Reaching the goal

through Universal Access to SRHR

Dr. Annette Sachs Robertson, Ph.D
Country Representative - UNFPA Indonesia

Presented at the National Forum for Indonesian Health Policies

Yogyakarta, 26 October 2017
What is SRHR?
• Reproductive Health
• Sexual Health
• Sexual & Reproductive Health
• Reproductive Rights
• Sexual Rights
• Sexual & Reproductive Health
& Reproductive Rights
• Sexual & Reproductive Health
& Rights

2
Reproductive health and rights
ICPD PoA 7.6 :
• Family-planning (counselling, IEC, services)
• Prenatal care, safe deliver and postnatal care
(education and services), breast feeding, infant
and women’s health care
• Prevention and appropriate treatment of infertility
• Abortion as permissible within the country laws,
prevention and management of consequences of
abortion
• Treatment of RTIs/STIs and other RH conditions
• IEC and counselling on human sexuality, RH and
responsible parenthood
• Referral services for further diagnosis and
treatment (for the above services) and
reproductive cancers should be available
• Active discouragement of harmful practices

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The 2030 Agenda for Sustainable
Development Goals

4
 GOAL Target Indicators
Goal 1. End poverty in all its forms everywhere 7 14
Goal 2. End hunger, achieve food security & improved nutrition & 8 13
promote sustainable agriculture
Goal 3. Ensure healthy lives & promote well-being for all at all 13 27
ages
Goal 4. Ensure inclusive & equitable quality education & promote 10 11
lifelong learning opportunities for all
Goal 5. Achieve gender equality & empower all women & girls 9 14

Goal 6. Ensure availability & sustainable management of water & 8 11

sanitation for all
Goal 7. Ensure access to affordable, reliable, sustainable & 5 6
modern energy for all
Goal 8. Promote sustained, inclusive & sustainable economic 12 17
growth, full & productive employment & decent work for all

Goal 9. Build resilient infrastructure, promote inclusive & 8 12

sustainable industrialization & foster innovation
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Goal 3
 GOAL 3: Ensure healthy lives & promote well-
being for all at all ages

• Achieve universal access to SRH

care, reduce global maternal death
rates, & end the AIDS epidemic
• Impoverished women suffer
disproportionately from
unintended pregnancies, unsafe
abortion, maternal death &
disability, STIs & related problems.
• Young people are also extremely
vulnerable, facing high HIV rates &
barriers to RH information & care.
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SRHR in SDGs
Goal 3: Ensure healthy lives & promote well-being
for all at all ages
Targets
Targets 3.1
By 2030, reduce the global maternal
mortality ratio to less than 70 per 100,000
live births
Targets 3.2
By 2030, end preventable deaths of
newborns & children under 5 years of age,
with all countries aiming to reduce
neonatal mortality to at least as low as 12
per 1,000 live births & under-5 mortality to
at least as low as 25 per 1,000 live births
Targets 3.3
By 2030, end the epidemics of AIDS,
tuberculosis, malaria & neglected tropical
diseases & combat hepatitis, water-borne
diseases & other communicable diseases
Indicators
3.1.1. Maternal deaths per 100,000 live births
3.1.2.Proportion of births attended by skilled
health personnel
3.2.1 Under-5 mortality rate (deaths per 1,000
live births)
3.2.2 Neonatal mortality rate (deaths per 1,000
live births)
3.3.1 Number of new HIV infections per 1,000
uninfected population (by age group, sex & key
populations)
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SRHR in SDGs
Goal 3: Ensure healthy lives & promote well-being
for all at all ages (2)
Targets
Targets 3.7
By 2030, ensure universal access to
sexual & reproductive health-care
services, including for family planning,
information & education, & the
integration of reproductive health into
national strategies & programmes
Targets 3.8
Achieve universal health coverage,
including financial risk protection,
access to quality essential health-care
services & access to safe, effective,
quality & affordable essential
medicines & vaccines for all
Indicators
3.7.1 Percentage of women of reproductive age
(aged 15-49) who have their need for family
planning satisfied with modern methods
3.7.2 Adolescent birth rate (aged 10-14; aged
15-19) per 1,000 women in that age group
3.8.1 Coverage of essential health services
(defined as the average coverage of essential
services based on tracer interventions that
include reproductive, maternal, newborn &
child health, infectious diseases, non-
communicable diseases & service capacity &
access, among the general & the most
disadvantaged population)
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MMR, ASEAN countries
Country MMR Range

