Sexual and Reproductive Health and Rights in Public Health Education

1. Repoliticizing Sexual & Reproductive Health & RightsA transformative framework: beyond ICPD and the MDGsLangkawi 2010 Sexual and Reproductive Health and Rights in Public Health Education  PASCALE ALLOTEY SIMONE DINIZ JOCELYN DEJONG SHARON FONN SOFIA GRUSKIN THÉRÈSE DELVAUX

2. Aims: share our concerns about the current status of sexual and reproductive heath and rights education in PH • Issues of social justice and inequalities have taken a back seat to more mainstream (de) politicized agendas • Politics, advocacy and activism cannot be separated from the ‘objective’ evidence • Brief overview of the key challenges facing SRHR today that should be addressed through the education of the health workforce: 3 case studies (Middle East, South Africa and Brazil)

3. Introduction • SRH is an area of need of both clinical practice and public health • SRH generates strong opinions steeped in social values, ideology, religion and morality • Cairo and Beijing legitimized SRHR perspectives, broadening the focus (infant mortality, pop growth) • The momentum for SRHR waxes and wanes depending on competing priorities and lobbies • The urgency for a workforce that is sensitized to these critical components of SRH can not be overstated • Capacity is required in technical skills, research, policy formulation and advocacy

4. Brief overview of the key challenges facing education of the health workforce. • A case study approach: institutions were purposively chosen based on the regions of practice or expertise of the authors • The content of the programs was analyzed and is reported based on the broad themes identified (Yin 2009). • We provide a critical analysis of the broader contextual factors that support or hinder education in SRHR.

5. Activism and public health education • Public health has its roots in social activism • In some countries, the social justice and rights ethos remains central to the development of schools of public health • Despite its roots in social justice, public health education in most countries is currently overwhelmingly technocratic • Most training programs address SRH in some form, but most focus on biomedical risk centered approaches • Near absence of strategies to address gender and ethnic inequities that are an important part of negotiating SR relationships and identities

6. Case study 1: Sexual and Reproductive Health Education in the Middle East • As in many regions, in the Middle East and North Africa SRH field has lost momentum since ICPD • Redirected political priorities, reduced donor funding for a comprehensive approach, fragmentation of the larger SRH constituency into different interest groups • Interlinkages between the various SRH fields, and active engagement between NGOs, advocates, researchers and policymakers was more evident at that time than it has been during the last decade • Lack of an institutionalization for capacity building in reproductive health in a sustainable manner

7. Short courses • Being short courses, however, they are vulnerable to the vagaries of donor funding, limited long-term sustainability • Social Research Center at the American University of Cairo (Ford Foundation) - once a year, in 2010 it was offered for the 12th time. • Strong focus on social determinants of reproductive health in the region, inclusion of gender and rights perspectives, a critique of existing information and providing a general introduction to main research methods used in SRH. • 5 main blocks: reproductive health paradigm, understanding RH dimensions, concepts and measurements, policy approaches and implications of RH for research and service delivery

8. Short courses • Part of the Transforming health systems: Gender and rights in RH (WHO) • Two-week regional short course offered at Ahfad University for Women in Sudan • Focuses on integrating gender and rights into RH services. • The course, which is taught in English, is open to up to 25 regional participants with backgrounds in gender, rights, policy and health. • Information is not available about graduates of these programs and any evaluation of the program is not published on the websites.

9. University programs • Much of the impetus for reform of medical education to pay greater attention to gender issues and SRH has originated by external agencies • Most public health programs are within medical schools, a biomedical approach, focused on disease • Reproductive Health Working Group (1988): annual meeting, valuable opportunity for capacity-building and networking in a region with many political divisions

10. Increasing debate and awareness about the need for a “public health workforce” in the region and discussion of what competencies such a workforce should command • Attention to the social determinants of health and to a rights perspective has been central to some of those larger debates - may be a new funding area, perhaps superseding reproductive health. • Need for a critical assessment in this region, joined with global initiatives, to reinvigorate the SRH field as an integrated field, not a collection of separate issues

11. Case study 2: Sexual and Reproductive Health Education in South Africa – a perspective from University of Witwatersrand • The School of Public Health, University of Witwatersrand in Johannesburg South Africa has a more than 20-year history of working in reproductive health. Post-apartheid transition • By 1997, a three week curriculum, entitled Transforming Health Systems: Gender and Rights in Reproductive Health, had been developed and field-tested in South Africa. • Tensions between a long history of programme specific, vertical, interventions – necessary because of the sheer enormity of health crises – and a focus on general health care system that start at a very low base.

