The Report

1. By Sivananthi Thanenthiran and Sai Jyothirmai RacherlaAsian-Pacific Resource & Research Centre for Women (ARROW)

2. The Report • The Asian-Pacific Resource & Research Centre for Women (ARROW) is deeply concerned about monitoring international documents such as the ICPD PoA and the BPfA to ensure government accountability to the international commitments that they have made. • 2009 marked the 15th year of implementation of the ICPD PoA and it is critical to evaluate progress at this juncture as the PoA had identified 2015 as the target date for achievements.

3. The Report • This ICPD+15 monitoring report spans 80 indicators across 12 countries in Asia (China, Thailand, Vietnam, Laos, Cambodia, Malaysia, Indonesia, the Philippines, Nepal, Bangladesh, Pakistan and India) with the support of 22 national partners. • In the 80 indicators, we have divided equal attention to, reproductive health, reproductive rights, sexual health and sexual rights.

4. FINDINGS: CONTRACEPTION • Total fertility rates have been declining steeply in all 12 countries (2008) but are still high in Pakistan (4) Cambodia (3.4), Laos (3.6). • Total fertility rates compared to wanted fertility rates, are consistently higher for women living in rural areas, mountainous areas, lowest education quintile and lowest wealth quintiles. • Women who have less forms of power at their disposal face greater inequities of fertility control, even when they desire it. • The same pattern in seen in CPR and unmet need.

5. FINDINGS: CONTRACEPTION • Moderate CPRs, except in China(90.2), but low usage of modern methods are seen in Cambodia (27.2), Laos (35), Malaysia (29.8), Philippines (33.4); even Vietnam records a drop (78.5 CPR but only 56.7 for modern methods) • The ICPD promise of range of contraceptive methods to women and informed choice still seems distant to many women (e.g. high CPR countries like China - 2 main methods IUD and sterilisation; Vietnam - IUD & traditional methods); provider bias towards one method is seen in many countries: sterilisation in India; injectables in Indonesia; ocps & sterilisation in Thailand.

6. FINDINGS: CONTRACEPTION • Informed choice on contraception methods and side-effects have not been emphasised in service provision; but a key factor in addressing the causes of unmet need in AP such as concerns about side-effects, health consequences and inconvenience of methods of contraception as well as non-use of contraception due to opposition. • Male contraception still remains at very low levels, although condoms offer dual protection against pregnancy and disease, despite the context of AIDS/HIV. Condom usage is highest in Pakistan (22.97% of all contraceptive methods), stands at 9-10% in Nepal, Malaysia and India; and stands lowest 1-2% in Indonesia, Laos and Thailand. • Male contraception is nowhere near the desired ideal of having both men and women sharing equal responsibility over SRH decisions as couples.

7. FINDINGS: CONTRACEPTION • The definition of unmet need, and programmes that aim to fulfill unmet need need to be cognizant of the fact that unmet need in East and Southeast asia (except Philippines and Cambodia) does not include unmarried women; unmet need does not take into account unmet need for STI prevention; work must also take into account changing mindsets on fertility desires. • Again women with lower or no education, poor women, women who lived in remote, hard-to-reach areas had less access to contraception, and hence less control over their fertility compared to their educated, wealthier, urban counterparts.

8. FINDINGS: PREGNANCY & CHILDBIRTH-RELATED MORTALITY & MORBIDITY • MMR is high in India, Pakistan, Nepal, Bangladesh (reduced), Laos, Cambodia and Indonesia. • The ICPD target - MMR below 100 and only Malaysia and China have accomplished this. • Progress can only be sufficiently monitored if we know what the baseline is. Different numbers through national, WHO/UNICEF/UNFPA, UNDP sources. For purposes of cross-country comparison we use the WHO/UNICEF/UNFPA data. • Variations within the national MMR: sub-regionally e.g. India (UP, Bihar, Jharkhand, Orissa, Madhya Pradesh, Rajasthan); China (western provinces) • Lifetime risk of maternal death is lowest in China (1 in 1300) and highest in Nepal (1 in 31)

9. FINDINGS: PREGNANCY & CHILDBIRTH-RELATED MORTALITY & MORBIDITY • Interventions that prevent maternal deaths include access to emergency obstetric care (EmOC), skilled attendants at birth and post-partum care. • Access to comprehensive EmOC and basic EmOC is part of the UN process indicators however not included in current MDG reporting. • Skilled attendants at birth - ICPD target was 80% - only achieved in China (97.8%), Malaysia (100%), Thailand (97.2%) and Vietnam (87.7%) and not in the other 8 countries. South Asia shows a poorer compliance in both provision of EmOC and skilled attendants at birth. • Professionalization of midwifery, and increased number of births with a skilled attendant, backed by facilities providing EmOC was associated with a declining MMR. • Post-partum care is also critical - 25-33% of all maternal deaths are caused by obstetric haemorrhage generally occurring postpartum I.e 24 hours - 2 days after delivery.

