Moving the SRHR Agenda Forward in Bangladesh

May 6, 2016 IMG_6609 copy

ARROW Executive Director Sivananthi Thanenthiran was in Bangladesh at the inaugural national SRHR Knowledge Sharing Festival where she gave the closing address.

Assalamu alaykum, Shubho bikhal,

Ami  apna dil conference eh ashti pere kubhi shommani bohudh  kuchi

Bangla amar bhasha noi tai ami ingrejite khotha bulbho

I’m deeply honored for this invitation to speak at your inaugural national SRHR Knowledge Sharing Festival. The unfortunate truth of our working life, even though we are working for an issue or for our movement, is that we are very often competitors. But when we see ourselves in the world we live in, we are allies, comrades, and events like this knowledge sharing festivals forge ties between us and bring us closer. I come from Malaysia, and as you may already know Malaysia and Bangladesh as countries also have a great friendship and respect for each other, and we also have much to learn from each other.

I work for a regional organization that works in 17 countries in the region, and as such I have the privilege of meeting many people and many organisations from the region. Indeed the progress Bangladesh has made on fronts such as reduction of maternal mortality has been impressive and cited as in many studies as an example for other developing countries. In fact progress in this front has been faster than neighbouring countries such as Pakistan and India.

Data from the Bangladesh Demographic Health Surveys show that there has been commitment and efforts by the government to improve access to a continuum of services: ante-natal care coverage increased to 79%, skilled birth attendance increased to 42%, and increase in facility deliveries and caesarian sections also show that women have better access to critical emergency obstetric care. This coupled with the high contraceptive prevalence rates, highest in the region (62%; with 53% modern methods)[1] also denotes the commitment to ensure the sexual and reproductive health and rights (SRHR) of women. Indeed, Bangladesh is cited as the only low-income country (though now you are moving to middle-income status), which has also invested in data to understand, programme and implement health in a systematic manner.[2]

Bangladesh has also been successful in ensuring menstrual regulation is accessible, ensuring that every pregnancy is a wanted pregnancy and enabling reproductive choices for women and this necessary and bold move was essential to reduce maternal mortality. Additional steps to increase access and term limits are also essential to saving lives.[3]

The presentations I have heard in the last few days show that there still remains an unfinished agenda. It is important to the development of the country and its citizens that the government continues these increased and accelerated investments in public health-care facilities to make sure that women and girls receive the continuum of quality health services they need.

Bangladesh is in a unique position. The economy of the country has been growing well in the past few years, marking at least 6% growth rate annually. When there is rapid growth, the benefits of this economic growth may not benefit all equally. In fact those most in need for the benefits of development may be left behind. Inequality due to uneven development is a reality across many countries in our region. The poor, especially from the rural areas and remote villages and especially women and girls, will be the most marginalized from urban-centred economic growth and development.

Investment in the social sector including providing universal access to health, especially sexual and reproductive health, should be regarded as a social leveler, and as a poverty reduction and an inequality reduction strategy because in such vulnerable situations being healthy, and not falling into debt when falling ill, can be a game changer for disadvantaged populations. This is critical in Bangladesh because government expenditure on health is only about 34% of the total health expenditure (THE) and the rest (66%) is out-of-pocket (OOP) expenses.[4] The international recommendation is to keep out-of-pocket expenditure on health at below 40% and many countries like Malaysia, Maldives, Bhutan, Thailand have numbers far below 40%.[5]

Investments in health should be accompanied by equal investment in gender equality, and sexual and reproductive rights which enable women and girls to exercise greater autonomy over their bodies and their lives. Providing access to a rights-based, continuum of quality care sexual and reproductive health services is an essential part of this approach. And these should be seen as programme strategies that will help even out or balance out the uneven development.

The second point I want to make is about young people. 30% of the population of Bangladesh are between the ages of 10-19 years and this is a group that all stakeholders, NGOs, the UN, the government and the private sector, need to look at more closely and invest in, to ensure that the country is able to reap what is called the demographic dividend. But before one can enjoy a dividend, one must first invest in young people.

In comparison to the progresses mentioned earlier, reduction of adolescent birth rate and reduction of early marriage is a continued challenge in the country. Data from the BDHS 2014 survey shows that 31% of adolescent girls aged 15-19 are already mothers with at least one child and 6% are currently pregnant. Early marriage and childbearing is more common in rural areas compared to urban areas. Average age of marriage for women in Bangladesh is 15.8, and 65% of girls are married off before the age of 18.[6]

If we want to see good health and developmental outcomes, we must engage in changing attitudes and mindsets but from a health policy-making perspective. And this calls for upholding the rights of women and girls.