12. The success of the program was recognised by the World Health Organization (WHO) and from among competitive applicants, four regional training centres were selected to adapt and host the training. • A 500 page step by step manual was published by WHO in 2001 • In the world, over 1,300 participants directly, and thousands on programs derived from that curriculum • Longevity and impact: WSPH offered this course for over 10 years and now parts of the course are incorporated into the teaching of Wits medical doctors, in the Masters of Public Health degree and the MSc in Epidemiology and Biostatistics.

13. However the focus of training currently undertaken in the Master of Public Health remains that of health systems development. • Gender equity is clearly evident as a theme, short courses periodically still offer a focus on women’s health. • However a review of the degree as seen from a more traditional stance – that of looking for a programmatic approach to maternal health or family planning would find it lacking. • The School of Public Health has chosen to define and defend the line of a systems approach

14. Case study 3: Sexual and Reproductive Health in PH Education in Brazil • In the 70 and 80s, as part of the political resistance to the military dictatorship (1964-1984) there was of a a strong movement for health rights (health party) • Most PH education programs come from this period, and the Brazilian association of these programs (Abrasco) was created in 1979. • As a result of the activism, health was defined in the 1988 Brazilian Constitution as “a right of every citizen and a State duty”, and the Brazilian public, universal health system (SUS) was created • Private sector (23%) little regulation, + SUS • Gender and Health working group in Abrasco (1994). • Boom in Gender studies, 2/3 production in SRHR.

15. Among the 23 most important programs, SRH is under “Gender and Health” • 1984 (pre-SUS) Women’s Comprehensive Health Program, a broad agenda (RH, SH, mental health, occupational health, violence etc) • Short courses in coalitions of several PH teaching institutions helped mainstreaming the field • Teaching reflects the limits of the political and legal context. Brazilian public health training is very SUS-oriented • SUS: universal access: fertility rate 1.8, high contraceptive use, condom use, abortion is very restrictive (provided in the private sector).

16. The use of the concept of gender in health varies and is sometimes just a descriptive substitution of the word “sex” for “gender” (especially in epidemiology). • Many of the most innovative training and service provision are ignited by activism (funding very scarce now). Transgender care: PH training? • Formal higher education follows it, often years later. Women’s health, HIV/AIDS, violence against women are examples • SRH dissociated from maternal health • High medicalization and depolitization of maternal health (“maternal-infantilism”), heteronormative, specially on Family Health Program, main PH strategy • Training PH X training service providers in SRH

17. Random reflections from the Brazilian case • The right to not have and to have children (1980s) – reproductive as part of sexual • SRHR separated from maternal care – the most de-politicized part of all (church, Family Health Program, maternal-infantilism) PPP and IUDs and abortion, condoms • Integrality (comprehensiveness) Bio, social, psycho health/prevention and treatment/all ages/ SUS principle • Men’s comprehensive health program (2008) chronic diseases, sexual health, violence • De-politization – power relations – women x men, women x health providers, women x institutions etc • Skilled birth care: episiotomy 80%, c-section 45% (85% in private), oxytocin 80%, alone (law?). Effective, safe, humane • We need to generate the evidence we need – and teach it - a political and scientific challenge / alliances

18. Complexities in SRHR education

19. Challenges • The extent to which the content of sexual and reproductive health education can be politicized clearly depends largely on the context • There are however some global trends. • Recent advocacy has attempted to forge stronger links between traditional public health education and the approach driven by social justice, equity and human rights • Objection to any move away from the technocratic approach • Erosion of academic freedom is also a real threat in some countries and a real danger in others • Current global health debates strongly favour programmatic foci (maternal health, family planning, abortion services) as these are perhaps more resilient and are clearly preferred by funding agencies

20. A number of issues remain open to discussion: • Is there an ideal qualification to work in SRHR? • What are the problems in our current approaches to SRHR education? • Does the technocratic, competency based model produce a ‘competent’ SRHR professional? • Do we need a shift in our approaches to SRHR education?