More than 15 years after the radical shift in policy from a focus on population control to a focus on individual needs and rights initiated at the 1994 International Conference on Population and Development (ICPD), sexual and reproductive health and rights (SRHR) indicators remain poor in sub-Saharan Africa (SSA). Specifically, the ICPD made advancing gender equality, eliminating violence against women, ensuring women’s ability to control their own fertility, and universal access to sexual and reproductive health (SRH) information and services cornerstones of population and development policies [1
]. At the conference, 179 countries agreed to implement the ICPD Programme of Action.
Although some progress has been made in SSA in terms of developing reproductive health policies and reforming laws to provide a framework for the implementation of SRHR programmes, SRHR still remain non-priority issues on the development agenda of many SSA countries due to limited political leadership and commitment to the realization of SRHR, and inadequate resource allocation [2
Consequently, in much of SSA, maternal mortality and morbidity remain unacceptably high, unsafe abortion claims an estimated 22,000 lives of women each year, contraceptive prevalence is low (varying between 10-50% among women in union), early marriages and teenage pregnancy persist, and gender inequities and incidences of gender-based violence remain high [5
It’s important to note that the difference between SRH and SRHR often leads to confusion at both policy and programme levels thereby presenting a barrier to operationalisation. Further, the lack of a universally recognised definition of SRHR at the international level [6
] is another challenge for implementing national policies and programmes to realise these rights. As used in this paper, SRH refers to everything encompassed in both sexual health and reproductive health, as defined by the ICPD 1994. The ICPD included sexual health as part of reproductive health and defined reproductive health as ‘a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capacity to reproduce and the freedom to decide if, when and how often to do so’ [1
]. SRHR, on the other hand, is based on international human rights law and is about the right to SRH information, services and autonomy. However, SRH-related human rights are spread throughout various international Human Rights frameworks and are interpreted in a range of ways by different stakeholders. The lack of a universally recognised definition of SRHR at the international level [6
] presents a challenge because SRHR covers a range of rights of varying levels of controversy, which can lead to confusion. SRHR, as used in this paper, is understood as the right for all, whether young or old, women, men or transgender, straight, gay, lesbian or bisexual, HIV positive or negative, to make choices regarding their own sexuality and reproduction, providing these respect the rights of others to bodily integrity [6
]. This definition also includes the right to access information and services needed to support these choices and optimise health [6
As mentioned above, some SRHR issues – provision of safe abortion, provision of SRH information and services to adolescents, sexual orientation and identities (Lesbian, Gay, Bisexual, Trans-gender, and Intersex), access to SRH services by people living with HIV/AIDS (PLWHAs), and sexual violence against women and girls – remain controversial in most countries. The controversies arise from their contradiction with certain cultural, religious and individual beliefs, norms and values. Thus, efforts to change SRHR policy often receive strong opposition from certain political, religious and community leaders. Given this ‘hostile’ environment, many African governments either shy away from addressing these issues or take discriminatory approaches in policy-making and legislation [7
As the contentiousness of certain SRHR issues persists compounded by the confusion between SRH and SRHR, these conditions continue to cause human rights violations, illness and even deaths, in addition to affecting other development indicators [2
]. Despite these policy constraints and setbacks, a number of stakeholders (including some government officials, human rights groups, women’s rights movements, donors, and researchers) continue to push for getting contentious SRHR issues on the government agenda in different countries.
Using one international and two national case studies, this review paper reflects on the constraints, dilemmas and strategies used for getting controversial SRHR onto the policy agenda and influencing decision-making in different African contexts. The authors pool learning from these three case studies to highlight the strategies that different stakeholders can use to work their way around the opposition to contested and complex SRHR issues in different policy arenas.
The purpose of this paper is not just to share experiences and lessons, but also to contribute to the debate on challenges and opportunities for bringing controversial SRHR issues onto the agendas of government in SSA and influencing decision-making on these issues. Literature on policy processes has shown that policy change is not simply a technocratic process based on rational analysis, but a profoundly political process that is complex, messy and power-laden [8
]. It has been argued that issues get onto the government’s agenda when three streams intersect – problems
]. The intersection can happen by chance and/or through the activities of different policy actors [9
]. Some studies have revealed the important role government policy actors can play in bringing about policy change [10
], while others have emphasized the role of policy coalitions in policy change [11
]. Still, others have argued for the important role of ideas, framing, and use of policy narratives in bringing about policy change [12
]. The discussion of the case studies will explore their linkages with the international literature on agenda setting and policy change.