Advancing sexual and reproductive health and rights in low- and middle-income countries: implications for the post-2015 global development agenda.

The papers and commentaries in this special issue illuminate progress made by low- and middle-income countries towards implementation of the Programme of Action (PoA) agreed by 179 countries during the International Conference on Population and Development in Cairo in 1994. The PoA presents a path-breaking sexual and reproductive health and rights (SRHR) framework for global and national population and health policies. While progress towards implementation has been made at global, regional and national levels, continuing and new challenges require that high priority be given to SRHR for all, particularly women and girls, during the remaining months of the millennium development goals and in the United Nations post-2015 development agenda. This paper highlights three critical gaps, raised in other papers: inequalities in access to sexual and reproductive health (SRH) information and services; the widespread need to improve SRH services to meet public health, human rights and medical ethics standards for quality of care; and the absence or inadequate use of accountability mechanisms to track and remedy the other two. We discuss priority actions to achieve equality, quality and accountability in SRHR policies, programmes and services, especially those that should be included in the post-2015 development agenda.

Use of human rights to meet the unmet need for family planning.

In this report, we describe how human rights can help to shape laws, policies, programmes, and projects in relation to contraceptive information and services. Applying a human rights perspective and recognising the International Conference on Population and Development and Millennium Development Goal commitments to universal access to reproductive health including family planning, we support measurement of unmet need for family planning that encompasses more groups than has been the case until recently. We outline how human rights can be used to identify, reduce, and eliminate barriers to accessing contraception; the ways in which human rights can enhance laws and policies; and governments' legal obligations in relation to contraceptive information and services. We underline the crucial importance of accountability of states and identify some of the priorities for making family planning available that are mandated by human rights.

Towards a sexual ethics of rights and responsibilities.

Sexual rights as human rights encompass individual freedoms and social entitlements. Both depend for their realisation on equally important social responsibilities on the part of individuals, couples, families, other social institutions, and the State. The principle that all persons must understand their own sexual rights and responsibilities and respect the equal rights of others - particularly those of their sexual partners - informs our interpretation of the ethical basis of sexual behaviours. We propose a conceptual framework for defining a sexual ethics of equal rights and responsibilities pertaining to five dimensions of sexual behaviour: 1) sexual relationships and the right to choose one's partner; 2) sexual expression and the right to seek pleasure; 3) sexual consequences and the right to cooperation from one's partner; 4) sexual harm and the right to protection; and 5) sexual health and the right to information, education and health services. We suggest that the ethical principles presented here pertaining to sexual partnerships should be incorporated into sexuality education, sexual and reproductive health services, and social policies aimed at promoting the health and rights of all persons regardless of gender, marital status, sexual orientation, religion, ethnicity and other personal or group identities.

Women's groups and professional organizations in advocacy for sexual and reproductive health and rights.

After the International Conference on Population and Development (ICPD) in 1994 and the Fourth World Conference on Women in 1995, sexual and reproductive health and rights (SRHR) have improved in many countries, and been supported by awareness raised by women's health advocates, increasingly by youth groups, and also by organizations of health professionals. In the HIV/AIDS area, involvement of organizations of people living with HIV/AIDS is crucial to improve prevention and care. However, after victories during the 1990s, combating opposition by social and political conservatives has taken up much energy in recent years. Continuous advocacy to broaden acceptance of the fundamental importance of SRHR, their role in meeting the Millennium Development Goals, and the imperative to increase funding, is essential.

Back to basics: HIV/AIDS belongs with sexual and reproductive health.

The Programme of Action of the International Conference on Population and Development (ICPD) held in Cairo in 1994 offers a comprehensive framework for achieving sexual and reproductive health and rights, including the prevention and treatment of HIV/AIDS, and for advancing other development goals. The United Nations Millennium Development Goals now incorporate a target of universal access to sexual and reproductive health within the goal of improving maternal health, but combating HIV remains a separate project with malaria and tuberculosis. We present a brief history of key decisions made by WHO, other United Nations' agencies, the United Nations Millennium Project and major donors that have led to the separation of HIV/AIDS from its logical programmatic base in sexual and reproductive health and rights. This fragmentation does a disservice to the achievement of both sets of goals and objectives. In urging a return to the original ICPD construct as a framework for action, we call for renewed leadership commitment, investment in health systems to deliver comprehensive sexual and reproductive health services, including HIV/AIDS prevention and treatment, comprehensive youth programmes, streamlined country strategies and donor support. All investments in research, policies and programmes should build systematically on the natural synergies inherent in the ICPD model to maximize their effectiveness and efficiency and to strengthen the capacity of health systems to deliver universally accessible sexual and reproductive health information and services.

Fertility regulation and reproductive health in the Millennium Development Goals: the search for a perfect indicator.

Although several key elements of sexual and reproductive health are included in the United Nations Millennium Development Goals, a measure of women's capacity to regulate their fertility safely and effectively is missing. We considered the usefulness of 3 pairs of indicators in monitoring this component of reproductive health: contraceptive prevalence and total fertility; unmet need for contraception and unplanned births; and unsafe abortion and abortion mortality. A single measure of contraceptive use is insufficient. The risks women face from unplanned births and unsafe abortion should also be incorporated into the monitoring process, either directly within the Millennium Development Goals framework or as a parallel effort by reporting governments and other agencies.