ICPD + 15: Debating Health Care When It’s No Longer “Business as usual”

Carolina Austria

ICPD+15 is an opportunity to reflect on public health systems as core social institutions in the face of market failures and inadequacies, including corporate ineptitude in meeting the needs of ordinary people.

The raging debate on health care in the United States appears to be all
about the cost of services, the burden of shouldering the expense and deciding
whether or not the state has a role in addressing the inevitable conflict over
the balance of benefits and burdens. But the drama unfolding in town halls
across the United States – with the rest of the global village watching — demonstrates
that this time, the stakes go way beyond the usual bureaucratic or even
technocratic challenges in health service delivery.

Conceiving health as a right makes a profound difference not only in how
people claim individual entitlements to health and standards of care, but also
highlights the role of public institutions both in service provision and as
purveyors of common interests. When the right to health belongs to everyone
regardless of race, class, sex and religion, confronting the issue of social
inequality is inevitable. Fifteen years ago, the International
Conference on Population and Development (ICPD) brought a special focus on sexual
and reproductive health
which unlike other fields of health is the most implicated
by socio-economic and cultural factors. Religious traditions are invoked
against women’s empowerment and decision making over their reproductive well
being. The same conservatism bars the education of young people on matters vital
to their sexual and reproductive health. And while there are signs of progress
as in the recent cases of Mexico (when the city passed an ordinance
decriminalizing early term termination of pregnancy) and India (where the
courts struck down the penal law against sodomy), archaic laws all over the
world continue to perpetuate discrimination primarily against women and
homosexuals. Indeed gender is a
significant marker of social and economic vulnerability
and its impact is visible
from inequalities of access to health care to the gender differences that
dictate people’s social positions as users and producers of health care.

Fifteen years later, many of the original opponents of the ICPD’s
framework of health as human rights can be expected to voice the same
antagonism against the ICPD, specifically its challenges to gender-based
inequality, traditional gender roles coupled with its positive frame on
sexuality. But while the opposition seems the same, the context has changed quite
radically. For one, while the US debacle over its health systems is easily dismissed
as a localized phenomenon, it’s also important to draw lessons from the
experience given that decades ago (long before the ICPD), many developing
nations embraced health sector “reforms” founded on the same faith in market
principles to cure the various ills of their health systems and they show no signs
of rethinking such strategies.

In fact even before the ICPD, pundits were already sounding alarm bells
about the free market principles behind many health sector reform initiatives. In
1994, William
Hsiao
called “marketization as the illusory magic pill” that developing
nations were depending on to alleviate their underfunded and inefficient public
sector dominated health systems. Yet as several countries’ experiences later
proved, the push
towards marketization did not occur outside a geo-political vacuum
.
From Mexico to Nigeria, the Caribbean and the Philippines, HSR traces its origins
from Structural Adjustment Programs which prescribed cut-backs on government
spending including social services.
Budget cuts affected marginalized
sectors but poor women bore the brunt as providers of health care. Majority of
community-based health workers in the global south are women volunteers or
minimally paid workers. In the meantime, key health professions such as nursing
and care giving grew even more focused on job markets abroad. A case in point
is the Philippines where remittances from overseas workers have been the
single-most determining factor of continuing economic survival. Thus it may be
argued (and it has been argued) that catering to the first world market in
health serves the economy. As in the Philippines, qualified
health professionals from Ghana, Malawi, Zambia and South Africa often seek
employment abroad
. In 2002 the World Health Organization (WHO) warned that
the trend of migration of nurses from third world countries would seriously
jeopardize the ability of many health systems to function. Indeed shortages
of skilled professionals such as nurses with midwifery skills, are now linked
to gaps in the provision of maternal, newborn and child health
.

