Thanks to a number of global initiatives – like FP2020, ICPD Beyond 2014, and the UN’s proposed Sustainable Development Goals (SDGs) – there is renewed commitment and focus on reproductive health. The current context offers an opportunity to elevate the discourse around what is most important – the rights, needs and health of women. However, conversations about tracking progress across these initiatives are often centered on numerical targets, a limited number of indicators, narrowly focused on outcomes and fail to appropriately capture rights dimensions.
Continuing an effort begun in 1995, PAI developed the Reproductive Health Index which provides an assessment that incorporates a multi-dimensional approach to reproductive health and adds a new perspective to how comprehensive SRHR is defined and measured. Rather than measuring health outcomes, our Index captures factors driving the attainment of SRHR, enabling us to understand the concrete steps that countries around the world are (or are not) taking to fulfill citizens’ SRHR.
Furthermore, amidst global conversations where tracking progress is often limited to a handful of indicators, our Index provides a more comprehensive metric. A country’s Index score aggregates key dimensions of SRHR into a summary measure of achievement. This summary measure offers a simple and direct way to: understand a larger and more complex set of issues; guide investments; measure progress; and spur appropriate action. A country’s Index score can also serve as a reference point to assess how well government investments, policies, and programs are respecting the rights and meeting the needs of women. Accordingly, the Index serves as a catalyst for dialogue and action among policymakers, program designers, advocates, and donors alike.
Rights and Results: A Reproductive Health Index
The Index and its accompanying report provide a measure of where women in 62 low- and lower-middle-income countries stand in attaining sexual and reproductive health and rights. Based on the 1994 Programme of Action (POA) of the International Conference on Population and Development (ICPD), we define SRHR according to the following four dimensions:
Preventing unintended pregnancy;
Increasing access to safe abortion and post-abortion care;
Helping women safely through pregnancy, childbirth and the postpartum period; and
Preventing and treating sexually transmitted infections, including HIV/AIDS.
A fifth dimension, termed the “enabling environment,” captures factors beyond the health system that support sexual and reproductive health and rights.
Rather than measuring the health outcomes corresponding to the dimensions noted above, this Index captures the factors driving the attainment of SRHR. Determinants include access to high-quality, voluntary and affordable health services and supplies; high-quality information; and non-restrictive and non-coercive laws and policies. As a result, this Index encapsulates the key dimensions of reproductive rights—including the right to reproductive self-determination; the right to sexual and reproductive health services, information and education; and the right to equality and non-discrimination.
To calculate an Index score for each country, 11 indicators representing the dimensions of SRHR were combined into a single measure—the Reproductive Health Index. To view the list of indicators and a full description of how the Index was constructed, please see the full RHI report.
The Index is scored on a 0 to 100 scale. Therefore, the strongest possible state of SRHR in a country according to the Index would be a score of 100.
Index scores for the 62 countries included in our study range from 25.5 to 86.5. Though scores vary greatly within that range, the fact that no country received a score of 100 means that there are opportunities to advance the sexual and reproductive health and rights of women in all 62 countries.
Seventy-three percent of the countries included in the Index have scores falling below 60, which is indicative of large gaps in the fulfillment of women’s reproductive rights. A variety of factors contribute to these gaps, including the failure of countries to satisfy demand for contraceptive information, services and supplies. In addition, restrictive legal and policy frameworks place limits on the realization of reproductive rights, particularly for women and girls. For example, abortion policies are highly restrictive (abortion is only allowed to save a woman’s life or prohibited altogether) in half of the countries in the Index. Furthermore, critical components of safe maternal care, like antenatal visits and the presence of well-trained and supported health personnel during delivery, are lacking in many countries. Barriers to preventing and treating sexually transmitted infections, including HIV, are also of concern. For instance, nearly half of the HIV-positive women eligible did not receive the antiretroviral therapy treatment they needed in 2012. Lastly, many women live within the context of constrained decision-making power and large imbalances in the social, economic and political opportunities available to them as compared to men. Without a strong enabling environment, women face tremendous obstacles to making informed decisions about their own health.
The Index findings demonstrate the need for greater investment in, and targeted attention to, fulfilling the sexual and reproductive health and rights of women in all countries included in the Index. Though gaps in meeting the needs and fulfilling the rights of women may be larger in some countries than others, even those countries with higher scores have room to grow. Our analysis indicates that improving the sexual and reproductive health and rights of women in these countries depends on three overarching actions:
- Strengthen political will and financial commitments: At the national level, family planning and reproductive health programs with high-level political support and sustainable financial resources are more successful. This type of leadership and commitment are critical to ensuring that policies promote meaningful access to contraceptives, resources are made available and reproductive health programs are prioritized.
- Craft and implement positive policies: There remains a need to go beyond eliminating policy barriers related to sexual and reproductive health information, services and supplies. Policies need to champion individual reproductive rights, including among historically disadvantaged and marginalized populations. For example, women’s reproductive autonomy should be ensured beyond simply eliminating spousal and parental consent regulations. The reproductive health needs of youth must be openly acknowledged in policies and youth-friendly services need to be prioritized and integrated within existing programs.
- Provide quality information and services: Attention is often centered on attracting new contraceptive users to increase contraceptive prevalence rates. However, investing in high-quality information, services and supplies is critical for meeting the needs of current users. Preventing unintended pregnancies depends upon sustaining satisfied contraceptive users, not simply acceptors. This requires greater emphasis on quality information, counseling and overall service delivery that meets the needs of women throughout their reproductive lives.
Now is the time to elevate SRHR as a top development priority at the global level and a key national investment at the country level. SRHR must have real commitment, meaningful implementation and wide-reaching accessibility if we ever hope to realize a world in which every girl and boy enjoys a safe, healthy, prosperous life shaped by her and his own choices.