10. FINDINGS: PREGNANCY & CHILDBIRTH-RELATED MORTALITY & MORBIDITY • Interventions that promote maternal health include access to antenatal care. • Of the 12 countries, Thailand (98%), Indonesia (92%), Vietnam (91%), China (90%), the Philippines (88%), Malaysia (79%) and India (74%) have at least 75% coverage. • It is worth noting that the Philippines (70%) and Indonesia (80%) of at least 4 visits for antenatal care, yet the Philippines’ MMR is 230 while Indonesia’s MMR is 420. The observation that antenatal care has poor predictive value for maternal deaths holds true here. • Antenatal care coverage is poor in South Asia.

11. FINDINGS: PREGNANCY & CHILDBIRTH-RELATED MORTALITY & MORBIDITY • An estimated 300 million women, or a quarter of the women in the developing world - are suffering from the consequences of complications during pregnancy. • Maternal morbidity accounts for nearly 31 million disability-adjusted life years lost annually. • Obstetric fistula and uterine prolapse are 2 common morbidities. • Fistula often occurs in first pregnancies of young wives in early marriages who lack education and access to services. • Prolapse often occurs in higher-parous women. • Current interventions focus on medical treatment but sufferers of fistula and prolapse also need counselling and support services.

12. FINDINGS:ADOLESCENT PREGNANCIES • Adolescent fertility, chracterised by births to women under age 20, account for 11% of all births worldwide and account for 23% of the overall disease burden. • Adolescent fertility rate per 1000 girls aged 15-19 years is higher in Bangladesh (127) and Nepal (106) than the Southeast Asian countries: Malaysia (13),Vietnam (35), Cambodia (52), the Philippines (55). • Adolescent fertility is a major concern for governments in Bangladesh, India, Indonesia, Lao PDR, Malaysia, Nepal, Pakistan, the Phillippines, Thailand and Vietnam and these countries have reported policies and programmes to address adolescent fertility.

13. FINDINGS:ABORTION • Although abortion is one of the most contentious issues within the ICPD PoA, it is regarded as an integral component of reproductive health services. • Access to safe and legal abortion remains one of the biggest challenge for many women across the globe. And this is one of the shortcomings of the ICPD PoA: access to safe, legal abortion is not recognised as part of reproductive health and rights; in deference to national laws; where illegal requiring treatment of complications only. • It is important to recognise abortion both as a public health issue and a human rights issue. • 4 countries in the region (Cambodia, China, Nepal and Vietnam) have abortion available on request; 1 country (India) provides abortion on all grounds except request; only in Bangladesh, Indonesia and the Philippines is it available on limited grounds.

14. FINDINGS:ABORTION • Changes in law/ policy since ICPD include: Vietnam legalised abortion and menstrual regulation in 1989; Cambodia legalised abortion in 1997 concerned with the high MMR due to unsafe abortions; Nepal legalised abortion in 2002; Thailand broadened the grounds for abortion to reasons of mental health in 2005; Indonesia amended grounds for abortion to those who had been raped in 2009. • Lack of knowledge about abortion laws - among women and service providers - continues to be an issue. • Unsafe abortion is negligible in China and Vietnam but continues to be a major factor in maternal deaths in the region contributing 14% and 13% of all maternal deaths in Southeast Asia and South Asia.

15. FINDINGS:ABORTION • Although access to safe abortion services has been proved to be linked to a lower level incidence of unsafe abortions and lower percentages of maternal deaths due to unsafe abortion progress on amending laws seems slow. • Where abortion laws are restrictive, it is important to look at how women’s NGOs are working to amend these laws as recommended by the Beijing Platform for Action. • It is useful to note that abortion services are provided safely through through the private sector in Malaysia and Thailand, through family planning methods such as menstrual regulation in Bangladesh and through private provision of medication abortion in Southeast Asia. • In Lao PDR, the Philippines, Indonesia, Bangladesh and Pakistan legal barriers curb access; in Malaysia - non-legal barriers such as hospital administration policies; in countries with liberal policies such as Nepal, India and Cambodia service barriers for safe abortion still exist and governments must follow through policies with services.

