Sexual and Reproductive Health Wrongs: What do we need to do to get them right? – An activist perspective: Part 2

By Mark Heywood and Thuthukile Mbatha, SECTION27

The latest edition of Spotlight, produced by TAC and SECTION27, is a special edition, edited by a young woman activist and SECTION27 researcher, Thuthukile Mbatha. It focusses on the state of implementation of sexual and reproductive health rights (SRHR) in South Africa. The edition illustrates that whether it be on access to termination of pregnancy, access to health services or the continued decriminalisation of sex work South Africa is failing badly in its duty to realise SRHR. In this article Mark Heywood and Thuthu Mbatha, attempt to ask, and suggest some answers to, the hard and painful questions arising from the articles in Spotlight. Why are we failing to advance – or even defend – rights issues that are central to our very being? Part 1 provided some analysis on the state of affairs. Part 2 published here makes an attempt to share some insights into what can be done. Mark and Thuthu do not pretend to have all the answers or to be authorities on the subject. This is an attempt to get an important conversation going and Spotlight will aim to publish a numbers of other opinion pieces on the subject.

Part 1 in the series ends with the statement that we have become complicit with a horrendous status quo. We kick off Part 2 with some suggestions about how we can change this.

SRHR require a struggle for power and equality.

Let’s be clear: SRHR cannot be achieved without confronting issues of power – particularly who has power and who doesn’t. Although they seem to be loved by Northern donors SRHR are not ‘soft’ or easy rights. Their realisation would have an immediate bearing on improved health and HIV prevention, but that recognition  doesn’t seem to be enough to persuade policy makers to act on them. In reality their implementation requires a challenge to men’s power in the world not only in the home, but particularly in politics and economy.

SRHR may exist in law and policy in many countries, they may be acknowledged in the SDGs, but they don’t get budgets.  This is because men dominate parliaments and men don’t take SRHR seriously. SRHR require a revolution.

SRHR require youth leadership and campaigns that prioritises young people’s well-being.

SRHRs are relevant to all people of all ages, but they are especially important for and to young people. Young people are in the phase of their lives where they are discovering the potential joy of sex and learning about their sexuality. South Africa’s Constitutional Court has recognised that:

“the majority of South African adolescents between the ages of 12 and 16 years are engaging in a variety of sexual behaviours as they begin to explore their sexuality.” Sexual experiences during adolescence, in the context of some form of intimate relationship, are “[n]ot only . . . developmentally significant, they are also developmentally normative.”

Yet despite this the law continues to deny young people access to sexual and reproductive health care services. Only last year did the Department of Basic Education (DBE) finalise a policy on HIV in schools.[1] Only in 2018 has the DBE published a very poorly written draft policy on Pregnancy in schools.[2]  Given that 59% of our population is under 30, and 17% are between the age of 15 and 24 of which nearly five million are women, this amounts to the denial of access to health care services to which they are legally entitled to a lot of people.[3]

Most women give birth before they reach the age of 30.[4] So, that’s when we most need recognition of these rights. Yet the world is mostly run by older people. For example, the average age of MPs in our National Assembly is over 50. SRHR therefore also force us to reflect upon the age and interests of the people who makes decisions and how these decisions reflect their priorities and preoccupations. They call for youth to mobilise and become much more involved in politics.

SRHR require us to recognise that experiencing sexual pleasure and freedom without risk is a right.

It is wrong to communicate and advocate for sexual and reproductive health rights as just/mainly about negative obligations and preventing harm. Young people especially pay little heed to SRHR because they are often spoken about as if they are primarily about minimising risks rather than enhancing pleasure, freedom and equality.

Another weakness in campaigns for SRHR is that they are often most spoken about by middle class people who have them; and, or, they are driven by a donor agenda that makes assumptions about the people who need them and takes little account of their real lives and needs. The people who most need SRHR are poor and marginalised. They experience multiple rights violations. There is a fight for survival, every day. They do not have the luxury to fight only for their SRHR.

Activists must start to assert SRHR as positive rights. They have been recognised in law because they are necessary to enhance human joys and freedom. They are vital for the achievement of freedom and equality, freedom particularly for women and girls, and for marginalised people and populations.

SRHR require us to join the dots between sex and struggles for equality and social justice in education and health.

Relevant SRHR at schools include access to well taught and informed life orientation programmes, that inform young people about sex, sexuality, sexual health and their rights. They should also include access to condoms, access to Pre-exposure Prophylaxis (PrEP) and voluntary medical circumcision for boys. But these rights cannot be achieved without being joined to struggles for social justice and equality in the provision of education.

