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Repoliticizing Sexual & Reproductive Health & RightsRepoliticizing Sexual & Reproductive Health & RightsA transformative framework: beyond ICPD and the A transformative framework: beyond ICPD and the
MDGsMDGsLangkawi 2010Langkawi 2010
Sexual and Reproductive Health and Rights in Public Health Education
PASCALE ALLOTEYSIMONE DINIZ
JOCELYN DEJONGSHARON FONNSOFIA GRUSKIN
THÉRÈSE DELVAUX
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)
IntroductionIntroductionSRH is an area of need of both clinical
practice and public healthSRH generates strong opinions steeped in
social values, ideology, religion and moralityCairo 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
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.
Activism and public health Activism and public health educationeducation
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
Case study 1: Case study 1: Sexual and Sexual and Reproductive Health Education in Reproductive Health Education in
the Middle Eastthe 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
Short coursesShort 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
Short coursesShort coursesPart 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.
University programsUniversity programsMuch 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
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
Case study 2: Case study 2: Sexual and Reproductive Health Sexual and Reproductive Health Education in South Africa – a perspective Education in South Africa – a perspective
from University of Witwatersrandfrom 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.
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.
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
Case study 3: Case study 3: Sexual and Sexual and Reproductive Health in PH Reproductive Health in PH
Education in BrazilEducation 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, + SUSGender and Health working group in Abrasco (1994). Boom in Gender studies, 2/3 production in SRHR.
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).
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 healthHigh 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
Random reflections from the Brazilian Random reflections from the Brazilian casecase
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
ChallengesChallenges 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
A number of issues remain A number of issues remain open to discussion: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?
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