Young women and adolescent girls on the “sidewalk” of Rwanda’s “road” to Universal Health Coverage

Kigali - Today, most young girls in Rwanda are likely to start being sexually active by age 15 while having no information on sexual and reproductive health and existing services. This is life-saving information that would prevent unwanted pregnancies or sexually transmitted infections, further preventing poor living conditions and lifelong consequences. Those who may know about Sexual and Reproductive Health and Rights (SRHR) services may not be able to access them due to affordability but also due legal and socio cultural restrictions, discrimination and stigma encountered at public health facilities.

In Rwanda, there were more than 19,000 teen pregnancies in 2018 and between 2016-2018, more than 55,000 teen deliveries (between 15 -19 years), reported by the Ministry for Health yet the sexuality of young people mostly young women and adolescents is largely unaccepted and their autonomy  to make sexual and reproductive health choices is suppressed in different ways.

In September 2019 for the first time, The United Nations will hold a high level meeting on Universal Health Coverage (UHC) with the theme: “Moving together to build a healthier world” to garner  momentum and political commitment for UHC. UHC is a framework re-emerging as a unifying approach for global health in the era of the Sustainable Development Goals (SDGs), with the hopes that it will provide an opportunity for renewed attention to meeting the health-care needs of all.

A sustainable approach of UHC should be to center preventative measures alongside curative and rehabilitation, thus, the importance of sexual and reproductive health and rights and gender equality as critical components of any discussion on UHC.

Rwanda’s context remains with numerous barriers for young women and adolescents’ SRHR, including legal restrictions requiring third party authorisation to access health services for young people below 18 years; limited access to comprehensive sexuality education and the  full range of SRHR services; insufficient funds allocation to youth and adolescents SRHR programs and social cultural restrictions that remain largely unaddressed.

Rwanda’s family planning and adolescent sexual and reproductive health strategic plan (2018-2024), which lays priorities for the health sector is designed to ensure that “all women, men, adolescent girls and boys in Rwanda have universal access to quality integrated family planning and adolescents SRH information and services in an equitable, efficient and sustainable manner”. The strategic plan highlights the importance of expanding SRHR information and services to young people and adolescents, which was identified as a major gap during the strategic plan development. However, the planned activities under the strategic plan’s objective 3 on “improved availability of quality youth-friendly FP/ ASRH services” focus mainly on providing information and thus limit accessibility to a full range of services including contraception for young people. For instance, it refers to providing “age appropriate contraception”, but implementation of the comprehensive sexuality education (CSE) curriculum doesn’t include a defi
ned referral system to SRHR services needed and the plan to equip existing youth friendly centers doesn’t include contraceptives.

Rwanda’s health sector’s main focus remains largely on primary health care mostly for maternal, newborn and child health (MNCH). Sexuality needs of young women and adolescents, in particular, continue to be at the periphery of the current public health care programs. Current programs which limit their needs to only “information” present a big risk of losing the gains made in MNCH investments and can result into vicious cycle of health burden on the country’s health sector.

Urgent and strategic actions need to be taken including amending article 7 of the Law N° 21/05/2016 of 20/05/2016 relating to human reproductive health and ensure all young people can access health services without age limitations; amending article 11 of the Law No 49/2012 on medical professional liability insurance to remove third party consent for young people to access SRHR services; and to ensure full access to services, also harmonise other policies such as the National Youth Policy, National School Health, adding emergency contraception on national list of essential medicines, repealing all legal barriers to access safe and legal abortion on all grounds and removal of taxes on menstrual health products.

The Ministry of Health should ensure that the 2019/2020 budget planning cycle increase funds allocation to ensure implementation of the comprehensive sexuality education (CSE) in and beyond school settings for all young people in all their diversity. CSE needs to ensure full and correct information on young people’s sexuality, gender equality, bodily autonomy,  pleasure and empowerment for decision making in relationships and must be accompanied by a referral system to access to all contraceptives, including emergency contraception to ensure exercise of agency and choice. Services need to be accessible at various youth friendly spaces such as schools, youth corners and service delivery by paid community health workers, public and private facilities, mobile clinics, pharmacies, e-health and outreach.

Rwanda has demonstrated highest political will to achieve primary health care and paving way towards UHC and has made progress in SRHR in general through passing of progressive laws and ratification of various of UHC & SRHR related international and regional human rights instruments. The current negotiations for a political declaration on UHC at the UN presents a golden opportunity for Rwanda to continue championing gender equality, to build on existing efforts and contribute to a robust outcome  that centers SRHR and gender equality as core priorities.

A sustainable approach to achieving UHC should be multi sectoral and implemented together with multi stakeholders and young women and girls as leaders and should ensure an interlinkage approach that also addresses structural and gender inequalities, and systemic barriers including economic justice aspects of young women and girls that could hinder full realisation of their health.

The writer is Rwandan feminist activist, director of SPECTRA Young women led NGO, and a youth advisory board member for the African Union

The views expressed in this article are of the author.