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ICPD+15 is an opportunity to reflect on public
health systems as core social institutions
in the face of market failures
and inadequacies, including corporate ineptitude in safeguarding the finances
ordinary people depend upon for their health and well being. As Lynn Freedman points
out, health systems are part of the very fabric of social and civic life –
because they function at the interface between people and the structures of
power that shape their broader society. Health as a right is premised on social
justice.

Commentary Health Systems

How We Are Failing Women and Girls in Humanitarian Emergencies

Jamie J. Hagen

“Protecting the sexual and reproductive rights of women and girls in crisis settings is essential and a matter of human rights, but it is also complicated and unsustainable without a change in the way humanitarian assistance is provided and funded,” states a recently published report from the UN Population Fund.

Every day, 507 women and adolescent girls die due to a lack of reproductive health services in humanitarian emergencies. There are now 13 million displaced refugees globally. This number will only continue to grow as more people seek refuge from war and violence.

In addition to this growing refugee population, there is an ever-increasing population of internally displaced people: about 38 million in 2014, equaling 30,000 per day. These individuals fleeing conflict within their own country spend an average of 17 years displaced from their home relying on international humanitarian assistance. Although the international community first recognized providing reproductive health services as a human right with widespread economic and social benefits 20 years ago, barriers remain to meeting these needs for the 25 million women and girls living in emergency settings.

A report from the UN Population Fund (UNFPA), titled Shelter From the Storm: A Transformative Agenda for Women and Girls in a Crisis-Prone World, urges new directions in financing for sexual and reproductive health to address this problem.

“Protecting the sexual and reproductive rights of women and girls in crisis settings is essential and a matter of human rights, but it is also complicated and unsustainable without a change in the way humanitarian assistance is provided and funded,” states the report.

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Two critical ways for the global community to begin making progress include, as the report notes, increasing the international community’s focus on the availability and accessibility of safe abortion and post-abortion care, and cultivating a culture of preparedness and prevention when it comes to providing a full range of such services in communities prior to any crisis. 

Access to Safe Abortion as a Human Right

An oft-cited 1999 UNFPA report estimates that 25 to 50 percent of maternal deaths in refugee settings are due to complications of unsafe abortions. (Little research has been done in the past two decades to learn more about this crisis.) This is a startling statistic, yet abortion remains politicized and difficult for non-governmental organizations and leaders to talk about in the international arena, let alone fund.

Few displaced women are in a position to demand access to abortion or organize to advocate for these services. Societal forces are a large part of this disenfranchisement, including pressure from family and the broader community to bring a pregnancy to term to replace lost family or to hide a pregnancy that is a result of rape, which can increase the stigma they are facing. In addition, clinics in most crisis settings are not outfitted with the necessary medical equipment to provide safe abortion care or even to address complications of abortion. Also, many organizations receiving international funding to provide relief to refugees are religiously affiliated and do not offer reproductive health care, including abortion, according to a report about safe abortion for refugees.

As a result, research specifically addressing the state of abortion and post-abortion care in conflict zones often is neglected, creating a gap in information around this specific program area.

Sandra Krause, director of Reproductive Health at the Women’s Refugee Commission, explained to Rewire that, according to a 2012-2014 Global Evaluation from the Inter-Agency Working Group on Reproductive Health in Crises (IAWG), access to post-abortion care in crisis settings has expanded since 2004 but “comprehensive abortion care—in particular, safe abortion care,” is still lacking. The IAWG has since formed a working group to address this gap.

However, the results of that working group are unknown, and much of this work remains unfunded. On a hopeful note, Krause said that she believes the working group will create a sea change in the conversation around funding safe abortion access in humanitarian emergencies. “We did just receive some funding to update the global guidelines for reproductive health and humanitarian settings to better integrate safe abortion care,” she added.

Economic Case for Funding Reproductive Care Services

In addition to recognizing these services as a human right, the UNFPA report points to obstetric care, safe abortion and post-abortion care, and services for those who experience gender-based violence as keys to achieving sustainable development. There are measurable economic impacts from denying these services to women and girls.

