CNS: Sexual and reproductive health services are essential services, including during pandemics like COVID-19

The recently released Asia and the Pacific SDG Progress Report 2020 shows that Asia and the Pacific region is not on track to achieve any of the 169 targets of the 17 sustainable development goals (SDGs), including those around ensuring universal access to sexual and reproductive health services. Despite commitments made by governments, inequality in the region is growing and the economic gains made by it are not translating into poverty reduction and gender equity.

A pandemic like corona virus disease (COVID-19) has added more fuel to fire to push the region (and perhaps the rest of the world too) several steps back to achieve 'Health for all' by 2030 by severely constraining (or threatening to constrain) health systems. It has also impacted delivery of several significant public health services, including sexual and reproductive health services.

Leading community experts voiced their concerns during the recently held #APCRSHR10 Dialogues, co-hosted by the 10th Asia Pacific Conference on Reproductive and Sexual Health and Rights (APCRSHR10) and CNS.

The COVID-19 impact

"While our day to day health needs, including sexual and reproductive health needs, do not stop because of an epidemic, but health service availability becomes still more difficult during such times:, said Alexandra Johns, Executive Director of Asia Pacific Alliance for Sexual and Reproductive Health and Rights (APA).

Alexandra foresees a global shortage of medical supplies, including medicines for people living with HIV, contraceptives and antibiotics, as a fallout of lockdowns imposed by governments to stem the tide of COVID-19. The situation is all the more grave for key and vulnerable populations, including sex workers. With weak health systems groaning under the load of COVID-19, service delivery to cater to their specific needs, like access to abortion services, contraceptives, and life saving treatments, along with a loss in wages, is bound to take a hard hit.

Even in normal times, there is more focus on sexual and reproductive health services for women and not for sex workers, rued Kay Thi Win, Regional Coordinator of Asia Pacific Network of Sex Workers (APNSW).

"It is very difficult for them to access these services, leading to unwanted pregnancies and also sexually transmitted infections like HIV. Moreover, they do not have easy recourse to safe abortions or even PPTCT (prevention of parent to child transmission of HIV) services."

In many countries, sex workers are facing a huge financial crisis, with the bars, restaurants and other places closed. For them, loss of income is a bigger concern than the virus, as they are sole breadwinners for their families. Then again, most of the health providers are focusing on managing COVID-19 and not on providing sexual and reproductive health services and treatment for other health problems, said Kay Thi.

Liz Hilton of Empower Foundation, a Thailand based sex workers' association, rightly says that COVID-19 is exposing the weaknesses of our society. "While the corona virus does not discriminate between different members of society, the relief and the government assistance package often does", she says.

She shared the example of Thailand, where sex workers are not looked down upon as 'other people'. Most of them are carers, mothers and family providers. They are not that different from other workers, but they are excluded from labour protection and social security benefits. They have not had any income since the 18th of March, when in response to the COVID-19 pandemic, Thailand had closed down all bars and entertainment places.

Meena Saraswathi Sheshu, founder of Sampada Gramen Mahila Sanstha (SANGRAM), an organisation that works for sex workers' rights in Maharashtra and northern Karnataka, India, echoed similar concerns: "The main problem that the sex workers face is that of livelihood. Since the lockdown (in India) sex workers have had no clients, and hence no income, and many of them are under severe mental stress. Just this morning (30th March) unfortunately, one of them committed suicide by burning herself because she could not deal with the tension of no work, no money, and living in isolation in the brothel."

Meena is also wary of the fact that as the brothels are all thickly packed with women, if one of them gets infected it will spread quickly to others. Then again, while most sex workers are young, there is a critical number of those who are old and/or who live with co-morbidities like diabetes, TB or HIV. Caste is another big issue in India: "Most of the sex workers we work with are from the Dalit caste which puts them in further vulnerability. Dealing with a pandemic like COVID-19 is not easy for communities that live in packed slum like situations and have to earn to be able to eat. There is no way this community is going to weather this easily. We will need the government to step in a big way to help them", she said.

Due to the existing social inequities, even the scientific advisories issued by governments of the region to protect oneself from the corona virus are beyond the capacity of many to follow. People are being told to wash their hands repeatedly assuming that they have access to clean water and sanitation facilities, which many do not have. Then again maintaining physical distancing is a huge problem for many, like those living in very confined spaces in brothels and slums.

Barriers to accessing sexual and reproductive health services

Hopefully COVID-19 will pass, albeit after having a devastating effect on our lives. But systemic barriers to make sexual and reproductive health services available to all will remain, unless governments act proactively. Alexandra lists some of these barriers as:

neoliberal corporate systems favouring the few over the many;
militarism that is diverting funds away from health services;
Gender discrimination in the workforce,
patriarchy and the rise of authoritarian governments that is preventing women from accessing rights-based sexual and reproductive health services, information and education;
discriminatory/ regressive laws and policies that are still in place in many countries of the region- criminalising of LGBTIQ communities and same sex activities, criminalising sex work, restricting access to abortion, early/ forced child marriages, female genital mutation, etc.

For sex workers, lack of information and lack of access to sexual and reproductive health services is a big barrier, says Kay Thi. In some countries these services are not available to them at all. Even where they are available, they are either not affordable for many sex workers and/or there is lack of information about what services are available and who provides them.

The way forward

Both Alexandra and Kay Thi emphasise that not only should governments address these issues urgently, but also generate more data around sexual and reproductive health and rights (SRHR). Even the UNESCAP progress report mentions that data is available for only 42% of the 169 targets of Agenda 2030 in the region. Evidence based qualitative (and not just quantitative) data from the community members is necessary to monitor progress and advocate with policy makers. Engaging civil society in decision making is imperative to ensure an effective and appropriate response. Kay Thi insists that governments must acknowledge the experience and expertise of the communities (like sex workers), and gain their trust to work with them. Meaningful community engagement is very effective, especially in times of crises like COVID-19, when sex workers' led organizations are working with the community to spread awareness around COVID-19 and also providing them with condoms, lubricants, masks and hand sanitisers.

It is crucial for governments to have strong health systems, and a rights-based approach to health, through meaningful (and not just tokenism) participation of the communities in the health response, to realise the goal of Health For All, leaving no one behind.

Shobha Shukla - CNS (Citizen News Service)

5 April 2020