Comprehensive Health Services: A Q&A with Dr. Githinji Gitahi
Healthy girls and women are the cornerstone of healthy societies. Provide girls and women access to health throughout their lives and they will deliver a healthier and wealthier world.
As momentum builds toward achieving Universal Health Coverage (UHC) – the goal of reaching everyone with quality, affordable health services for all – governments have a responsibility to ensure effective systems are in place to provide a continuum of care for girls and women, including access to sexual and reproductive healthcare. Without an intentional, relentless commitment to gender equality, even well-meaning plans to advance universal health coverage can leave girls and women behind.
This month, the Deliver for Good campaign explores the road to Universal Health Coverage that delivers for girls and women with a special Q&A between Katja Iversen, President/CEO of Women Deliver and Dr. Githinji Gitahi, Director General of Amref and co-chair of UHC2030.
1. Katja Iversen: As I have said before, “girls’ and women’s health and rights are more than a measure for progress on UHC. They are a prerequisite.” In your experience, what are the strongest links between gender equality and health and how can we work to ensure UHC delivers for the unique health needs of girls and women?
Dr. Githinji Gitaji: In many communities in Africa, women are not the final decision makers even in matters of their own health. This inequality has a devastating effect on the health of women and girls. Gender inequality and unequal gender norms influence access to health services. The imbalance in power between men and women is the single most important cause of the higher rates of HIV and other sexually transmitted infections in women. Women do not always have the power to ensure safe sex; in fact they may not have the ability to choose when and with whom to have sex and or to decide if or when to have children. The proportion of women who have an unmet need for modern contraception is highest in sub-Saharan Africa – at 21%.
UHC is not only about access and affordability. Even if women are empowered to make decisions about their own health, they may not have the resources to pursue their health needs.
Therefore, for me, UHC starts at the community. Communities – women and men, girls and boys – need to be empowered to raise their voices and claim their rights not only from their duty bearers but also within their own communities. Social norms that enable and perpetuate inequality need to be challenged and changed within communities. At Amref Health Africa, we have found that when we bring together all community members – women, elders, religious leaders, girls, boys, men – practices that drive inequality and prevent lasting improvements in the health of girls and women can, and do, end.
2. Katja Iversen: Many governments and organizations have committed to advancing UHC for all – yet there is still debate around the inclusion of sexual and reproductive health and rights. What argument do you make to ensure SRHR is prioritized on global health and sustainable development agendas? Provide examples.
Dr. Githinji Gitaji: The 2018 Guttmacher-Lancet Commission’s report shows the broad scope of the unfinished sexual and reproductive health and rights (SRHR) work: in developing countries, still more than 200 million women are not using modern contraception methods whilst they would like to avoid a pregnancy; more than 45 million women have inadequate or no antenatal care; and more than 30 million pregnant women do not go to a health facility for delivery because they can’t access one or they haven’t been informed about the health benefits for themselves and their babies.”
There is widespread agreement among the global community that UHC will never be achieved if we continue to ignore large gaps in the health system created when sexual and reproductive health and rights are not made a priority.
On the road towards UHC, I see a risk that the focus of the global community will be predominantly on approaches that are rooted in a “universality” perspective, clearly aimed at achieving universal coverage. However, when talking about universal coverage, it is an easy mistake to assume “uniformity” of populations at the community level. We know different population groups have different health needs. We know that equity measures are needed for marginalised groups to ensure that all people can access the health services they need. We know that these equity measures can be very specific. The problem is that the voice of these population groups in the process of defining these equity measures often gets lost in statistical data, where they always remain a small minority. This is also why I have been advocating for a 7th building block of the health system in addition to the current 6 WHO building blocks for health systems that incorporates communities and citizen needs.
Only if we make the road towards UHC an inclusive pathway of change, we will be able to realise universal coverage of sexual reproductive health and rights as part of UHC. This starts at community level, where we need to empower women, men, girls, boys, teenagers, health workers and community leaders to hold decision makers in the health sector (and other sectors, e.g. education, agriculture) accountable for high quality sexual and reproductive health and rights for all. This requires an open and well-informed citizen dialogue, engaging all community members, civil society, government actors and private sector. At the same time, the global community needs to critically reflect on the implementation plans for UHC to see if the right accountability mechanisms are in place to ensure that the target of UHC includes sexual and reproductive health and rights for all. The 2017 Global Monitoring report by WHO and World Bank has 16 tracker indicators of which one is on level of family planning demand satisfied with a modern method among women 15–49 years who are married or in a union (%). This indicator needs to be rethought to capture ‘sexually active’ women so it’s not discriminative either by choice of age.
It is only with well-defined accountability mechanisms that tracking of sexual and reproductive health and rights progress in the light of UHC at the national level can be facilitated.
3. Katja Iversen: Amref and Advocacy Accelerator are working on a new initiative to increase capacity and support for youth to advocate for policy changes that would advance gender equality and sexual and reproductive health and rights in Kenya. When we talk about UHC2030, how can organizations ensure meaningful youth engagement at all levels?
Dr. Githinji Gitaji: 77 percent of the population in sub-Saharan Africa is younger than 35 –that's around 770 million people. These are 770 million young people with dreams, potential and aspiration to shape Africa now and into the future. Young people want to be involved and empowered to strategically engage in specific issues that affect them in their communities, counties and countries.
Whilst the time to act is at the greatest, the impact of youth advocacy is often hindered by a lack of skills, tools and resources. There are also limited mechanism for identifying, connecting and engaging youth in strategic advocacy. Furthermore, we have to understand that young people are not a homogenous group and that power imbalances already start at birth between boys and girls that sometimes hinder female participation. For example, in Kenya we know that rural and pastoral communities have fewer female led organisations. It is important to understand and act upon that.
Strengthening skills of youth led and female led grassroots organisations is essential to make inclusive impact.
Therefore organisations need to support youth to increase their representation and promote meaningful youth engagement in national and county district level decision making bodies. We need the voices of young rural women, to ensure that UHC indeed becomes Universal. Understanding communities, empowering girls and boys, engaging them in decision making bodies and providing them the tools will help us to shape UHC for our youth. For example, at Amref Health Africa we organise youth parliaments where young people are given a voice to discuss sexual and reproductive health and rights policies and governance. Through these initiatives we strengthen social accountability at the grassroots level so that their voices are heard in policy making.
4. Katja Iversen: Achieving UHC is a complex and ambitious goal. How do you personally remain committed and resilient in this work?
Dr. Githinji Gitaji: I come from a community where access to health has remained poor through the ages. I have seen people die young from diseases that are preventable and treatable. In Amref Health Africa we believe in partnering with communities to bring lasting health change to reverse the current trends. We have been able to achieve good results in a number of countries and each little success we achieve fires me up to develop and scale up more innovative interventions for reaching UHC.
5. Katja Iversen: What is your one, tweetable, commitment to advancing gender equality and the health, rights, and wellbeing of girls and women?
Dr. Githinji Gitaji: Universality is not uniformity. Think women and girls first. Courageously, unapologetically!