At the United Nations (UN) General Assembly gathering in September 2015, member states held a special summit to consider and adopt a global development agenda for the next 15 years, a plan of action for "people, planet and prosperity" entitled the Sustainable Development Goals (SDGs).1 The SDGs are ambitious in their size and scope, consisting of 17 goals and 169 targets that are applicable to all countries, rich and poor equally, and take into account the economic, social and environmental challenges of our world. They differ from the Millennium Development Goals (MDGs) that preceded them by focusing not only on meeting the needs of the world’s poor but also on sustainable development—that is, "development that meets the needs of the present without compromising the ability of future generations to meet their own needs."2 This expansive approach involves all sectors of society and a host of topics, including ending hunger, promoting access to efficient energy sources, enhancing economic growth and employment, promoting health and well-being, and achieving gender equality.
The SDGs matter because they are intended to drive the allocation of global financial and human resources, and to help direct nations’ and donors’ policy priorities between now and 2030. With this global consensus in hand, the real work will be in the details—specifically, how countries commit to these global goals, adapt and implement them locally and measure their progress.
For the field of sexual and reproductive health and rights (SRHR), the SDGs include several relevant goals and targets such as those related to health, education and gender equality. The goals and targets encompass many key aspects of SRHR, including access to sexual and reproductive health (SRH) services, comprehensive sexuality education and the ability to make decisions about one’s own health.
From the MDGs to the SDGs
The SDGs will build upon the work of the MDGs—the first set of time-bound global development targets focused on global partnership and human development (see chart).3 Adopted by UN member states in 2000, the MDGs consisted of eight goals designed to measure progress on poverty reduction in developing countries through 2015. The initiative led donors and host countries to align their investments and their development strategies, and provided benchmarks for countries to track their progress against each of the goals. The MDGs had a mixed record of success: For example, over those 15 years, developing countries reduced the number of people living in extreme poverty by more than half and improved access to sanitation for more than two billion people, and a majority of countries achieved gender parity in primary education.4 However, the MDGs were less successful in the area of SRHR. This may, at least in part, be attributable to the fact that the MDGs were originally completely silent on the role or importance of SRHR in improving health—especially, maternal and newborn health—and in promoting economic and gender empowerment. Even though SRHR related directly or indirectly to all eight MDGs, political opponents of these rights and services—including the George W. Bush administration—helped to sideline these well-established links during the MDGs’ initial years. The absence of SRHR from the description of the goals signaled to donors and countries that they should focus their attention elsewhere.
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It was not until 2007 that advocates convinced the UN to specify that achieving universal access to reproductive health by 2015 was a necessary component of Goal 5, to improve maternal health. Although this new target represented major progress, its narrow focus failed to reflect the much broader SRHR agenda that has developed over the last two decades. That agenda, which focuses on individual choice and rights, was set in motion by two groundbreaking framework documents from major international conferences in the mid-1990s, the Programme of Action of the International Conference on Population and Development (ICPD), and the Beijing Platform of Action.5
By stark contrast, the process of devising the post-2015 global development plan for the ensuing 15 years has been transparent and consultative on a global level. The UN began the process of creating the SDGs several years ago with hundreds of discussions and meetings, and with the solicitation of input from the general public, including an online consultation that garnered millions of comments. The SDGs that resulted from this process represent an opportunity to make up for where the MDGs fell short, especially regarding SRHR. UN member states have taken a crucial first step toward that end by adopting a framework that explicitly recognizes how integrally important enhancing SRHR is to achieving the larger goals.
Measuring SRHR Progress
The 17 goals of the SDGs are far-ranging and ambitious. They are also interconnected, as are the strategies for addressing them (see table). These strategies are reflected in the 169 targets listed under the various goals. Three of these targets are particularly relevant for promoting SRHR, one each under the health, gender equality and education goals (see tables).1
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Determining what constitutes success toward these goals and their targets to ensure that the SDGs amount to more than a political declaration will be both complex and vital. An interagency expert group established by the UN Statistical Commission will formally approve specific global indicators for each SDG target early in 2016. The expert group must balance a wide range of competing priorities and technical limitations to come up with a formal list of indicators that is narrow enough to be usable, applicable and achievable for every country, and is as insulated from politics as possible (see box). To inform and influence this process, advocates and technical experts are putting forward specific recommendations for the interagency expert group—and ultimately countries themselves—to consider and adopt.
