1 Comments on the strategy for: The Promotion of Sexual and Reproductive Health and Rights By Jens Byskov, DBL-Institute for Health Research and Development. 12.01 2006 Comments are in English as is the case for the document. Comments and statements can be referred to or used as desired for the final version of the strategy. ____________________________________________________________________ Background The UM web site introduces the document as based on a 2004 Government decision to develop a new strategy for Denmark’s support within the areas of population and health with a particular focus on women and the link and coordination between prevention of HIV/AIDS and Sexual and Reproductive Health and Rights (SRHR). This puts the document into a wider context than just SRHR as e.g. the Ministry of Foreign Affairs Health Sector Policy of 1995 remains valid in principle. A number of other strategies, guidelines and papers have since interpreted such policies or given new direction in the areas of health and population. These include amongst other documents on sector program development and financing, a discussion paper on the a Danish perspective concerning assistance to the Health Sector, area and cross cutting specific documents such as the Africa Policy as well as those on gender issues and HIV/AIDS. Poverty Reduction strategies have provided broader framework and new direction to development efforts, also within Health. The MDG and global focus The document is much tuned to getting its justification from and to assisting in achieving the Millennium Development Goals. These provide a direction for developments and include 3 goals for health outcomes among the total of 8 Goals. Reference is made to goals 3 for gender, 5 for maternal health and 6 for HIV/AIDS, malaria and other diseases. Goal 4 concerning reduction in child mortality could be included as well, as the document repeatedly argues the case for improved health of children as a necessary part of support for SRHR. MDG Targets and indicators within MDG 3,4,5 and 6 include a majority of health outcome measures, but fortunately also a number of output areas. The extensive reference to the MDG’s is important, but also an inherent weakness of the strategy as MDG’s do not easily translate into the most important output or assign concrete responsibilities to select the most important products (output, results) needed to achieve them or the underlying relevant activities and the input (resources, money) needed to produce them.   

2 This is illustrated in most chapters of the document through its reference to a large number of mainly international organizations, which are to carry the agenda of the strategy. Most of these organizations have many agendas to follow and there is a risk that some may just pay lip service to some of the most important aspects of this strategy. One must also be aware that they also have their own core agendas and are not necessarily interested in diluting such focus or risk contraction by effectively sharing with or delegating to others. Expectations of the strategy are carried on to national levels and to efforts within and across sectors into decentralized systems such as those at district level. The role, importance and even capability of current resource poor settings in setting priorities according to information and local values within a realistic resource envelope is inadequately realized especially in a document that puts so much effort on empowerment. Basing on such resources will be a guarantee for sustainable local development and provide an opportunity for a transparent and accountable increase of resource allocation to such settings. Such local capability will be further empowered if allocated supplementary resources. Organizations providing additional resources must then adapt their support according to local priorities and will probably have to accept local checks and balances to introduction of new global “one size fits all” programs and global paradigms. Values, involvement and sustainability The current document makes reference to documents such as those mentioned in the first section on the background for the strategy paper and may in many ways be seen to draw strong lines back to the main and still valid principles of Primary Health Care (PHC) in the Health Policy, which focuses on the guiding principles of focus on prevention, equity, appropriate technology, intersectoral collaboration and community participation. All these principles are strongly included in the document with increased present focus on multi stakeholder involvement, quality improvement, cost effectiveness and other value criteria (e.g. equity –  see above) as well as a stronger result oriented management and monitoring. The financial implications and sustainability have also gained importance, but are possibly covered by the broader human and other resource considerations and may not be intended to be very concrete at the level of a strategy document In other ways the document strongly promotes universal values, which were globally agreed in the 1994 International Conference on Population and Development in Cairo (ICPD). This document does support consistency by referring to this global agreement with proper references throughout the document to later confirmations, developments and set backs. It still, just as Primary Health Care, provides value based criteria for population and health development that have been globally agreed at the time and to our knowledge not been replaced by any similarly comprehensive and globally agreed frameworks. Such criteria have been challenged repeatedly by many governments, but there has not been sufficient agreement to remove them. Their further development and adaptation to current

3 day conditions and not least to regional, national, sub-national and the most local settings is necessary. The document also perfectly and openly displays the more controversial areas of the rights based approach such as the issues of abortion, that have to remain for open discussion even if not possible to solve in the short term. The other strength of the document is that it addresses support to the major large disadvantaged groups. Even more disadvantaged groups exist, e.g. disabled persons and as double disadvantaged such as disabled women, but these may also benefit if systems through the focus on SRHR are developed to identify and empower/support disadvantaged groups.  Any strategy aimed at improving conditions for and empowering major disadvantaged groups will address equity. It may be worth while to examine the Swedish policy for health development, which to my knowledge targets sexual and reproductive health as a core element, which strongly influences the whole policy. However, the necessary balance between rights based and needs based approaches must be  explicit. Rights based approaches in many areas at the same time may lead to conflict in the ever present limitations of resources and have to build in mechanisms to resolve such conflict. They tend to be more based on rights and ethics at the individual level. So care must be taken to attain a reasonable level of rights that do not compromise rights of others. They should therefore be adapted and combined with more needs based approaches focusing on needs of groups, though these may not provide as striking arguments for the urgency of addressing the problem. Optimally the two approaches can work together. It seems that the document recognizes this through repeated reference to alignment to sector wide approaches and Aid Agency coordination at all levels. Such compromises are very setting specific and if such approach is agreed the document could become more explicit in the way that the strategy could support sustainable improvements through empowerment of not only the disadvantaged groups, but also the decision making stakeholders at peripheral level, whether government, private or more civil society NGO and community based organizations.  It is therefore important to involve stakeholders that work through e.g. UN agencies and governments and those that directly support services, civil society and communities, thus combining both top down and bottom up approaches. Health and Education The document includes a number of elements of a strategy that could apply much more broadly as a currently most updated unifying and guiding document for cross cutting efforts in a number of sectors and giving e.g. the health sector a wider context to strengthen its contribution to a development that will be better targeted to optimizing its impact on health. In this respect the strategy will not only assist in improving SRHR and measure changes by a number of specific indicators, but may will also support developments in broader areas of health and development and thus contribute to improvements in indicators for progress for these areas as well – th   ough a direct attribution may not be possible. This therefore also illustrates a need for continuous