16. FINDINGS:REPRODUCTIVE CANCERS • Reproductive cancers include breast, ovarian, endometrial and cervical cancers but this review only focuses on cervical cancer and breast cancer. Both are at epidemic proportions. • Cervical cancer accounts for approximately 12% of all cancers in women. • Cervical cancer is the most frequent cancer among women in Bangladesh, Cambodia, India, Lao PDR, Nepal, Thailand and Vietnam. It ranks as the second most frequent cancer among women in Malaysia, Indonesia and the Philippines. • In addition to pap smears, VIA (visual inspection approach with acetic acid) with cryotherapy is being researched as an alternative method. • In the 12 countries, Malaysia has made a commitment to universal vaccination against cervical cancer. • Breast cancer is common and early detection through screening and improvements in therapy have reduced mortality - however early detection and screening are inaccessible to large segments of the population in the region.

17. FINDINGS:STIs INCLUDING HIV/AIDS • About 1 million STIs occur everyday in the world, nearly half of them in Asia. HIV epidemics have largely followed the trend of STI, where STI control measures have been scaled-up, rapidly growing HIV epidemics have been halted even reversed. Thus an effective STI control programme reduces the burden of both HIV infections as well as other STIs. • However, most STI interventions are being driven by HIV/AIDS intervention programmes. HIV intervention targets high risk behaviour groups and the larger population who are at risk of STI, but do not fall under the high risk categories are neglected by prevention and treatment programmes.

18. FINDINGS:STIs INCLUDING HIV/AIDS • 4.9 million people were living with HIV in Asia, including the 440,000 who became newly-infected last year and approximately 300,000 died from AIDS related illnesses. • National HIV prevalence is highest in Southeast Asia; prevalence declining in Cambodia and Thailand; but on the rise in Indonesia (especially in the Papua region), Pakistan and Vietnam. • Considerable progress in the area of HIV prevention, treatment and care but few governments have addressed stigma and discrimination. Stigma especially for vulnerable populations hinders access to treatment and care. • Women are more vulnerable to the epidemic due to lack of negotiating power or asserting their rights due to societal norms and embedded cultural beliefs; lack of access to information and healthcare; lower education levels and lower social status and taboos related to communication about sexuality.

19. FINDINGS:ADOLESCENT SEXUAL RIGHTS • There are 2 clear strains of thinking about adolescents. In South Asia, where the age of marriage is low, adolescents are very often married and their rights are recognised within this framework. In Southeast Asia, age of marriage is higher, adolescent sexual activity is often perceived as taking place outside the framework of marriage. • SRH services have been so often subsumed within the framework of reproduction, access to services and information becomes problematic. • Progress on imparting sex and sexuality education to adolescents is uneven and sketchy across all 12 countries. Only in 3 countries (Vietnam, India and Nepal) are there attempts to introduce sex education as part of the curriculum. Only Thailand has started to address and attempt to provide sexuality education.

20. FINDINGS:SEXUAL RIGHTS • Sexual rights is a highly contested term in international arenas; and seen as terminology which has not been ‘agreed upon.’ • Many governments limit and equate sexual rights with legalisation of homosexuality and same sex marriage however the majority of women who live in patriarchal societies continue to struggle with sexual rights. • In order to achieve desirable SRH outcomes, the ICPD PoA notes it is crucial to empower men and women with rights that enable them to be equals in the public and in the most private spheres of life; and to empower women to exercise their decision-making with regards to sexuality and reproduction; and to establish rights for women where those rights may not currently exist, in order to enable women’s decision-making capacities.

21. FINDINGS:SEXUAL RIGHTS • Legal age of marriage and existence of arranged and forced marriages indicate rights around choice of partner, decision to be sexually active or not, consensual sexual relations and consensual marriage. • Differences between legal age of marriage and median age of marriage show that in Bangladesh, India and Nepal laws on legal age of marriage are not enforced. • There are many loopholes within the law which makes it is possible to marry off young girls. • In Southeast Asia, arranged marriages are practised in Cambodia and Indonesia. In South Asia both arranged marriages and forced marriages have been documented. • Child marriages have been documented in South Asia especially in Pakistan and Bangladesh and in Indonesia.

22. FINDINGS:SEXUAL RIGHTS • Traditional practices which are harmful to women, sexual violence and trafficking denote rights on bodily integrity. • Among traditional practices,female circumcision is widespread in Indonesia, reduced in Malaysia, low in Pakistan and completely non-existent in all the other 9 countries. Symbolic prick is recorded in the Philippines. • In 2007 the CEDAW committee recommended to the govt of Indonesia to speedily enact legislation prohibiting female genital mutilation and to ensure that offenders are prosecuted and adequately punished.

