Whether marginalized populations, such as adolescents, LGBTQ+ people, migrant workers, and sex workers are included in health services can be a “litmus test” of our progress towards universal health coverage (UHC), said Sivananthi Thanenthiran, Executive Director of Asian-Pacific Resource and Research Centre for Women (ARROW). Thanenthiran spoke at a recent Wilson Center event with the United Nations Population Fund (UNFPA) and the World Health Organization (WHO) Department of Sexual and Reproductive Health and Research about the importance of engaging stakeholders in sexual and reproductive health (SRH) to achieve UHC for all. In SRH services, the most marginalized and most vulnerable populations are often left out, she said. When engaging stakeholders, representatives from these groups must be included to ensure equity in healthcare services.

“Progress depends very much on ensuring the participation of all relevant stakeholders in priority-setting processes,” said Veloshnee Govender, Scientist, Department of Sexual and Reproductive Health and Research at WHO. Certain stakeholders, such as healthcare workers, must be included in planning and implementation of services, because they are actually those who are going to provide the services to the population, said Dr. Atiya Aabroo, Deputy Director of Programs at the Ministry of National Health Services, Regulations, and Coordination in the Government of Pakistan. But UHC advocates must cast a wider net to include all relevant stakeholders. Civil society should be involved in designing and implementing population programs to ensure that they meet key populations’ unique needs, said Jacques van Zuydam, Chief Director of Population and Development at the Department of Social Development, South Africa.

The COVID-19 pandemic has exposed and amplified pre-existing challenges to health systems and restricted access to SRH services for many vulnerable populations, said Govender. But the pandemic also presents a new opportunity to advance sexual and reproductive health on the global stage. An unprecedented political commitment toward universal health coverage and sexual and reproductive health is “growing” tools to make progress toward both goals, said Govender.

Marginalization and Criminalization of Populations Leads to Poor Health Outcomes

Three key fault lines dominate the conversation about SRH and UHC: marginalization and criminalization of populations, social norms and sanctions around sexuality, and conscientious objections, said Thanenthiran.

Sex workers are one of the key criminalized populations left out of reproductive health conversations, said Ruth Morgan Thomas, Global Coordinator at Global Network of Sex Work Projects. They face significant structural barriers to care. Since sex work is not recognized as formal work, sex workers are not offered the same social protections and occupational health protections as those who work in other sectors. Sex workers’ SRH needs are greater than just HIV prevention and treatment, said Thomas, and they must be included in conversations about UHC to create programs that fit their needs.

Other criminalized groups, like migrant workers, lack access to safe SRH care and go “underground” to seek services. Migrant workers suffer higher rates of maternal deaths and are not covered by insurance that provides access to contraception, family planning, or safe abortion services. Removing legal barriers and affirming the rights of all marginalized groups is key to ensuring access to sexual and reproductive health for all, said Thanenthiran.

Social Norms Stigmatize Discussions about Sex

Adolescents are a key group that must be reached in discussions about SRH. Young people often face discrimination when trying to access HIV services and other SRH services, said Zandile Simelane, Youth HIV Advocate in Eswatini. Healthcare providers can be judgmental and question why young people need contraceptives, she said. To reach adolescents, Simelane utilizes social media to meet them where they are and start conversations about HIV prevention and SRH care. Young people must have a seat at the table to design programs for HIV prevention so that programs are accessible and applicable to their needs.

A country’s Department of Education is a key stakeholder in engaging adolescents and implementing these programs, said van Zuydam. Comprehensive sexuality education is “part and parcel” of sexual and reproductive health and rights, said Thanenthiran, and will help adolescents realize their SRH needs and prevent gender-based violence. Yet there is no formal or standardized training for sexuality teachers. Engaging education systems in conversations about SRH will help bridge inequities in access to information for adolescents, said van Zuydam.

Both Simelane and van Zuydam said social media was a key tool for engaging adolescents, but huge digital inequality particularly affects marginalized communities. When schools closed at the beginning of the COVID-19 pandemic, people were scared or unable to access SRH services and turned to social media for information. Those who can access this information are mostly people who live in urban areas with smartphones, leaving poor young people in rural areas further behind. Social media on its own is not enough, said Simelane. Bridging these inequities requires community-led interventions and mobilization outside of the digital sphere, said van Zuydam.

Conscientious Objections

In conservative societies where abortion is illegal, women and girls struggle to access services, said Thanenthiran. In countries like India and Nepal, a social barrier prevents young unmarried women from accessing abortion. They must seek approval from a court, which delays service delivery, and courts rely on doctors’ opinions to decide whether the individual is capable of safe delivery, rather than a person’s bodily autonomy, to decide whether an abortion is allowed, said Thanenthiran. Similarly, conscientious objections to homosexuality in conservative societies often lead to a lack of funding for health services, like HIV prevention and treatment, because taxpayers do not want to fund these services. In countries where homosexuality is criminalized, LGBTQ+ populations turn away from formal health systems, which exacerbates health inequities.

“What these fault lines actually show us is that the uniformity of what constitutes SRH services and who can access SRH services is fragmented across countries,” said Thanenthiran. A wide variety of barriers including laws and stigmas prevent people from seeking sexual and reproductive health services in different countries. Across the globe, the most marginalized communities are being left behind in the effort to reach UHC. Marginalized and criminalized communities must be brought into conversations about SRH so that programs reflect their unique needs.

“And we have to put the last mile first, if we’re going to leave no one behind and actually achieve universal health coverage for all,” said Thomas. Criminalized and marginalized populations should be at the forefront of conversations about SRH and UHC. When individuals face stigma and discrimination, like when their rights are denied, she said, that keeps us from what we’re all trying to achieve, which is “health for all with no exception.”