Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission

Human Rights – Sexual and Reproductive Health

Featured Journal Content

The Lancet
Jun 30, 2018 Volume 391 Number 10140 p2575-2692

The Lancet Commissions
Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission
Ann M Starrs, Alex C Ezeh, Gary Barker, Alaka Basu, Jane T Bertrand, Robert Blum, Awa M Coll-Seck, Anand Grover, Laura Laski, Monica Roa, Zeba A Sathar, Lale Say, Gamal I Serour, Susheela Singh, Karin Stenberg, Marleen Temmerman, Ann Biddlecom, Anna Popinchalk, Cynthia Summers, Lori S Ashford

Key messages
:: Sexual and reproductive health and rights (SRHR) are essential for sustainable development because of their links to gender equality and women’s wellbeing, their impact on maternal, newborn, child, and adolescent health, and their roles in shaping future economic development and environmental sustainability.
:: Everyone has a right to make decisions that govern their bodies, free of stigma, discrimination, and coercion. These decisions include those related to sexuality, reproduction, and the use of sexual and reproductive health services.
:: SRHR information and services should be accessible and affordable to all individuals who need them regardless of their age, marital status, socioeconomic status, race or ethnicity, sexual orientation, or gender identity.
:: The necessary investments in SRHR per capita are modest and are affordable for most low-income and middle-income countries. Less-developed countries will face funding gaps, however, and will continue to need external assistance.
:: Countries should incorporate the essential services defined in this report into universal health coverage, paying special attention to the poorest and most vulnerable people.
:: Countries must also take actions beyond the health sector to change social norms, laws, and policies to uphold human rights. The most crucial reforms are those that promote gender equality and give women greater control over their bodies and lives.

Executive summary
Sexual and reproductive health and rights (SRHR) are fundamental to people’s health and survival, to economic development, and to the wellbeing of humanity. Several decades of research have shown—and continue to show—the profound and measurable benefits of investment in sexual and reproductive health. Through international agreements, governments have committed to such investment. Yet progress has been stymied because of weak political commitment, inadequate resources, persistent discrimination against women and girls, and an unwillingness to address issues related to sexuality openly and comprehensively.

Health and development initiatives, including the 2030 Agenda for Sustainable Development and the movement toward universal health coverage, typically focus on particular components of SRHR: contraception, maternal and newborn health, and HIV/AIDS. Countries around the world have made remarkable gains in these areas over the past few decades, but the gains have been inequitable among and within countries, and services have often fallen short in coverage and quality. Moreover, in much of the world, people have insufficient access to a full set of sexual and reproductive health services, and their sexual and reproductive rights are not respected or protected. Acceleration of progress therefore requires adoption of a more holistic view of SRHR and tackling of neglected issues, such as adolescent sexuality, gender-based violence, abortion, and diversity in sexual orientations and gender identities.

Progress in SRHR requires confrontation of the barriers embedded in laws, policies, the economy, and in social norms and values—especially gender inequality—that prevent people from achieving sexual and reproductive health. Improvement of people’s wellbeing depends on individuals’ being able to make decisions about their own sexual and reproductive lives and respecting the decisions of others. In other words, achieving sexual and reproductive health rests on realising sexual and reproductive rights, many of which are often overlooked—eg, the right to control one’s own body, define one’s sexuality, choose one’s partner, and receive confidential, respectful, and high-quality services.

The evidence presented in this report reveals the scope of the unfinished SRHR agenda. Each year in developing regions, more than 30 million women do not give birth in a health facility, more than 45 million have inadequate or no antenatal care, and more than 200 million women want to avoid pregnancy but are not using modern contraception. Each year worldwide, 25 million unsafe abortions take place, more than 350 million men and women need treatment for one of the four curable sexually transmitted infections (STIs), and nearly 2 million people become newly infected with HIV. Additionally, at some point in their lives nearly one in three women experience intimate partner violence or non-partner sexual violence. Ultimately, almost all 4·3 billion people of reproductive age worldwide will have inadequate sexual and reproductive health services over the course of their lives.

Other sexual and reproductive health conditions remain less well known but are also potentially devastating for individuals and families. Between 49 million and 180 million couples worldwide might be affected by infertility, for which services are mainly available only to the wealthy. An estimated 266 000 women die annually from cervical cancer even though it is almost entirely preventable. Men also suffer from conditions, such as STIs and prostate cancer, that go undetected and untreated because of social stigma and norms about masculinity that discourage them from seeking health care.

This report proposes a comprehensive and integrated definition of SRHR and recommends an essential package of SRHR services and information that should be universally available. The package is consistent with, but broader than, the sexual and reproductive health targets of the 2030 Agenda for Sustainable Development. Our recommended package includes the commonly recognised components of sexual and reproductive health—ie, contraceptive services, maternal and newborn care, and prevention and treatment of HIV/AIDS. Additionally, the package includes less commonly provided components: care for STIs other than HIV; comprehensive sexuality education; safe abortion care; prevention, detection, and counselling for gender-based violence; prevention, detection, and treatment of infertility and cervical cancer; and counselling and care for sexual health and wellbeing. Recognising that many countries are not prepared to provide the full spectrum of services, we recommend that governments commit to achieving universal access to SRHR and to making continual and steady progress, regardless of their starting point.

Our assessment of the costs of the major components of sexual and reproductive health services for which cost data are available shows that meeting all needs for these services would be affordable for most countries. The cost of meeting all women’s needs for contraceptive, maternal, and newborn care is estimated to be on average US$9 per capita annually in developing regions. The investments would also yield enormous returns; evidence shows that access to sexual and reproductive health services saves lives, improves health and wellbeing, promotes gender equality, increases productivity and household income, and has multigenerational benefits by improving children’s health and wellbeing. These benefits pay dividends over many years and make it easier to achieve other development goals.

The means and knowledge—in the form of global guidelines, protocols, technology, and evidence of best practices—are available to ensure that all people receive the confidential, respectful, and high-quality sexual and reproductive health services they need. Successful interventions have been piloted in many low-income and middle-income countries, some of which are highlighted in this report, but many effective approaches have not been implemented on a wide scale. Thus, civil society groups and others committed to advancing SRHR must work across sectors, and they must hold governments accountable to their commitments not only to improve health but also to uphold human rights.