“It prevents girls from being able to go to school, it prevents girls and women from accessing education more generally, and seeking higher education. It pulls women out of the workforce and makes them unable to provide for their families and for themselves,” Katherine Mayall, a global advocacy adviser at the Center for Reproductive Rights, told Rewire.

“There is a strong economic case to be made for meeting the reproductive health needs of a country’s population in humanitarian emergencies,” added Kade Finnoff, an economics professor at the University of Massachusetts. “In lower-income countries where many humanitarian emergencies occur, we now have empirical studies that document the economic impact to individuals and local economies.”

One study of Ghana and Bangladesh about the impact of increased access to reproductive health services found that improved access to family planning services led to “improved birth spacing” and an increase in women’s earnings and participation in paid employment. Further, children of women with access to family planning were better educated than those without these services. Another study of Nigeria found, “reproductive health is a panacea towards reversing the stalled socio-economic growth of Nigeria as evident from the linkage between reproductive health and development.”

A long-term strategic focus on providing sexual and reproductive health services could also allow non-governmental organizations to increase their support for prevention and preparedness before a humanitarian emergency.

As the UNFPA report notes, “Humanitarian funding is mainly directed towards the response to crisis, with relatively little directed to prevention and preparedness.” This lack of preparation often exacerbates already devastating situations, as we’re seeing now in countries affected by the Zika virus. Some government leaders in these affected nations are advising their citizens not to get pregnant for fear that their fetuses will develop a life-threatening anomaly. But many of these same countries don’t have the health-care systems in place to assist the women in need of contraception or abortion care, because of restrictive anti-choice laws.

Ultimately, meeting the needs of every community requires a holistic approach that includes support for prevention and preparedness as well as emergency services.

Cultivating a Local Response

IAWG encourages all communities to implement the Minimum Initial Service Package (MISP) for reproductive health, which is a “life-saving” set of guidelines “to be implemented at the onset of every humanitarian crisis,” the website reads. “It forms the starting point for reproductive health programming and should be sustained and built upon with comprehensive reproductive health services throughout protracted crises and recovery.” For example, a MISP checklist includes a form with sections on how to gather information about the demographics of a humanitarian setting, how to prevent sexual violence and respond to the need of survivors, how to reduce the transmission of HIV, and how to prevent excess maternal and newborn morbidity and mortality. And a yes/no checklist fosters the development of a weekly monitoring initiative at the onset of a response and then tapers down to a monthly review of the status of reproductive health-care services in the humanitarian setting.

“We know in every crisis women and girls are going to have these priority needs, even if it’s in New York City,” said Krause. “Pregnant women are going to need emergency obstetric care because of the breakdown in civil society in cities. There is always an increase in risk for sexual violence and so women are going to need access to care. A certain percentage of women who are pregnant are going to have emergency complications. Newborn care is essential.”

Some local communities are already focusing on prevention and preparedness. “There are some wonderful efforts—led by displaced communities themselves—to address these issues, such as the Adolescent Reproductive Health Network (ARHN) on the Thai-Burma border and Association for Refugees with Disabilities in Uganda,” noted IAWG researcher Sarah Chynoweth. Both organizations work on issues often overlooked in emergency situations.

Rewire reported on the work of ARHN to meet the needs of adolescent refugees, such as providing condoms, peer sex education, and birth control pills. The UN Human Rights Council has recognized the Association for Refugees with Disabilities in Uganda as an example of good practices for allowing refugees living with disabilities to advocate on their own behalf.

Chynoweth emphasized the importance of focusing on those who are particularly marginalized when preparing for emergency response and outreach. “Displaced adolescents, people with disabilities, LGBTQ individuals, and sex workers are particularly vulnerable to sexual violence and exploitation, and they also have specific [sexual and reproductive health] needs. We can’t just keep ‘doing business as usual’—targeted outreach must be conducted to engage these groups, something which humanitarian agencies often neglect.”