4 monitoring and evaluation of progress and relations supplemented by further in depth insight through targeted research. The reference to HIV/AIDS, Sexually transmitted infections, maternal health and child health in relation to SRHR raises some critical concerns arising from priority setting and management decisions based on evidence and values. Taking prevention and anti retroviral (ARV) treatment for HIV/AIDS, a rights based approach will claim that a known effective treatment must be made available for all in need. A more general needs based approach will caution, not only in terms of the need to achieve long term prevention and control of HIV transmission but also the need to not trade lives (and attainment of rights) across programs. MDG 6 includes HIV/AIDS and malaria. The risk is that all the resources needed to extend a life for an AIDS patient for 10 years will not only take sparse human and financial resources away from HIV prevention (and other aspects of SRHR) but also from early effective treatment and prevention of malaria in infants and thus fail to prevent one or likely more infant and child deaths. The argument can be carried to other balances necessary in working for SRHR and other areas of empowerment and development. There are no simple solutions and a need for a continuous process of compromise closest possible to the specific situations and involving representatives of the disadvantaged persons and communities. Some arguments in relation to ARV provision may not even be valid. E.g. the issue of minimizing stigma and thereby opportunity for HIV transmission prevention through ARV availability is a noble, but not proven argument. On the contrary, there are signs from both Kenya and Botswana (verbal statements and unpublished reports) that ARV does assist in decreasing stigma, but does not assist prevention as HIV infection seems to be increasingly considered an open and unavoidable risk of life that has to be accepted and can just be handled once AIDS develops. Within education the strategy also displays core areas for innovation and increased impact on SRHR. Life skills are mentioned and feed into the global debate on the focus for schooling. Newer educational approaches can make a difference such as a stronger targeting of school child action competence – an area where e.g. the Danish University of Education has research experience also from settings in Sub-Saharan Africa. The importance of ensuring school attendance and involvement of girls in such empowerment is crucial. At the same time parents must be actively involved in support of such initiatives if they are to become effective. Implications for general development issues The three main areas mentioned by the Danish Prime Minister in his address on 11.01 2006 in the open debate meeting in the Council for International Development Cooperation included (1) support to economic growth and better access to markets, (2) Good governance and (3) A healthier and better educated population and a sustainable environment.

5 The document is highly relevant as a strategy under item 3, but will also need to ensure its internal programmatic compliance within item 2, and will need the support emanating from growth of resources under item 1. Effective channels and coordination mechanisms for support and better achievement of SRHR already exist in the form of sector program support and cross cutting poverty reduction strategies. To reach an acceptable standard for SRHR in an acceptable time will also need development efforts to move further towards a long term support to civil society development and selected NGO’s and community based organizations. Such support must as far as possible be coordinated with government budget support to the poorest countries based on conditions agreed under item 2 and further including strengthening of national and sub-national priority setting, management and monitoring and evaluation. Such principle is well established in Danish national long term budget support to district and highest to the weakest districts as well as indirectly to poorer areas of the EU to support local standards of living and rights attainment in a locally defined sustainable development. The Danish advantages from globalization would make it logical to extend such conditional budget support to the selected main countries of collaboration. Conclusion The document provides: The most recent update on a Danish cross cutting approach to a strategy for Development assistance and will already in its current form be an important reference for targeting the assistance. A focus on SRHR, which illustrates an approach to systems development and empowerment, that can be a guide to all areas of sustainable social development. The highlighting of values based on past and present global agreements provides a strong guiding reference, which must be fully maintained in its final version. Important strategic guidance for Danish embassies and programs for all areas of assistance. The document can be further improved or supplemented in other documents and initiatives: Solutions to some contradictory elements and areas for necessary compromise within and outside the rights based approaches should be elaborated. Many of the inherent choices and compromises to be made between different criteria for priority setting for SRHR (and other social areas) are setting specific and can only reach a fully agreed and effective solution through processes at national and not least at sub-national levels. This necessity can be strengthened in the document.

6 A clearer and more explicit strategy is needed for assigning responsibility for achieving the goals and supporting overall MDG attainment through definition of necessary output and resources – budget support. The paper should further point to a need to translate its main stated principles into areas of international agency coordination, national and sectoral plans. The need for strengthened monitoring, evaluations and in depth insight from research should be more strongly included in the document in order to track, assist and as necessary redirect the more adaptable development approaches argued for.   Finally the SRHR strategy in documents presenting its final version, or in follow up documents should urge the Ministry of Foreign affairs to initiate a process of internal consensus building for aligning subsequent updates of the ministry’s sector and cross cutting policies and strategies for development according to the now set out general principles in the SRHR strategy.