Brunei Darussalem 23 15-30

Cambodia 161 117-213

Indonesia 126 93-179

Lao PDR 197 136-307

Malaysia 40 32-53

Myanmar 178 121-284

Philippines 114 87-175

Singapore 10 6-17

Thailand 20 14-32

Timor Leste 215 150-300

Vietnam 54 41-74 10
Source: UN: Trends in Maternal Mortality Estimates 1990-2015
 Maternal Mortality Ratio (MMEIG), ASEAN
1600
2010-2015

1400

1200
Timor-Leste
Lao PDR
1000 Myanmar
Cambodia
Indonesia
800
Philippines
Vietnam
600 Malaysia
Brunei Darussalam
165 156 Singapore
148 140
400 133 126 Thailand

200

0
2010 2011 2012 2013 2014 2015

Source: UN 2016: Trends in Maternal Mortality Estimates 1990-2015

Survived but ill health & disability continue
• While millions of women have survived
the ordeal of death, many more suffer
from disabilities
• Obstetric fistula (Myanmar, Lao
PDR, Cambodia)
• Prolapse of the uterus
• Conditions make women’s lives miserable
& forced to lead a life of shame
• Malnutrition (low BMI) leading to LBW &
inter-generational stunting
• Anaemia

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 Births Attended by Skilled Health Personnel,
ASEAN Countries
120

99 99.6 99.7
100 93.8
87.4 89

80
70.6 72.8

60

41.5
40
29.3

20

0
Timor-Leste Lao PDR (2012) Myanmar (2010) Philippines Indonesia (2013) Cambodia (2014) Viet Nam (2014) Malaysia (2014) Thailand (2012) Brunei
(2010) (2013) Darussalam
(2013)

Source: UNESCAP, 2017

SBA Progress at National level but significant inequities exist

Source: UNESCAP, 2017 14
 Delivery by SBA, C-section
Country Delivery by SBA (%() C-section %

Cambodia 71 3

Indonesia 83 12.3

Lao PDR 42 4

Myanmar 60 17.1

Philippines 72.8 9.3

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 New HIV infections among Adults (15+) Per 100,000
ASEAN, 2014
40

35.5
35

30
27.7

25
23

20

15

9.6
10

0
Cambodia Lao PDR Malaysia Indonesia

Source: UNESCAP, 2017

Men who have sex with men – increasing trend

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 Proportion of Women (15-49) Whose Need for FP
Satisfied
ASEAN, 2010-2015
100

90

82.1 82.4 82.7 83 83.3 83.4

80

70 Timor-Leste
Philippines
60 Myanmar
Lao PDR
50 Cambodia
Malaysia
40 Indonesia
Singapore
30
Thailand
Viet Nam
20

10

0
2010 2011 2012 2013 2014 2015

Source: UNESCAP
Rights based FP:
Unmet Need & Demand Trend in Indonesia
Unmet Need, CPR, and Demand Satisfied 1991-2012 • Unmet need continued
to decline
• Percentage of demand
satisfied increased
slightly

BUT THESE NATIONAL

AVERAGES MASK DISPARITIES:
* Geographic
* Economic
* Age & marital status
Source: Indonesian Demographic and Health Surveys
1991, 1994, 1997, 1997, 2002/3, 2007, 2012
*among currently married women

Key indicators & high impact areas for accelerating family planning 19
 Adolescent Birth Rate
ASEAN Countries
100

90
90

80

70

60
60 57 57

50 48

40 36

30
22
20
12.7
10
2.7
0
Singapore Malaysia (2012) Myanmar (2013) Viet Nam (2013) Indonesia (2012) Philippines Cambodia Thailand (2012) Lao PDR (2010)
(2013) (2012) (2013)

Source: UNESCAP 2017

 Adolescent birth rate higher in less educated & lower
wealth quintile groups in Indonesia

Proportion of Women Age 15-19 who had Proportion of Women Age 15-19 who had a
a live birth by Education, Indonesia, 2012 live birth by Wealth
30 Quintile, Indonesia, 2012
14 13.2
25 23.9
22.3
12
20 10.4
10
15.6
15
8
6.7
10 6
6 4.2
5 3.6 4

0.6 1.9
2
0
No Some Completed Some Completed More than 0
education primary primary secondary secondary secondary
Lowest Second Middle Fourth Highest