Today South Africa’s basic education system fails poor learners without discrimination. Of every 100 learners who enter the education system at grade 0, fewer than 5 complete school with a qualification that admits them to University education.[5] However, girls and young women bear the main burden of this failure.[6] The denial of a quality education, the denial of knowledge and information, the denial of a safe learning environment, reduces a young woman’s power and autonomy.

Having been failed by the education system, a young woman falls into a society that further marginalises her in higher education and the economy. This disempowerment may affect a women’s ability to stand up for her SRHR. It predisposes poor women and girls towards older men (‘sugar daddies’) and in some cases sex-work, it leaves many women dependent on men and subject to domestic violence. The question for activists then is how we can integrate campaigns for SRHR into struggles for quality basic education.

A similar situation exists in relation to access to health care services. Because sex and reproduction can be affected by and impact on our health, and because the people most in need of these rights are poor, many SRHR depend upon a functional, accessible and quality public health system, a health system that has sufficient doctors and nurses, appropriate medicines and a budget to meet needs. A health system designed more with the users in mind as well as with the rights of health workers, for example the simple matter of clinic hours. Many patients complain that operating hours are solely determined by what suits healthcare workers with no consideration for what is best for those who need the services.

The issue of the right to abortion (termination of pregnancy) is an example of all that is wrong. It is also an example of the overlapping of SRHR with health and basic education rights. South Africa has a high rate of teenage pregnancy, starting at a shockingly young age.[7] The right to abortion doesn’t only exist on paper; it exists in law, and the law is explicit that a girl can seek a termination without involving her parents from the age of 12. Yet less than one in five (20%) of health facilities offer abortion. According to Marie Stopes International, 245,211 unsafe abortions were carried out in South Africa in 2010 alone.[8] SRHR would be advanced if there was a properly trained cadre of community health workers, able to play a role in community based health education on issues including sexual and reproductive health.

So the question facing human rights activists again is how SRHR can be fought for not as stand-alone rights, but as an integral part of primary health care and as an essential part of a National Health Insurance scheme? How can activists research and then educate politicians and policy makers about the personal and social cost of not respecting these rights? How can we gather the evidence to show that a sufficient and dedicated budget for SRHR would be cost-saving to the health system as well as advancing women’s rights to dignity and equality?

This is why SRHR advocacy needs well researched activism, not just slogans – however justified the slogans are. Unfortunately SRH rights are still battle-grounds and battle grounds require a battle plan.

What is to be done?

In South Africa activists have a huge advantage over our comrades in many other countries because of the legal power given to us by the Constitution and because of the entrenchment of SRHR in the Constitution, law and policy. However, no rights are ever capable of enacting themselves. They require campaigns and activism.

Before and immediately after the advent of democracy in 1994 a number of organisations fought valiantly for SRHR, initially the Women’s Health Project, Reproductive Rights Alliance and the National Coalition for Gay and Lesbian Equality. More recently the One in Nine campaign, Soul City, and others have taken forward this struggle. Social justice movements such as TAC, have taken up individual issues that overlap with SRHR, without fighting for these rights as a whole. But at best most civil society organisations have been silent and at worst many, particularly in the trade unions, have been complicit in gender based violence. Today we need to learn from and follow the lead of those who have fought in this field, but also cut a path to a much broader and more powerful activist front. SRHRs must no longer be in a silo. As I have tried to show above, they are central to social justice. We all have a responsibility to make SRHR part of our practice.

Below are some tentative suggestions about the types of campaigns that must be launched and sustained.

Make millions of people aware of their rights: The people who most need SRHR are not aware that the law and Constitution views things such as bodily autonomy and reproductive choice as fundamental rights.[9] Even the term SRHR is confusing and foreign – it is ‘NGO-talk’. To change this a massive and accessible communication campaign is needed that reaches young women and other vulnerable communities to make it clear that they are not powerless in the face of violence and to start to suggest local strategies and campaigns to advance these rights. This campaign must have scale. It cannot reach only small circles of communities. It needs to be carried through public and accessible media, like the indigenous language radio stations on the SABC which reach over 30 million people.

But linked to this a campaign is needed to educate society as a whole about SRHR, overcome misunderstandings and to engage those who think they are opposed to SRHR.

