Elsevier

The Lancet

Volume 380, Issue 9837, 14–20 July 2012, Pages 172-180
The Lancet

Series
Use of human rights to meet the unmet need for family planning

https://doi.org/10.1016/S0140-6736(12)60732-6Get rights and content

Summary

In this report, we describe how human rights can help to shape laws, policies, programmes, and projects in relation to contraceptive information and services. Applying a human rights perspective and recognising the International Conference on Population and Development and Millennium Development Goal commitments to universal access to reproductive health including family planning, we support measurement of unmet need for family planning that encompasses more groups than has been the case until recently. We outline how human rights can be used to identify, reduce, and eliminate barriers to accessing contraception; the ways in which human rights can enhance laws and policies; and governments' legal obligations in relation to contraceptive information and services. We underline the crucial importance of accountability of states and identify some of the priorities for making family planning available that are mandated by human rights.

Introduction

Other articles in this series outline the many benefits of investment in family planning, including acceleration of progress towards achieving the Millennium Development Goals. We explain how measures to respect, protect, and fulfil human rights1 enable people to use contraceptive information and services and help achieve the full benefits of such investments.

Many people think of human rights in terms of violations. This aspect is important, and the history of family planning policies and programmes—particularly some undertaken for population control—includes instances of people being coerced to accept contraceptive implants or intrauterine devices and being subjected to forced abortion or sterilisation.2, 3, 4, 5, 6, 7, 8, 9 Human rights mechanisms, such as treaty monitoring bodies, regional human rights tribunals, and national courts, enable individuals and communities to seek redress for such violations.6, 7 Human rights law can also be used to prevent violations occurring in the first place. For example, consideration of human rights standards can ensure that health services do not discriminate against particular groups such as people younger than 18 years, ethnic minorities, or people with HIV infection, and can also require improvements in the quality of services. When human rights are integrated into policy-making processes, they can help to ensure that health facilities and services are non-discriminatory and of good quality from the outset. The application of human rights law and standards to programme design and monitoring, and use of human rights mechanisms to hold governments accountable, are essential devices to ensure health for all.

Internationally agreed human rights that are particularly relevant to contraceptive information and services include the rights to: non-discrimination, information and education, the highest attainable standard of health, privacy, and life.10, 11, 12 These rights are inextricably linked. For example, the right to the highest attainable standard of health, which includes access to health services and health-related information, cannot be fulfilled without promotion and protection of the rights to education and information because people must know about services to use them. In this report we give special attention to the right to contraceptive information and services, which is grounded in these internationally recognised human rights,13, 14 and we suggest that the promotion and protection of these rights should be part of a multidimensional strategy to satisfy the unmet need for family planning.

Over the past four decades, international human rights law has established and expanded standards for sexual and reproductive health, including family planning. For example, states have affirmed the right to the highest attainable standard of health,10 authoritatively interpreted to encompass “sexual and reproductive health services, including access to family planning”.15 They have also agreed to “eliminate discrimination against women in the field of health care in order to ensure, on a basis of equality of men and women, access to health care services, including those related to family planning”.11 These agreements are legally binding for all the countries that have ratified the relevant covenants and conventions, such as the International Covenant on Economic, Social and Cultural Rights, the Convention on the Rights of the Child (CRC), and the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). All states in the world have ratified at least one of the core international human rights treaties and most have ratified many more.16 Many have translated these standards into their national laws and regulations, and many national constitutions guarantee rights such as the right to non-discrimination. These standards place legal obligations on governments to make high quality contraceptive information and services accessible for everyone, and to enable people to demand access to such services.

Key messages

  • Promotion and protection of legally binding human rights enable people to use contraceptive information and services and are essential to fully address the unmet need for family planning.

  • The principle of non-discrimination and the rights to the highest attainable standard of health, information and education, privacy, and life, provide the basis for the right to contraceptive information and services. Long-held programme, policy, and demographic definitions of who has unmet need for family planning need to be expanded to include unmarried people, particularly adolescents, women whose contraceptive method is unsatisfactory to them, and marginalised groups who are commonly discriminated against by health services.

  • International human rights law and various human rights mechanisms can be more effectively used to hold governments accountable for their obligations to remove barriers to contraceptive information and services, such as conscientious objection by health-care providers, poor quality services including shortages of commodities, and lack of community engagement.