23. FINDINGS:SEXUAL RIGHTS • 4 aspects of sexual violence have been reviewed: rape, marital rape, sexual harassment and new and emerging forms of sexual violence. • Rape: all 12 countries have anti-rape laws; most laws crafted around ‘consent’ and ‘forced vaginal penetration.’ Consent difficult to establish, especially problematic with women who are perceived as transgressing society’s acceptable expressions of sexuality e.g. young women who have had consensual sexual relations and sex workers. ‘Forced vaginal penetration’ fails to recognise rape can be a crime against children, men and transgender people. • Marital rape: is highly contested. In 5 countries (Cambodia, India, Thailand, Indonesia and Vietnam) the marital rape provision is found within the Domestic Violence Act. In the Philippines, it is part of the anti-rape law. In Malaysia, marital rape is part of the penal code (amended 2007). In Nepal, it is part of the gender equality bill. China, Lao PDR, Bangladesh and Pakistan do not have legal provisions for marital rape. Probably in deference to the idea that there is no concept of rape within a marriage.

24. FINDINGS:SEXUAL RIGHTS • Sexual harassment: anti-sexual harassment provisions exist in Bangladesh, Cambodia and Nepal; are part of the labour law in Malaysia and Thailand; only the Philippines has an anti-sexual harassment act; no such laws exist in China, India, Indonesia, Lao PDR, Vietnam and Pakistan. • New and emerging forms of sexual violence include harassment via email and mobile phones - no legal curbs and little retribution for perpetrators. • The data collected for violence currently does not disaggregate women, men and transgender. In analysing violence as a manifestation of unequal power relations, women are not the only group that suffers. Violence also occurs against gays, lesbians, bisexual and transgender people. • Trafficking: all 12 countries have laws on trafficking; Cambodia, India, Indonesia, Malaysia, Nepal, the Philippines and Thailand have specific laws. Although laws are in place, enforcement and implementation seem to be questionable.

25. FINDINGS:SEXUAL RIGHTS • As indicators of the rights to the highest attainable standard of health in relation to sexuality, in choice of partner, in consensual sexual relations and to pursue a satisfying, safe and pleasurable sex life we looked at laws around sex work and laws on diverse sexual and gender identities. • Status of sex work: no country has legalised sex work; Vietnam is a clear example of ‘abolitionist’ approach; China, Lao PDR, Thailand, the Philippines, Malaysia criminalise sex work; India, Pakistan and Nepal decriminalise sex work. • Status of same sex sexual preference, relations & marriage: in all countries laws silent on preference; in 6 countries (Cambodia, China, Lao PDR, Vietnam, Thailand and the Philippines) the law is silent (and hence construed legal) on same sex sexual relations; same-sex sexual relations are illegal (although limited to interpretations of sodomy) in Bangladesh, India, Pakistan, Malaysia and Nepal; in Indonesia illegal for all Muslims and if relations are with a minor; same sex marriage criminalised in Vietnam; in Nepal the Supreme Court has directed the govt to formulate a same sex marriage act.

26. FINDINGS:SEXUAL RIGHTS • Transgenderism is an issue of gender identity and there can also be issues of sexual orientation. Transgender people comprise some of the most marginalised and most vulnerable groups within societies in the Asia-Pacific region. Range of attitudes are found. • In Thailand, Laos and Cambodia - called literally the ‘third’ gender (as in another gender, not as in a hierarchy of genders) - high levels of social acceptance. Thailand easily enables sex reassignment surgery; some provision of separate toilets for transgender people. • In Malaysia and the Philippines little recognition of their rights. Malaysia- even harassed by the police. • In India and Pakistan, specific social roles for transgender people. • Nepal most progressive having decriminalised laws which control sexuality and having recognised people of diverse gender identities and sexual orientation as citizens with equal rights.

27. CONCLUSIONS • 1.Progress across the region is uneven and slow with regards to sexual and reproductive health and rights (SRHR): no one country has made progress in every single indicator; CPRs are still low and burden of contracpetion falls on women; maternal deaths remain a challenge in South Asia and Lao PDR; abortion policies take a long time to change and progressive laws must be backed up by service provision and quality of care; reproductive cancers are yet to be addressed in a cohesive and comprehensive manner within health systems; sexual health is still defined by ‘disease prevention’ paradigms.

28. CONCLUSIONS • 2. Political will of governments is crucial to recognising the sexual and reproductive health and rights of citizens: political will of governments is a key factor for achievement of SRHR outcomes as seen in the success stories of fertility reduction in China, India and Indonesia; of maternal deaths reduction in Malaysia and Thailand; of safe abortion services provision in Vietnam and China; of reproductive cancer prevention, treatment and care in Malaysia; of voluntary counselling and testing (VCT) and anti-retroviral therapy (ART) services provision in all countries; of legislation to recognise same-sex sexual relationships and transgenderism in Nepal. • Once the importance of the issue is established, governments create policies and programmes and deploy budgets and trained personnel and provide facilities and access.

