The integration of sexual and reproductive health and rights into universal health coverage: a FIGO perspective.

Universal health coverage (UHC) aims to make promotive, preventive, curative and rehabilitative health services available for the entire population. It ensures that quality healthcare services are controlled and regulated by governments, which are expected to subsidise the cost of provided services, making them available and affordable for the whole population regardless of socioeconomic status.[1] On 23 September 2019, UN Member States made a political agreement to include UHC aims at the national level by 2030.[2] A remarkable achievement in this regard was the integration into the UHC Declaration of sexual and reproductive health (SRH) services and SRH and rights (SRHR), based on International Conference on Population and Development and Beijing Platform for Action review documents. SRHR is a crucial component of human rights and health rights, and its incorporation into UHC enables individuals with diverse needs to make informed decisions regarding their reproductive health, sexuality, gender, consent, termination of pregnancy and sexual health.

The integration of SRH services – in the context of SRHR – into UHC is key to ensuring accessibility to high-quality services, especially among marginalised and impoverished communities. In the past decade, there has been a marked increase in the quality and availability of SRH services in some low- and middle-income countries (LMICs). The implementation of UHC will help to address several gaps that remain at service level: for example, ensuring access to quality services by disadvantaged groups; applying non-discrimination as a broader social policy; and securing financial protection.[3,4] Nevertheless, UHC faces challenges related to ethical dilemmas and public health principles owing to multiple weaknesses in healthcare systems that require tough trade-offs for policymakers.[5] The Ebola epidemic in western Africa and, more recently, the COVID-19 pandemic have revealed the need to strengthen health systems. The restricted capacity of health systems in African countries such as Guinea, Liberia and Sierra Leone also facilitated the rapid spread of Ebola in 2014. Consequently, remarkable efforts are required to increase the resilience of health systems to respond to potential pandemic threats.[6] Moreover, because of a lack of formal accountability mechanisms, some countries may face difficulties in addressing the ineffectiveness of essential health services, monitoring levels of coverage, distributing supplies and services to the most vulnerable and needy populations, as well as ensuring the effective use of medications and supplies.[7]

The International Federation of Gynecology and Obstetrics (FIGO), a leader and a global voice on women’s health, strongly believes that prioritising SRHR as part of national UHC agendas has far-reaching consequences such as improved health outcomes, women’s empowerment, gender equality, reduction of poverty, and improved educational level and employment.[8] SRHR is a guiding tool for the promotion of FIGO’s comprehensive clinical services, which is crucial as FIGO and its partners strive to help reduce maternal and reproductive morbidities and mortalities at a time when an estimated 25 million unsafe abortions take place every year.[9] In addition, in a recent study of 290,783 births from 54 LMICs, it was found that fewer than 50% of pregnant women initiated antenatal care within the first trimester as recommended by WHO. In total, 11.2% reached the WHO recommendation of a minimum of eight visits, while 60.6% achieved at least four contacts.[10] Approximately 214 million women of reproductive age who want to avoid pregnancy are not using a modern contraceptive method.[11] Furthermore, in 2020, for the first time, the number of deaths from cervical cancer will exceed maternal deaths.[12] FIGO – being fully cognisant of the burden of these problems on women’s empowerment, autonomy, productivity and gender parity – is adopting and advocating for SRHR and SRH services within UHC, as evidenced by its involvement in interventional projects to reduce SRH morbidity and mortality among underprivileged and marginalised populations (e.g. projects on safe abortion, postpartum haemorrhage and postpartum intrauterine device [IUD] insertion). FIGO’s Committee for Human Rights, Refugees and Violence Against Women ensures an SRHR perspective for FIGO’s outlook and services, with the inclusion of issues related to gender and gender-based violence (GBV), access to safe abortion and post-abortion care, as well as refugee health. Recommendations are provided for strategic planning to include those groups neglected by SRH services within UHC. Access of vulnerable individuals to SRH services can be context-specific and restricted by social, cultural and gender-related factors, making it crucial to address social determinants of health such as education, discrimination, poverty and gender inequality. Even in countries with high-quality SRH services, young individuals and underprivileged women who live in rural and remote areas face difficulties in accessing these services, which can be due to low literacy levels, gender-based and age-based discrimination and violence, fear of stigmatisation, and need for permission from the husband, parent or guardian.[13]

Working within an SRHR framework, and aiming to improve women’s health and rights in accordance with the Sustainable Development Goals (especially SDG3 and SDG5), FIGO collaborates with global federations such as the Federation of Arab Gynecology and Obstetrics Societies (FAGOS) and the African Federation of Obstetrics and Gynecology (AFOG), which includes the Eastern Mediterranean region. The collaborations pertain to family planning services, safe sex methods, access to safe abortion and post-abortion care, and protection from sexual violence among refugee populations: for example, Syrian refugees in the Middle East, Venezuelan refugees in Colombia, and Rohingyas displaced to Bangladesh. Furthermore, many of the 132 FIGO member societies operate and provide services in difficult contexts where women are marginalised, such as in humanitarian crisis situations and where there is discrimination against sexual preferences; and for female genital mutilation and forced child marriage, which place the health of adolescent and young women at risk.[14] Political and cultural contexts remain a major challenge for FIGO, which is working closely with local authorities through its national member societies towards amending and changing policies that help to promote women’s health and wellbeing – for example, through the Advocacy on Safe Abortion and the Postpartum IUD projects.

The experience of countries that have integrated SRH services into UHC shows an increase in accessibility of services for marginalised populations.[15] The health of women and adolescents across the life course remains the main aim of FIGO, which has adopted an SRHR perspective to widen the scope and coverage of healthcare provision in order to facilitate the concept of “leaving no one behind”. Integration of SRHR within UHC means that the availability, accessibility and affordability of quality services, medications and skilled medical personnel must be ensured, and components of comprehensive sexual education included. The provision of scientifically and medically accurate information will allow individuals greater freedom of choice regarding their SRH[13,16,17] and strengthen SRHR in the path towards achievement of UHC.