When policy isn’t enough: Examining accessibility of sexual and reproductive health rights for displaced populations in South Africa

Author: Lidya Stamper
Research Fellow, Centre of Human Rights, University of Pretoria

The right to sexual and reproductive health services (SRHS) is a fundamental human right for all, guaranteed under international human rights law. Legal protections outlining these rights have been recognised in South Africa through international, regional and domestic instruments. More specifically, these protections are highlighted and specified in documents such as the ‘Convention on the Elimination of all Forms of Discrimination Against Women’ (CEDAW), the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (Maputo Protocol), and the 1996 Constitution of the Republic of South Africa. Despite the presence of these legal frameworks, outlining equality and non-discrimination, persistent inequalities continue to act as barriers to exercising SRHS. Legislative and policy advances in SRH have been undermined by a lack of successful implementation and improvements in service delivery, service accessibility, and service availability. Implementation challenges combined with a fragmented health sector have resulted in various obstacles including a lack of standardised care, gaps in the dissemination of information, overburdened health facilities, and provider opposition. Social conditions such as gender inequality, poor access to health services, and provider attitudes continue to reinforce these barriers, undermining many of the intended outcomes of the existing legislative and policy advances in the SRH realm.

While access inequality has become a recognised problem amongst all individuals, the right to care continues to disproportionately impact displaced populations in the country, whose numbers have dramatically increased in the past 20 years.^[1] Within South Africa, and specifically within Johannesburg, critics have argued that large-scale development projects reflect one of the largest reasons for internal displacement in the post-apartheid era. These massive evictions often create situations of arbitrary displacement, in which individuals are torn from their homes, communities, original habitats, sources of work, and access to adequate health facilities. Displacement often places individuals a distance away from their regular point of access to health services, often leading to an infringement on their right to freely and fully access SRHS. As this year marks the 20th anniversary of the UN Guiding Principles on Internal Displacement, it is now more important than ever to advance and protect internally displaced persons (IDP) by ensuring equitable access to fundamental human rights services.

Due to the chaotic nature of the public health sector, many non-governmental organisations (NGOs) have undertaken reproductive service initiatives in areas with a weak or non-existent capacity to provide these services. This past year, I sat down with over 30 international, regional, and national organisations with the goal of identifying key variables that may impact rights-based SRHS intervention programming for IDP populations within the country.

My research findings reveal that providers play a critical role in determining access to, and quality of, SRHS outcomes. Participants explained that rights-based reproductive health frameworks and policies have little impact on everyday services when providers are not included in the creation and implementation of these initiatives. Organisations working specifically with community-based health clinics repeatedly referenced “moral policing,” “stigma” and “discriminatory attitudes” as some of the biggest barriers to accessing care. Gaps in sensitisation training and rights literacy as well as community-based beliefs around SRHS has made the baseline for accessing care extremely difficult. When individuals hold reservations about the judgmental and disapproving attitudes of their service providers in public sector facilities, they are more likely to seek alternative abortion options outside of the formal health sector. As noted by one of the interviewees:

“Individuals become overwhelmed with all the barriers from community partners, staff, friends, family etc…so much so that they stop accessing services because nobody’s going to go where they’re not wanted.”

The top-down policy process purportedly characterising the health system not only has led to a substantial gap in communication between policy makers and health care workers, but has reportedly exacerbated pre-existing challenges in health facilities such as overcrowding and staff shortages. Organisations working specifically with displaced populations not only re-echoed these challenges but spoke to the unique ways in which migrant populations have been impacted by these attitudes. Medical xenophobia in the form of delayed waiting periods, slower staff response times, and/or being turned away from treatment continue to disproportionately impact individuals on the move within the country. Intergovernmental establishments such as the International Organisation for Migration (IOM) further reference documentation or a lack thereof, as well as language barriers as indicators of service inaccessibility within migrant populations in South Africa.

For many, the context in which they live in determines access. Outside of sociocultural obstacles, economic circumstances and structural environments were considered the largest indicators of SRHS inaccessibility, with one participant explaining that:

“Clearly, everything we do as human rights activists is affected by people’s socioeconomic circumstances…personal finance mitigates any problem in terms of human rights access.”

For those reliant on public health facilities for SRHS, clinic availability and proximity become significant indicators of accessibility. High levels of poverty and unemployment within the country leaves individuals with little to no money to access transportation to the clinics as well as services. However, once an individual physically arrives at a clinic, findings reveal that service access remains challenging. Underfunded clinics with staff shortages often characterise facilities providing SRHS. Stock-outs and shortages were reportedly extremely common leaving the individual with only one contraceptive option, which undermines an individual’s ability to make autonomous decisions about their health. Barriers such as inconsistent hours, location, wait times, and underdeveloped facilities continue to impede access to SRH rights-based frameworks.

While these challenges impact everyone’s reliance on the public health system, populations on the move reportedly experience these barriers at higher rates, due to the inconsistent nature of service accessibility. Participants explain that the challenges facing vulnerable communities become exacerbated amongst populations on the move, as economic, physical, and structural insecurity are found to be more prevalent within displaced and migrant populations.

“When you have no fixed address or your address is constantly changing because of displacement, maintaining the details needed by service providers becomes extremely difficult, how can you provide contact details with no address?”

Barriers to accessing SRHS are multiple and often interdependent, with poverty, discrimination, gender inequality, resource and capacity constraints, and adverse political and legal environments working to undermine an individual’s ability to make autonomous and fully informed decisions regarding their sexual and reproductive health. My findings reveal implementation failures have shown that SRHS interventions cannot be founded on strictly biological, demographic, or qualitative rationales. While policies within South Africa are progressive in nature and work to advance the right to access SRHS, gaps between national and provincial implementation standards continue to act as a barrier.  Effective interventions require a contextual analysis of the service delivery environment using intersecting instruments of analysis including subjectivity, culture, politics, economy, social relations, and ethic and/or religious values. Understanding the role of power and politics in the development of health systems as well as analysing implementation frameworks at the service delivery level remain critical in creating effective interventions.

^[1] Starrs, A. M., Ezeh, A. C., Barker, G., Basu, A., Bertrand, J. T., Blum, R., Coll-Seck, A. M., Grover, A., Laski, L., Roa, M., Sathar, Z. A., Say, L., Serour, G. I., Singh, S., Stenberg, K., Temmerman, M., Biddlecom, A., Popinchalk, A., Summers, C., & Ashford, L. S. (2018). Accelerate progress—sexual and reproductive health and rights for all: Report of the Guttmacher–Lancet Commission. The Lancet, 391(10140), 2642–2692. https://doi.org/10.1016/S0140-6736(18)30293-9

About the Author:

Lidya Stamper served as a 2019-2020 Fulbright Research Fellow with the Centre of Human Rights at the University of Pretoria. She has spent significant time working within women’s rights spaces and is interested in understanding the broader implications of policy paradigms. Her research is focused on the ways in which policy agendas account for social, economic, and political contexts. She plans to expand on her work around sexual and reproductive health access for vulnerable communities in 2021 as a Research Fellow with the Research in Color Foundation, as well through her master’s program with the London School of Economics