Define an agenda for SRHR: short, medium and longer term and demand action. Below are some examples of demands we should make:

In the short term (2018) we should demand:

• A costed, budgeted national strategic plan to confront rape culture.
• The immediate and extensive provision of PrEP to young women and girls, including through school health programmes;
• Immediate implementation of the policy on access to condoms in schools;
• Immediate provision of sanitary pads in every school nationally;
• Drastically improved accesss to services for abortion.
• Communication and mass media strategies that publicise all of the above.

In the medium term (2019-2020) we should demand:

• The decriminalisation of sex work;
• Implementation of the draft policy on pregnancy in schools;
• Access to a wide range of safe contraceptives in the public health sector;
• Extensive provision of contraceptives in schools and higher education institutions;
• Improved access to screening, testing, diagnosis and treatment of cancers in the reproductive system;
• Improved access to SRH services that are suitable for queer folk and health services that recognise the special needs of adolescents, LGBTQIA+ folk, pregnant teenagers and so on.

In the longer term:

• Establishment of more shelters for gender based violence survivors;
• Improved access to affordable breast, cervical and prostate cancer treatment in the public health sector;

Get civil society to join the dots and connect its own struggles: Civil society organisations’ greatest weakness, and the reason why we don’t often bring about lasting and systematic change, is that we don’t make enough effort to work together. NGOS and social movements have not yet worked out how to focus on ‘their’ particular issues, but at the same time reinforce others campaigns. We have not learnt how to work at the intersections of issues. Despite all the lip-service we pay to issues of gender and women’s equality, they are almost never at the centre of rights practice or advocacy. Gender and SRHR issues are on the margins unless you are an organisation  focussing on ‘woman’s rights’ or LGBTQI issues. And, as we have seen most tragically with regards to Equal Education, even the social justice sector is not immune to the plague of sexual harassment and exploitation. This is not unrelated to the fact that most of civil society, whether in the form of churches, trade unions or NGOs, is led by men and therefore – by default – reflects patriarchy and men’s agendas. Even where women lead organisations, they are not ‘allowed’ to reorient the method and focus of these organisations to take into account gender and a woman’s perspective on the approach to struggle and rights.

In the context of SRHR the biggest problem is that identified by Pumla Gqola: we treat each act of violence, whether deliberate or by omission – as if it is an individual aberration. The only weapon in our armoury seems to be outrage. Outrage is a necessary starting point, but it alone doesn’t bring change. We have to fight a system of rape by consistently demanding and campaigning for a system of rights. In the words of Pumla Gqola:

“… we need to rebuild a mass-based feminist movement, a clearer sense of who our allies in this fight really are, to return to women’s spaces as we develop new strategies and ways to speak again in our own name, to push back against the backlash that threatens to swallow us all whole.”

If this challenge is not taken up by civil society immediately, ultimately our other efforts will be unsuccessful.

The question is how and when?

[1] Url to policy on HIV in schools

[2] Url to policy on pregnancy and S27 and EELC submission

[3] https://www.indexmundi.com/south_africa/demographics_profile.html

[4] Of the 969 415 births registered in 2016, 136 996 (13,9%) were born to mothers who were between the ages of 10 and 19 years old. A large number (783 322) of the births registered in 2016 occurred to mothers between the ages of 20 and 39 years; of these, 243 148 (31%) occurred to mothers within the 20−24 years age group. A total of 34 923 (3,6%) of births registered in 2016 were to mothers in the 40−54 years age group. http://www.statssa.gov.za/?p=10524

[5] Nicholas Spaull, What Should We Be Focusing On in the Next 10 years, October 2017 https://www.dropbox.com/s/7lz256gjl3wk2sv/Penreach%20-%20Spaull%20(Oct%202017).pptx?dl=0.

[6] http://www.hsrc.ac.za/uploads/pageContent/4991/Gender%20inequalties%20in%20education%20in%20South%20Africa.pdf

[7] https://africacheck.org/reports/sa-teen-pregnancies-not-increasing-as-bbc-claimed/

[8] https://www.dailymaverick.co.za/article/2018-01-29-health-e-news-abortion-the-legal-service-performed-mostly-illegally/#.Ws7aImXBbou

[9] According to a recent study by the Foundation for Human Rights http://www.fhr.org.za/index.php/latest_news/democracy-challenged-south-africas-largest-attitudinal-survey-constitution/ only 51% of respondents were aware of the Constitution and the Bill of Rights and “as poverty levels increased, so the awareness levels decreased.” Shockingly, but perhaps not surprisingly “In response to the statement that married women are allowed to refuse to have sex with their husbands, a worrying two fifths (41%) of all respondents disagreed with this statement. Again the differences between male (44%) and female (39%) were not that stark.”