As the third global symposium on health systems research draws to an end in Cape Town, on Thursday we had an exciting and energizing discussion in the session entitled “Gender and rights-oriented health systems research: methodological approaches and challenges”. It was realized that there are important sexual and reproductive health challenges at the health systems level but limited research is being done with a gender perspective. As Sharon Fonn from University of the Witwatersrand said, “The health system is the sea on which any program floats”. We were left hungry for more discussions.
This made me reflect on this topic that I am passionate about, that is, the issue of sexual and reproductive health and rights, with particular focus on women in sub Saharan Africa. In 1994, the landmark International Conference on Population and Development determined that access to sexual and reproductive health services and rights and access to family planning should be universal. It was ratified by 179 countries. Fast forward to 2014: It is alarming that currently, many women in this setting are unable to access basic sexual and reproductive health services. For example in Uganda, although the use of family planning has increased over the years, “Only 47% of the family planning needs of married women are being met”. We cannot even begin to talk about providing these services to adolescent girls, apparently this may tempt them to engage in early sexual activity (shaking my head). So, we continue to bury our heads in the sand.
Women continue to have their right to sexual and reproductive health services ignored for various reasons. These include patriarchal cultures that allow men to determine whether their wives should utilize these services or not. This has led to some women getting contraception stealthily, hence the preference for injections which leave no signs. Cultural issues also go deeper by making women deliver their children from home even when health facilities are available and accessible. This is one of the causes of obstetric fistula that is common in the continent, because when things go wrong during labour, women are encouraged to “be strong”, and by the time the decision is made (for them) to go to the health facility, it is too late. How you can be strong while death is knocking at your door beats my understanding. Lack of access to sexual and reproductive health services is also affected by other socio-demographics like low levels of education, the ‘holier than thou’ religious mongers, low socio-economic status, and others.
Further barriers come from the health infrastructure side, where sometimes the services may not be available at all or may be provided intermittently. In sub-Saharan Africa, the situation is often much worse for rural women, who face multiple health systems challenges when it comes to sexual and reproductive health. How can we say that sexual and reproductive health rights are recognized when health workers are delivering babies by candle light (unintended consequences of making candles-I’m sure that is not what the makers intended them to be used for, but perhaps Elton John feels ok about it). Maybe we should ensure that rural health facilities have scented candles, just so that everybody is comfortable. Worse still, they may not know that they have the right to make their own decisions regarding how many children they want and when; where to go for delivery; what type of contraception to take and when (many decisions are made by the wise in-laws), and many other related scenarios.
As we talk about people-centered health systems during and after the symposium, we need to ask ourselves how we can ensure that the rural woman in sub-Saharan Africa benefits, as we conduct our research. Let us put more focus on these rural women and these rural communities and develop locally relevant solutions. Women in rural areas need to have power over their lives, or all the talk and ICPD beyond 2014 will remain as nicely written words in documents that not many people ever read.
As Goran Tomson said this morning in another session – we have enough of NATO (No Action, Talk Only)!
 Report of the International Conference on Population and Development. 1994
 Uganda Bureau of Statistics (UBOS) and ICF International Inc. 2012. Uganda Demographic and Health Survey 2011. Kampala, Uganda: UBOS and Calverton, Maryland: ICF International Inc.