As the UNFPA report and other researchers have shown, the best way to provide for immediate and long-term support for sexual and reproductive health services is to fund both global and local initiatives aimed at spurring sweeping improvements in the lives of women and girls.

Analysis Abortion

In Our Own Hands: What U.S. Women Can Learn from Self-Use of Medication Abortion Worldwide

Francine Coeytaux & Leila Hessini

There is much we can learn from our sisters in the Global South who, rather than trying to gain access to services that all too often do not exist or fail to treat them well, are obtaining pills to induce abortion and taking them at home without seeing a health provider.

Correction: A version of this article incorrectly noted that “Misoprostol is typically sold in tablets of 200 mcg; four tablets are taken by mouth to initiate an early abortion, followed by four more 12 hours later if required.” In fact, Misoprostol is typically sold in tablets of 200 mcg; four tablets can be taken by mouth to initiate an early abortion, followed by four more pills every three hours for a maximum of three doses. We regret the error.

Every day in the United States, abortion is under attack. Even when the news is positive, as in the recent dismissal by the Supreme Court of an Oklahoma law effectively banning medication abortion, we are still faced with the immediate and long-term implications of anti-choice groups and legislators systematically eliminating the health services women need.

There is much, however, that we can learn from our sisters in the Global South who have become active agents in securing their own reproductive health and autonomy. Women living in countries where abortion is legally or socially restricted have come up with a creative way to meet their needs: Rather than trying to gain access to services that all too often do not exist or fail to treat them well, they are obtaining pills—primarily misoprostol, also known as Cytotec—from pharmacists or informal markets and taking them at home without ever seeing a health provider. Because misoprostol is safe and effective, the use of pills to end pregnancy without formal medical guidance has significantly increased access to safe abortion for many women, especially poor, rural, and young women who are chronically under-served. And it allows women to be in control of the process.

Women in the United States have also been taking matters into their own hands. Over the past several years, there have been reports of home use of misoprostol by immigrants from countries where such use is more common practice. And recent articles describing the severe restrictions being imposed on abortion services in Texas attest to the fact that women who can no longer access clinic-based services are going to Mexico to obtain misoprostol, where it is available in pharmacies without a prescription. Given the rapidly dwindling access to abortion providers in large swaths of the United States, this practice is likely to increase.

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But because the drug distribution system in the United States is well regulated, gaining access to the pills is more difficult than in countries in the Global South. And obtaining information about the correct use of misoprostol for abortion can also be challenging, particularly in states where abortion is stigmatized and providing information is outright illegal. There is a lot we can learn from the solid body of evidence and experience from across the globe to increase public knowledge about the correct and safe use of various abortion pills and to ensure women’s access to quality products even in extremely restrictive settings.

Misoprostol and Women’s Agency

Women have been having abortions since time immemorial. The criminalization of abortion, however, is a more recent phenomenon, dating back to the 19th century, and supported by patriarchal social norms linked to female domesticity and motherhood, and a desire to control female sexuality.

In this context, women’s self-care is nothing new. Women have been fighting systems designed to limit their rights and protect the status quo for centuries, and those women who are most likely to be ignored by health systems have advanced some of the most innovative strategies for meeting their own needs.

One key advance has been abortion with pills, also known as medication abortion. Misoprostol, a pill available over-the-counter in many countries, provides a safe, low-cost, and easy-to-use method to terminate early pregnancies. In fact, self-use of misoprostol for abortion began in the 1980s, when women in Brazil, living under very restrictive abortion laws, realized they could take advantage of the contraindications of an otherwise readily available drug. The label on Cytotec (the trade name for misoprostol), a drug sold over-the-counter in Brazil to treat gastric ulcers, included a warning that it might induce abortion in pregnant women. Recognizing that this could serve their needs when faced with an unwanted pregnancy, women in Brazil began to use it and passed on their knowledge through word-of mouth, woman-to-woman. Since then, word has spread widely across borders and continents, and we now have global evidence that misoprostol is being used by women in many countries where abortion is restricted, including the United States.