Early marriage limits the ability of girls and of women to fully realize their educational and employment possibilities. At the same time, it increases the burden on their health and well being – because early marriage is almost always accompanied by early child-bearing, and the resulting scenarios of facing perinatal mortality, fistula, STIs and HIV, a lifetime of violence – are undesirable for any young girl. Providing equal educational opportunities, ensuring comprehensive sexual and reproductive health information to young people and enabling girls to exercise decision-making and have the choice of whether to marry or not – will be key programme strategies for the government to consider.

When we talk about a comprehensive approach to young people, this means enabling young people from all income levels, and from different environments, to have access to quality education, to be able to finish school, to have equal opportunity to jobs, to lead a life free from violence – whether it is with regards to sexual orientation and gender identity, ethnicity, migrant status, or political beliefs. Encompassed within the comprehensive approach are certain rights which are sexual and reproductive rights: the right and freedom to choose who to love, when to marry and whom, if at all, to marry, when to have children, how many children, if at all, to have. These choices are critical choices for everyone, especially for young people. These choices determine what we do with our bodies, and that shapes what happens in our lives.

Young people have the very same rights adults do. Though we may live in cultures, communities and religions which teach us to respect our elders and give deference to our elders, young people possess these rights in the fullest essence, even if they may not be exercising it. And those in decision-making positions need to recognise that and respect that.

The last two days have been absolutely delightful. Bangladesh is a beautiful country with amazing people. You have produced poets, musicians, writers, artists, researchers, intellectuals and activists. I was reminded during one of the sessions on the first day, how Bangladesh in the 1990s was a leader among nations on the global level, as a champion for ICPD in 1994 and for Beijing in 1995. Indeed with all of the progress with regards maternal health services, all of us hope that Bangladesh will again take up the torch to lead the agenda at the global level as it once did, and demonstrate to other developing countries not only the progress that can be made, but also that we too are able to fulfill and live up to international commitments and are capable of progressive policies – especially those with regards human rights.

To take this up and ensure continued prosperity and development, it is critical that we are frank about the challenge of extremism and handle that challenge. This challenge of extremism is coming up in my beautiful country of Malaysia as well, and across many countries in our region. Throughout time extremism has been a force to contend with when we take up a progressive agenda, whether the agenda is development, human rights, women’s rights or SRHR.

And because we live in Asian countries, I have had different people from our region who come up to me and ask me if I think that the SRHR, especially the sexuality and rights agenda is compatible with our Asian cultures and Asian values. I very often tell them that we have had sexual diversity and gender diversity from time immemorial in our cultures. And we have always accepted and lived with this diversity. What is alien to our region is actually this intolerance, accompanied by hate speech and violent acts. This intolerance and violence is incompatible not only with our past, but also with the visions we have for our future.

Extremists have a completely different vision of what our countries should be like, and we have to keep pressing ahead and offering the alternative vision of what peace, development and rights can achieve. Public policy-making must be guarded by rule of law, and ensure that we create a more equal, more just, more fair, more tolerant, more accepting society, community and country at the end of the day.

What I have learned in the last three days is the ability of the Bengalis to navigate difficult and controversial issues such as menstrual regulation, and maybe the time has also come for us to create language around the issues of sexual orientation and gender identity which enables us to push forward the agenda, put forth our perspectives, our principles, our values – because we too have values – which enable us to move forward with the agenda and recognize and fulfill the sexual and reproductive rights of all our citizens.

We have to work together in solidarity, with courage, with creativity, in collaboration – and all of us outside of Bangladesh, we are there with you – because your success is our success, and your failure is our failure – we are all in this together.

[1] BDHS 2014
[2] Maternal mortality in Bangladesh: a Countdown to 2015 country case study Prof Shams El Arifeen, Prof Kenneth Hill, Karar Zunaid Ahsan, Kanta Jamil, Quamrun Nahar, Peter Kim Streatfield
[3] Menstrual Regulation and Postabortion Care in Bangladesh: Factors Associated with Access to and Quality of Services. Guttmacher 2012. Michael Vlassoff, Altaf Hossain, Isaac Maddow-Zimet, Susheela Singh and Hadayeat Ullah Bhuiyan
[4] Anwar Islam, Tuhin Biswas. Health System in Bangladesh: Challenges and Opportunities. American Journal of Health Research. Vol. 2, No. 6, 2014, pp. 366-374. doi: 10.11648/j.ajhr.20140206.18
[5] WHO National Health Accounts
[6] BDHS 2014