Anand Grover UN Special Rapporteur on the Right to Health Lima, Peru, 13 June 2013

1. Perspectives on the Cairo Consensus: Realising the Right to Sexual and Reproductive Health in the Andean Region Anand Grover UN Special Rapporteur on the Right to Health Lima, Peru, 13 June 2013

2. The right to health • Recognised in a number of international instruments • Primary basis is article 12 of the International Covenant on Economic, Social and Cultural Rights • Normative framework elaborated in General Comment 14 of the Committee on Economic, Social and Cultural Rights

3. Framework for realising the right to health • The right to health is not a right to be healthy, but a right to have equal choices and opportunities in relation to health • Contains both freedoms (e.g. autonomy, informed consent) and entitlements (e.g. access to health care facilities, goods and services) • Includes the underlying determinants of health (e.g. clean water, adequate food and shelter, clean environment, social equity)

4. Framework for realising the right to health Health goods, services and facilities must be made • Available: Numbers must be sufficient • Accessible: Economically and physically • Acceptable: Culturally • Good Quality: No compromise on it

5. Framework for realising the right to health In respect of the Right to health, States have the obligations to:- • Respect – refrain from directly violating (e.g. discrimination, criminalization, forced treatment) • Protect – prevent third parties from violating • Fulfil – facilitate, provide and promote conditions that allow full realisation of the right (e.g. providing health services, goods and facilities, providing information)

6. Framework for realising the right to health • Principles of non-discrimination and equality are central to the right to health • Special attention must be paid to the needs of vulnerable groups (e.g. children, low-income groups, ethnic minorities, sexual minorities, women) • Policies must be evidence-based • Policies must be made with the participation of affected communities

7. Framework for realising the right to health • Progressive realisation • States may progressively realise the right to health, but must immediately take steps and should avoid taking retrogressive measures • Core obligations • Some obligations must be realised immediately and cannot be derogated from, including obligations of non-discrimination and protection of vulnerable groups • Immediate obligations • Some measures, such as removing punitive criminal laws or disseminating information, involve no resource burden so should be undertaken immediately

8. Sexual and Reproductive Health under the Right to Health Framework • General Comment 14 recognises that the right to health includes sexual and reproductive health • Convention on the Elimination of All Forms of Discrimination against Women • Article 12. Right of women to equal access to health services, including sexual and reproductive health services • Article 16. Right to decide freely on the number and spacing of one’s children • Convention on the Rights of the Child • States must provide family planning education and services

9. Sexual and Reproductive Health under the Right to Health Framework • 1994 Cairo Programme of Action on Population and Development • Principle 4: Advancing gender equality and equity and the empowerment of women, and the elimination of all kinds of violence against women, and ensuring women's ability to control their own fertility, are cornerstones of population and development- related programmes.  • Principle 8: States should take all appropriate measures to ensure, on a basis of equality of men and women, universal access to health-care services, including those related to sexual and reproductive health care.

10. Sexual and Reproductive Health under the Right to Health Framework • 1995 Beijing Declaration and Platform for Action • Para. 96: Women have the right to control and decide freely and responsibly on matters related to their sexuality • Millennium Development Goals • Target 5A: Reduce by three-quarters the maternal mortality rate • Target 5B: Achieve universal access to reproductive health

11. Sexual and Reproductive Health Report – Education and Information • Education and information is critical to the full realisation of the right to health • Important for the reducing the incidence of maternal mortality, HIV/AIDS and sexually transmitted diseases • Important for making informed choices about sexual and reproductive health • Important for reducing gender-based stereotypes and stigma against sexual minorities • Important for reducing rates of adolescent pregnancy • States have an obligation to promote, not restrict, access to accurate and evidence-based information

12. Adolescents&the right to health • Adolescents boys and girls need sex education is schoolsabout sexual & reproductive health, family planning and contraception • Sex in education in school not available in most countries • State cannot abdicate the responsibility andcannot foist it on families as family responsibility (marriage at 16 but no sex education) • In case of pregnancy advice adolescent girls cannot access them because they don’t have legal capacity under civil codes • Male dominated societies: forced sex resulting in increased pregnancies of adolescents leading to increased suicides • If pregnancy results from rape even in a stable relationship, the adolescent cannot access abortion services

13. Sexual and Reproductive Health Report – Contraception and Family Planning • Restricting access to contraception and family planning disempowers women and restricts their ability to make autonomous and informed choices about their sexual and reproductive health • Also increases the risk of maternal and infant morbidity and mortality by restricting access to an important preventive and primary health service • World Bank estimates that voluntary family planning reduces the risk of maternal mortality by 25 to 40% • Family planning reduces the risk of unsafe abortion and perinatal transmission of HIV