29. CONCLUSIONS • 3. Access for marginalised groups is a concern across all countries: women who are poor,less educated, live in remote areas and/or rural areas face greater difficulties in accessing services and realising the autonomy of their bodies. Tribal women, women from ethnic minorities, women from lower castes, younger women, sex workers, women of diverse sexual orientation and gender identities are also marginalised. This happens regardless of whether the service they require access to is contraception, maternal health services, safe abortion services, ART, reproductive cancer screening and treatment. Sexual and reproductive health and rights are an issue of socio-economic inequity as well as gender inequity.

30. CONCLUSIONS • 4. Sexual rights are not as contentious as perceived: many different aspects have already been commonly accepted and legislated on by the governments in the 12 countries. All countries recognise women’s right to bodily integrity and freedom from sexual violence. All countries recognise the rights of choosing partners and entering into consensual marriages. • Politically, governments are only comfortable recognising the reproductive functions of sexuality and the sexual rights that go hand-in-hand with these. The non-reproductive functions of sexuality are considered secondary and have not been attributed commitment and importance.

31. RECOMMENDATIONS • 1. Policy change underpinned by commitment to the ICPD PoA, with respect to reproductive rights and sexual rights: policies need to be mainstreamed into already existing national plans and machineries, policies on SRHR should be aligned to providing the range of services; policies should be implemented and backed by functional health systems and adequate budgets; policy review should be backed by robust data and should measure new indicators of rights; SRHR policies need to be created and reviewed in secular spaces; policy review processes need to be integrated with CEDAW and ICESR reporting mechanisms to put pressure on governments; policy review should be underpinned by the human rights paradigm and policy review efforts sould integrate good practices in the region as performance benchmarks and engage in knowledge sharing.

32. RECOMMENDATIONS • 2.Ensure universal access to affordable, quality, gender-sensitive services to enable the realisation of the highest standard of sexual and reproductive health: make comprehensive SRH services available from the primary healthcare level which is most accessible to most of the population; renew commitment to making the full range of services available; renew commitment to staffing health facilities with skilled and trained human resources; integrate services especially RH and HIV; gender-sensitive service provision which includes accountability mechanisms; registration systems for births and deaths and marriages should be instituted within systems.

33. RECOMMENDATIONS • 3.Ensure continued, committed and sustained investments in women’s sexual and reproductive health and rights by governments and donors: donors and governments should meet agreed funding requirements through allocating ODA to SRHR, prioritising SRHR in the Poverty Reduction Strategy Papers (PRSPs) and incorporating SRH service components into the Essential Service Packages (ESPs); government reporting to the national health accounts should track expenditure on SRH; strengthen capacities of partners and constituencies to engage effectively in policy-making and decision-making; donors should fund all components of SRHR and health system strengthening from primary healthcare level and review vertical funding mechanisms.

34. RECOMMENDATIONS • 4. Concretise the rights to sexual and reproductive health and the sexual and reproductive rights especially those of adolescents, marginalised groups of women and those with diverse sexual orientation and gender identities: by creating adolescent-friendly policies, ensuring comprehensive sex and/or sexuality education and removing barriers of consent and discrimination; create comprehensive programmes, policies and plans to address marginalised groups who will require more than one intervention to improve their SRHR and understand the barriers that impede their access; create policies which entitle sex workers and people with diverse sexual and gender identities to equal, fair,non-discriminatory SRH service,care and treatments; empower marginalised communities to recognise their rights and build capacity to claim these rights from duty-bearers; implement policies and programmes with an understanding of the different aspects of vulnerability - exposure to risks and danger as well as lack of capacity to cope with negative consequences of risks and threats.

35. THANK YOU! • Thank you for your time. • The full report is available at: http://arrow.org.my/home/images/publications/ICPD+15/Reclaiming&RedefiningRightsICPD+15.pdf “States are not moral agents, people are, and can impose moral standards on powerful institutions.” • Noam Chomsky Citation format (APA style): Thanenthiran, S. (2010). Reclaiming & Redefining Rights – ICPD+15: Status of Sexual & Reproductive Rights in Asia [PowerPoint Slides]. Retrieved from The Asian-Pacific Resource & Research Centre for Women (ARROW) website: www.arrow.org.my/home/images/publications/ICPD+15/Reclaiming%20&%20Redefining%20Rights%20ppt.ppt