Investing in sexual and reproductive health and rights of women and girls to reach HIV and UHC goals Each year, 200 million women have an unmet need for modern contraception, more than 45 million women receive inadequate or no antenatal care, 1 million women and girls acquire HIV, and 25 million abortions are unsafe. 1,2 These numbers illustrate huge gaps in access to basic sexual and reproductive health services, posing serious challenges to achieving universal health coverage (UHC) by 2030. These gaps in access are heightened by reduced financing for international development, and highlight the importance and urgency of strengthening linkages between HIV and sexual and reproductive health and rights (SRHR) programmes. The Guttmacher-Lancet Commission 3 on SRHR highlights the need for all women and girls to be able to access an integrated package of SRHR interventions, which includes HIV prevention, treatment, and care. Although this integrated approach has been promoted for two decades and was the cornerstone of national AIDS responses in the 1980s, the progress since then to move national health systems from vertical programmes to more integrated HIV and SRHR policies, financing, and service delivery, has been insufficient. 4 Supporting countries to implement strategies that enable UHC, including sustainable approaches to advance universal access to integrated sexual and reproductive health and HIV services, must be a priority for the global health community. Three key strategies are required to address multiple SRHR and HIV needs, improve access to essential health services, and ensure financial protection so no woman or girl is left behind. The first key strategy involves engaging, empowering, and building individual, community, and collective capacities among women and girls. These capacities must build upon the knowledge and lived experiences of women and girls, 5 and should include initiatives to promote, support, and safeguard community engagement. To design and implement both effective and acceptable sexual and reproductive health interventions, community norms arising from women's lived realities and expressed priorities need to be understood. Patriarchal norms that prevent good sexual and reproductive health-such as non-consensual, age-disparate sexual relationships, violence against women, and disregard for women's rights-need to be addressed. Woman-centred inter ventions are possible through education and empowerment, to equalise power dynamics in intimate, family, community, and health-care relationships. 6 WHO recommends the provision of evidence-based interventions on self-efficacy, and empowerment for maximising and fulfilling the SRHR of women and girls, including women living with HIV, in all their diversity. 5 These interventions are crucial to reduce stigma, disrespect, violence, and lack of safety faced by many women and girls within and outside the health-care sector. 1 The second key strategy involves securing accountable leadership, governance, and financing from governments and international agencies. Annually, 100 million people face extreme poverty due to health-care costs. 7 Although the share of out-of-pocket expenditures has been decreasing overall, households remain the main source of funding for reproductive, maternal, neonatal, and child health, and pay for about half of these expenditures in some low-income and middle-income countries. 7,8 High health-care need in socioeconomically disadvantaged women and girls is often inversely related to their access to financial resources. Thus, public financing of integrated SRH and HIV services is vital so that they are accessible at the point of delivery. 1 It is entirely feasible to use national and global financing mechanisms to reorient existing, vertical health systems and services to implement comprehensive, integrated, user-centred SRHR and HIV programmes. 1,4 To date, fragmented evaluation and minimal accountability of integrated SRHR and HIV approaches have resulted in scarce evidence on the health, economic, and social benefits arising from these linkages. 4 Investments are needed in implementation research, particularly to understand and inform the scaling up of evidence-informed, multisectoral approaches that have proven effective in small-scale pilots. This research can assist in the implementation of health service delivery that promotes and supports principles of gender equality, human rights, and woman-centred care.
Narasimhan, M., Pillay, Y., García, P. J., Allotey, P., Gorna, R., Welbourn, A., … Haufiku, B. (2018, October 1). Investing in sexual and reproductive health and rights of women and girls to reach HIV and UHC goals. The Lancet Global Health. Elsevier Ltd. https://doi.org/10.1016/S2214-109X(18)30316-4