14. Sexual and Reproductive Health Report – Criminalization of Abortion • Unsafe abortion counts for 13% of maternal deaths globally • Availability of legal, safe options key determinant of whether women seek illegal, unsafe options • Disproportionate impact on poor, less educated women or women from marginalised groups • Wealthier and better educated women have the option of travelling to receive abortions, and are more able to access professional services illegally • Poorer and less educated women more likely to self-induce abortion or seek untrained providers

15. Sexual and Reproductive Health Report • Criminalization of sexual and reproductive health remains an ongoing challenge globally • 2011 Report of the UN Special Rapporteur on the Right to Health to the General Assembly focused on criminal laws and sexual and reproductive health • “The causal relationship between the gender stereotyping, discrimination, and marginalization of women and girls and [restrictions on] their enjoyment of their right to sexual and reproductive health is well documented” (para. 17).

16. Sexual and Reproductive Health Report – Criminalization of Abortion • Criminalization of abortion infringes women’s dignity and autonomy by severely restricting decision-making by women in respect of their sexual and reproductive health (para. 21) • Stigmais direct consequences to the woman • Reporting on abortion in accordance with public health law: As good as criminalization • Also generates poor physical and mental health outcomes, • Results in preventable deaths, morbidity, ill health • Affected women are prevented from seeking care and are instead pushed into the criminal justice system • Complications of pregnancy and childbirth are not adequately treated due to fear of harming foetus

17. Sexual and Reproductive Health – Control over Pregnancy • Many states criminalize certain conduct while pregnant • Including consumption of alcohol or illicit drugs, HIV transmission, sexual intercourse, miscarriage and stillbirth, and failing to follow a doctor’s orders • These laws stigmatize women and violate their dignity by treating them as objects rather than subjects • Also discourage women from seeking health care and testing for fear of prosecution, or from fully disclosing relevant information to health care workers

18. Sexual and Reproductive Health Report • Importantly, criminalization of sexual and reproductive health is not justified for either public morality or public health reasons • Public morality cannot justify human rights violations • Public health measures must be evidence-based and proportionate • Criminalization of sexual and reproductive health is not effective from a public health perspective and violates the dignity of women from a human rights perspective

19. Sexual and Reproductive Health in the Andean Context • Abortion is criminalized in all Andean states except to save the mother’s life • Four states also allow exception for the physical and mental health of mother (may be limited by seriousness) • Two states also allow exception for rape (may be limited to vulnerable groups such as mentally ill persons) • One state also allows exception for foetal deformities • Despite this, abortion rates are high – indicates recourse to illegal abortion • E.g. in 2006 Peruvian women were estimated to have on average two abortions over reproductive lifetime (totalling 370,000 abortions/year) • Unmet need for contraception contributes to high rates of abortion

20. Maternal Mortality • Source: World Health Organization/UNICEF/UNFPA/World Bank/UN Population Division Maternal Mortality Estimation Inter-Agency Group

21. Unmet Need for Contraception • Source: UNECLAC 2007 unless otherwise noted. Refers to percentages of women who are not using contraception despite stating an intention to not have further children.

22. Adolescent Pregnancies • Source: World Bank unless otherwise noted

23. Sexual and Reproductive Health in the Andean Context • Unsafe abortions one of the major causes of maternal mortality regionally • E.g. Peru – One in seven maternal deaths caused by abortion-related complications (Amnesty 2009), one of top five causesof maternal morbidity • E.g. Bolivia – Principal causes of maternal deaths are complications of childbirth and unsafe abortion, including haemorrhages and infections (UNICEF 2012) • World Health Organization estimates that 20% of maternal deaths in Latin America and Caribbean region are caused by unsafe abortion, compared to global average of 13%

24. Regional Jurisprudence • KL v. Peru (Human Rights Committee) • Refusal to provide abortion to KL, a 17 year old whose foetus had a fatal birth defect that also caused a risk to KL’s life and health • Violation of the right to be free from torture and cruel, inhuman and degrading treatment, and right to privacy • LC v. Peru (CEDAW Committee) • LC, a girl who became pregnant from rape, attempted to commit suicide by jumping off balcony, doctors refused to give her emergency care for fear of harming foetus • Violation of equal access to health care, right to equality, right to freely decide on number and spacing of children • Inter-American Commission held thematic hearings on sexual and reproductive health in Bolivia, Brazil and Argentina in March 2013

25. Conclusions • Andean region has improved in many health indicators but many challenges remain for meeting MDG and Cairo goals • Criminalisation of sexual and reproductive health is a barrier to meeting these goals, as well as a violation of the right to health in respect ofinformation, education, health care services and decriminalization • States should remove restrictions on accessing sexual and reproductive health information, services, goods and facilities and provide information, services, goods and facilities and safe options for reproductive health care • Particular attention should be paid to teenage girls as a vulnerable group