Since this discovery by women of the “other use” of misoprostol, much research has been done to prove the safety and efficacy of misoprostol for abortion. Misoprostol is very effective in the termination of early pregnancies—up to nine weeks—and has an efficacy rate of 85 percent. Numerous studies have shown that women can use this life-saving drug safely and effectively by themselves, provided they have accurate information about its use. Misoprostol is typically sold in tablets of 200 mcg; four tablets can be taken by mouth to initiate an early abortion, followed by four more pills every three hours for a maximum of three doses. (Gynuity Health Projects and Women on Waves have posted clear guidelines for how to use misoprostol on their websites.) When combined with another drug—mifepristone—the efficacy of complete abortion approaches 98 percent. But while mifepristone followed by misoprostol is now the “gold standard” in countries where medication abortion is available, its use is limited for self-care because mifepristone is only registered in countries where abortion is legal.

Sharing Accurate and Trusted Information

So what tools do women in the United States need to safely and successfully terminate an unintended pregnancy on their own? To begin, women need:

  • Accurate information about misoprostol—its efficacy, safety, and how its use can enable women to be active agents in securing their own reproductive health and autonomy.

  • Trusted networks of friends, family, health professionals, and others who can be relied on to provide accurate information.

  • Access to affordable supplies of quality misoprostol (and/or other safe abortion pills, such as mifepristone).

  • Access to back-up health care and support should they need or want it.

Imparting information about the correct use of misoprostol for abortion and how to obtain the pills can be challenging, particularly in places where abortion is stigmatized and/or outright illegal. Successful approaches that have been developed in other countries where abortion is restricted include:

  • Ensuring access to medication abortion information and drugs over the internet. Women on Web provides virtual counseling and mail delivery of medication abortion in countries where it is not accessible.

  • Demystifying and democratizing medication abortion by sharing information with women where they work, reside, and socialize. In Nepal, information is shared at women’s hair salons, factories where they live and work, and during soap operas aired over the radio.

  • Training community health workers to distribute medication abortion information and pills, thus reaching a wider range of women. In Kenya and Ethiopia, research has shown that community health workers are often a first and trusted access point for women.

  • Sharing women’s knowledge and expertise related to abortion. In the Philippines and Mexico, networks have been created to share women’s knowledge and provide support to others.

  • Creating hotlines to share information about multiple uses of misoprostol. Such hotlines—often used by young women who may prefer anonymity—have been set up in countries where abortion is restricted, like Chile, Ecuador, and Indonesia.

  • Using mHealth technologies to deliver information to women on medication abortion. In South Africa, Ipas is partnering with a technology-based solutions company to send free, informational SMS text messages to women who have chosen to have a medication abortion and want to receive support and follow-up information.

  • Establishing women-centered pharmacies where medication abortion is available and affordable. The Women’s Promotion Center in Tanzania set up its own pharmacy due to the lack of distribution sites in that country.

  • Educating journalists to document the harms of legal and social restrictions on abortion. In Nicaragua, a prize is awarded annually to journalists and social communication students for outstanding writing on the topic of abortion.

Adapting These Strategies for the United States

Many of these strategies could be adapted to assist women in the United States to take advantage of the benefits offered by misoprostol: its simplicity of use, its low cost, and, most important, the fact that women can take it themselves, without medical assistance. There are many opportunities for reproductive health and rights advocates to come together to ensure that women in the United States who use misoprostol (or other abortion pills) do so safely and effectively. Misoprostol has the potential to reduce the barriers to abortion care that we face in the United States today by facilitating women’s agency and autonomy.

The lessons from our sisters who have created networks of knowledge around misoprostol are there for us to learn from; the evidence on its efficacy is in. Are we ready to use these tools in the United States to give women what they need—to take matters into their own hands?