In late 2014 and early 2015, the Guttmacher Institute led one of many informal processes to produce recommendations relating specifically to SRHR indicators. Potential indicators were assessed in terms of their relevance and feasibility given the targets agreed upon for the SDGs. That included the extent to which each indicator reflects core SRHR principles and outcomes, and how it is prioritized by advocates, as well as whether data are available for a significant proportion of countries, are nationally representative and are tracked over time. The recommended indicators—some of which are currently measurable and some of which are "aspirational"—fall under the health, education and gender equality goals and span the gamut of SRHR issues (see tables):
Contraception
Contraception is an essential component of family planning and SRH that allows individuals to determine if and when to have a child. Measuring the number of people whose contraceptive needs are being met with modern methods can help governments gauge how accessible services are for individuals who say they want to control their fertility.
SRH Service Availability
Ensuring that SRH services are made available along with other basic health care—for example, immunization services or treatment for tuberculosis—may increase access to care and information, especially for disadvantaged populations, such as adolescents, people with disabilities and those living with HIV. Identifying geographic areas where and types of services for which availability is lagging can help governments better target resources and technical assistance.
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Knowledge about SRHR
Improved SRHR knowledge can help young people make healthy, informed choices about their reproductive lives. Understanding levels of knowledge among adolescents can help identify gaps in preparing young people for this important part of life.
Adolescent Fertility
Measuring the adolescent birthrate and whether those births were planned can help quantify challenges facing young people, including their unmet need for contraception and lack of access to education, information and services appropriate for them. For very young adolescents (ages 10–14), early childbearing can be a marker of forced marriage and abuse.
Quality of Care Including Respect for Rights
It is critical that when people do access services, health care providers and institutions respect their rights and offer them high-quality care, including a wide choice of contraceptive methods and the information needed to make decisions about their care. Measuring quality of care is especially important when it comes to marginalized populations whose health outcomes have been threatened.
Prevention of STIs
Women and men who have contracted an STI can experience a range of serious and costly health consequences, including infertility, cervical cancer and an elevated risk of HIV. Tracking the uptake of vaccines against strains of the sexually transmitted human papillomavirus (HPV), which causes most cases of cervical cancer, can help governments assess how well they are meeting a particularly important STI prevention need.
Abortion
In order to protect women’s health and lives, it is critical to promote access to safe abortion and to reduce the incidence of and complications from unsafe abortion. Better data collection is necessary in this area to improve the medical and legal environment for providing safe abortion care and to reduce the stigma surrounding the procedure.
Comprehensive Sexuality Education
Accurate, evidence-based, age-appropriate information and education on sexuality and sexual health can improve sexual health knowledge and reduce risky sexual behaviors. Tracking whether schools are offering this type of instruction can help governments understand whether young people are receiving the information they need to protect themselves.
Gender Equality in SRHR
Lack of gender equality affects almost every facet of life for women and girls around the world. Measuring societal attitudes about women’s autonomy in marriage will help countries to assess how well they are addressing gender disparities. Equally important is assessing national policies that reflect the rights of informed decision-making about and access to sexual and reproductive health information and services.
Measurement Challenges
The UN’s interagency expert group and the independent technical experts who are working to identify and define indicators for the SDG process are facing numerous competing priorities and technical challenges. One key piece is the capabilities of the existing data collection systems, including the Demographic and Health Surveys Program (DHS), a trusted source for global collection and dissemination of national health data. To the extent possible, experts are grounding their proposed indicators in existing data collection systems. However, truly comprehensive global monitoring will require some countries and nongovernmental organizations to expand their statistical systems, particularly where data and research are not widely used in health-related decision making. Moreover, some "aspirational" indicators will require investment in entirely new data collection efforts, as well as further work to develop common definitions and data collection methodologies.
A second key challenge is the adaptation of current data collection systems to fully assess disparities within and across countries, and to protect human rights in health. Data collected through national and international surveys are often broken down by characteristics such as sex, age and location. To the extent that it is technically feasible, experts are looking to include a wider range of characteristics, including wealth, education, gender identity, sexual orientation, disability, race, ethnicity and marital status. That will help governments and researchers to better assess which populations are being left behind. Another important consideration in developing and choosing indicators is ensuring that governments respect and protect the privacy rights of individuals who are surveyed. Many actors involved in the SDG process are promoting a "big data" approach, by setting up new data collection systems around the world. This could greatly improve the way that governments identify and solve social, economic, health and environmental challenges;15,16 however, without proper management and strong legal protections, personal data—including health data—could end up in the wrong hands. If that were to happen, the personal information of millions of individuals could be exposed and members of marginalized groups could end up subjected to further stigmatization and harm, especially in developing countries.