  • In several diverse countries, human rights have shaped laws, policies, and programmes, accelerating progress towards universal access to contraceptive information and services, and to comprehensive sexuality education.

  • Three considerations should guide decisions about priorities for addressing unmet need for family planning: contraceptive information and services are best delivered as part of a package of mutually reinforcing sexual and reproductive health services; policies and programmes must be designed to serve everyone in need, especially vulnerable and disadvantaged people, without discrimination; and human rights, not only scientific evidence, must also be used to establish priorities.

  • From a human rights perspective, to eliminate the unmet need for family planning and achieve universal access to contraceptive information and services, the legally required priorities are: concrete national and subnational plans that will provide universal access; removal of legal and regulatory barriers; continuous supply of high quality reproductive health commodities, including the widest possible range of safe and effective contraceptives; appropriately skilled and supervised health workers who respect privacy and confidentiality, provide full and accurate information, and ensure free and informed consent; good quality facilities; removal of financial barriers to access; and effective monitoring and accountability mechanisms to check that human rights and other commitments are kept.

Human rights treaties are supported and amplified by intergovernmental consensus documents such as the Programme of Action of the International Conference on Population and Development.17 Such agreements can be used by various groups to hold accountable the governments that are party to them, and they also guide the policies and programmes of UN agencies, donor governments, and non-governmental organisations.

Because this series focuses on family planning, defined as contraceptive information and services, we do not discuss access to other essential sexual and reproductive health services such as prevention, diagnosis, and treatment of sexually transmitted infections, and provision of safe abortion, although access to safe abortion is also central to women's ability to regulate their fertility. International human rights law requires that governments provide a comprehensive legal and policy framework to ensure that abortion services allowable by law are safe and accessible in practice.18, 19, 20 This obligation requires that health providers be trained and equipped, and that other measures be taken to protect women's health. Other issues crucial to the health and human rights of women are outside the scope of this report, such as early and forced marriage and female genital mutilation, both of which breach international human rights law.12, 21, 22, 23

Section snippets

Whose unmet need?

The human rights principle of non-discrimination leads us to examine who is included in prevailing definitions of unmet need by policy makers, programme managers, service providers, and demographers. The sources used to estimate unmet need generally include only married or cohabiting women of reproductive age who do not want to become pregnant, but who are not currently using a modern method of contraception. However, as data have become available from some countries for sexually active

Use of human rights to overcome barriers to access

The right to the highest attainable standard of health requires that everyone can access health information and services without restrictions, including specific services related to family planning15 that are both affordable and delivered in a timely fashion.33 Nonetheless, many barriers impede women's access to contraception, including: conditions that do not allow them to make free and informed decisions (such as lack of intelligible information or counselling); lack of confidentiality; the

Laws and policies in line with human rights commitments

Making human rights explicit in a country's laws, policies, and programmes can help to ensure positive health outcomes for all. For example, for more than a decade, Brazil has put in place various strategies aimed at improving women's health, particularly sexual and reproductive health, explicitly shaped by human rights.59 In 1996, the National Congress approved a law on family planning according to which family planning is a right of every citizen.60 Thereafter, two successive national

Legal obligations and mechanisms for accountability

Because international and national human rights give rise to legally binding obligations on states, they demand accountability of states for their performance. Accountability can be achieved through many different mechanisms and procedures that vary from country to country, and also include the UN and other mechanisms with global responsibility. A few examples include national courts, national human rights institutions, international human rights treaty bodies, democratically elected local

Conclusions: legally required priorities

We have shown that taking a human rights perspective of unmet need for family planning results in a broader definition than that conventionally used of who has a need and right to contraceptive information and services, of what kind, under what conditions. The right to contraceptive information and services, like other human rights, requires translation into many practical actions that will meet the needs of diverse groups living in diverse circumstances. Thus priorities and plans must be

Search strategy and selection criteria

We reviewed all major human rights sources, such as international and regional covenants and conventions, international, regional, and national human rights law relevant to family planning, together with work (including published and unpublished material) done by UN agencies, human rights experts, and non-governmental organisations in which human rights have been actively used in support of sexual and reproductive health. Because a PubMed search with the terms “human rights” and “family

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