Source: IDHS, 2012

GOAL 5
GOAL 5: Achieve gender equality &
empower all women & girls

• Women are more likely to be

impoverished, deprived of education &
opportunities, & victimized by sexual &
domestic violence
• End all forms of VAW & girls, all forms of
gender based discrimination, & harmful
practices including child marriage &
FGM/C
• Universal access to SRH & RR

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 SRHR in SDGs
Goal 5: Achieve gender equality &
empower all women & girls
Targets
Target 5.1
End all forms of discrimination
against all women & girls
everywhere
Target 5.2: Eliminate all forms of
violence against all women & girls
in public & private
spheres, including trafficking &
sexual & other types of exploitation
Indicators
5.1.1 Whether or not legal frameworks are in place to
promote, enforce & monitor equality & non-
discrimination on the basis of sex
5.2.1 Proportion of ever-partnered women & girls aged
15 years & older subjected to physical, sexual or
psychological violence by a current or former intimate
partner, in the last 12 months, by form of violence & by
age group
5.2.2 Proportion of women & girls aged 15 years &
older subjected to sexual violence by persons other
than an intimate partner, in the last 12 months, by age
group & place of occurrence
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 SRHR in SDGs
Goal 5: Achieve gender equality &
empower all women & girls (2)
Targets
Target 5.3 Eliminate all harmful
practices, such as child, early & forced
marriage & female genital mutilation
Target 5.6 Sexual & reproductive health
& reproductive rights
Ensure universal access to SRH & RR as
agreed in accordance with the
Programme of Action of the ICPD & the
Beijing Platform for Action & the
outcome documents of their review
conferences
Indicators
5.3.1 Percentage of women aged 20-24 who were
married or in a union before age 15 & before age 18
5.3.2 Percentage of girls & women aged 15-49 who
have undergone female genital mutilation/cutting,
by age group
5.6.1 Proportion of women aged 15-49 who make
their own informed decisions regarding sexual
relations, contraceptive use & reproductive health
care
5.6.2 Number of countries with laws & regulations
that guarantee women aged 15-49 access to sexual
& reproductive health care, information &
education
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 Percentage of Women Married before Aged 18
ASEAN Countries
40

35.4
35

30

25
22.1

20 18.5

15
15 13.6

10.6
10

0
Vietnam (2014) Indonesia (2013) Philippines (2013) Cambodia (2014) Thailand (2012) Lao PDR (2012)

Source: UNESCAP, 2017

 Percentage of Women Married before Aged 15
ASEAN Countries
10

8.9
9

4 3.8

1.9 2
2

0.9
1

0
Vietnam (2014) Cambodia (2014) Philippines (2013) Thailand (2012) Lao PDR (2012)

Source: UNESCAP, 2017

Indicator 5.6.1: Proportion of women aged 15-49 years who
make their own informed decisions regarding sexual
relations, contraceptive use & SRH care
The three questions :
1. Whether a woman can say no to her husband/partner if
she does not want to have sexual intercourse (DHS q.
1054)
2. Whether using contraception or not using contraception
has been mainly the woman’s decision (DHS phase 7 q.
819 and 820)
3. Whether a woman can make a decision about SRH
healthcare for herself (DHS q.922 with added language)
Denominator: Women of reproductive age 15-49
Disaggregation: By age, location, economic
quintile, education, marital status (married, in
union, unmarried), & disability.
Measurement:
• DHS & MICS covering most of low & middle income
countries
• National household surveys in developed countries
Proposal to DHS: Add SRH Care question as current is general
health, add age, marital status & disability
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Indicator 5.6.2: Number of countries with laws &
regulations that guarantee women aged 15-49 access to
SRH care, information & education
Legal/regulatory frameworks covered by this
indicator include laws and regulations that explicitly
guarantee :
1. Access to SRH services without third party
authorization (from the
spouse, guardian, parents or others);
2. Access to SRH services without restrictions in
terms of age and marital status;
3. Access by adolescents to SRH information and
education.
Note: the indicator also measures the absence of
laws that prohibit or restrict access to SRH services
Denominator: All Member States, for federal states
this will be reflected in central governments’ self-
reporting
Sources of information and methodology: Initial
self-reporting by governments through a detailed
survey

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SRHR Issues & Priorities in INDONESIA

1. Persistently high maternal

mortality & morbidity
2. Persisting HIV new infections
3. Stagnation of family planning
4. Addressing SRH needs of
adolescents

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The elephant in the room

 To what extend the JKN will or has

improved/addressed SRHR issues
and contributes to the achievement
of SDGs??
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