Several key issues related to SRHR have been left off the Guttmacher-led list of recommended indicators. For example, the areas of HIV and maternal health are covered by other targets under the health goal (3.1, 3.2 and 3.3). And most notably, sexual rights remain poorly represented: That topic has been excluded from the adopted SDG targets, thus making it difficult to introduce at the indicator level. Although there is no universally agreed upon definition of the term, for years the SRHR community has drawn from both the internationally negotiated 1995 UN Conference on Women in Beijing and the World Health Organization’s working definitions, which include the rights to choose one’s partner, to information and education and to a satisfying, safe and pleasurable sex life.6,7
In recent years, the understanding and use of "sexual rights" has expanded to include sexual orientation and gender identity. In fact, last month, such a definition was promoted by the U.S. State Department when it announced its use of the term to show "support for the rights and dignity of all individuals regardless of their sex, sexual orientation or gender identity."8 This definition is a step in the right direction, although it fails to define sexual rights as human rights or as legally binding.
2016 and Beyond
Money and political will need to come together to turn the SDG declarations into action. Global institutions, such as the World Bank Group, have put forward a plan to finance global development over the next 15 years, including the SDGs. Governments—both those traditionally cast as donor and as recipient—UN agencies and the private sector must all be involved in identifying and managing the substantial amount of funding that will be required to implement and monitor the SDGs, as no one country or funding source can foot the bill alone.9,10
Countries have numerous decisions to make as they implement the SDGs. For example, they must choose which indicators to measure and focus on; whichever global indicators the interagency expert group ultimately adopts, each country is free to delve more deeply. There is also an opportunity to align future aid planning with indicators and targets in national and regional development plans. Governments can use the indicators suggested by the SRHR community to guide funding and policy priorities in this area for both national and regional planning over the next 15 years.
Nongovernmental organizations are already playing a key role by identifying and advocating for an expanded SRHR presence in the post-2015 framework.11 Given the way that SRHR issues have been sidelined in the past, advocates know that they must be vigilant at the global and country levels to ensure that SRHR remain a high priority, especially toward achieving the goals on health, education and gender equality. That includes holding governments accountable to adopt comprehensive indicators related to SRHR and to follow up when those indicators identify potential areas for investment and improvement.
As the single largest donor to the developing world—for family planning and reproductive health assistance, as well as more generally12—the United States has been a strong leader in this area for decades. At this important global moment, U.S. leadership is more vital than ever. Expressing the nation’s official support of SRHR in the 2030 agenda, Tony Pipa, the U.S. State Department’s special coordinator for the post-2015 development agenda, recently stated, "We welcome also the recognition of women’s sexual and reproductive health and reproductive rights. We believe we could have gone farther and broken new ground."13
This call for even more advancement in the area of SRHR should be taken up by all parts of the U.S. government. For example, the U.S. Agency for International Development has the technical expertise to help refine existing measurement systems, such as the Demographic and Health Surveys, and to help create new measures to catch up to modern priorities. Moreover, advocates are looking to the U.S. government to increase its financial commitment to family planning and reproductive health abroad to at least to $1 billion, from the current $610 million,14 to meet the existing need and to actively participate in supporting the SRHR agenda related to the SDGs.
The success of key SDGs will depend in significant part on the extent to which important stakeholders—including governments, UN agencies and nongovernmental organizations—take seriously the specific SRHR targets and fully implement the relevant policies, services and programs to attain them. If these targets can be met, it will increase the prospects for achieving the goals of health, education and gender equality. And, approaching success on these three goals will increase the prospects for the SDGs overall. No doubt, the SDGs lay out a hugely ambitious agenda for the global community between now and 2030, but at the same time they offer a path toward enhancing the health and lives of people around the world.
This article was made possible by grants from the William and Flora Hewlett Foundation and the John D. and Catherine T. MacArthur Foundation.
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