, such as those living in poverty or detention.
- Provide emergency obstetric services, especially in rural and peri-urban areas, as a human right and in order to prevent obstetric fistula. Guarantee free healthcare services for all women and girls living with obstetric fistula.
- Conduct outreach campaigns to reach women and girls living with obstetric fistula in order to reduce stigma and connect them with healthcare services.
- Ensure the implementation of the Minimum Initial Service Package (MISP) at the onset of every humanitarian crisis.
- Integrate and train young people in the implementation of MISP in crisis situations.
- End impunity for sexual and gender-based violence as international crimes.