The Last Mile: Addressing challenges for reaching the under-served in sexual and reproductive health and rights

Authors: Hajer Hadi, Nashwinder Kaur, Molly O’Meara, Laura Pohl and Fleur van Acht

“A big issue…is that we don’t listen to women. We ignore their pain, we ignore their complaints and then we miss really big issues.” Risha Hess 

On the 20th of September, the School of Global Health – in collaboration with Masanga DK, IMCC Global and UNFPA Nordic Office – hosted a symposium centred around the crucial topic of sexual and reproductive health and rights (SRHR) in rural populations. Entitled ‘Reaching the hard-to-reach’, the symposium focused primarily on the most vulnerable 10% of people, the so-called “Last Mile”.

The purpose of the event was “to gather experts and future actors within development work and to create a professional discussion about the interventions that are made in the field, their strengths and weaknesses and how we all can get better at reaching The Last Mile.”

Around 200 participants gathered to watch representatives from different organisations take part in four panel discussions centred around four different case studies. The discussions were short, but featured thought-provoking perspectives and solutions including mobile health clinics and eHealth, capacity building, community mobilisations, cost subsidies, peer-to-peer education, efficient supply chains, and even using tuk-tuks to reduce ambulance delays.

Screenshot 2019-10-22 at 23.07.02
Courtesy of School of Global Health

Professor Siri Tellier’s keynote speech gave an overview of the history and scope of SRHR. From the initial development of women-controlled contraceptives in the 1960s, to the incorporation of family planning and prevention of maternal deaths as a human right in the 1970s and 2000s respectively – as well as the inclusion of menstrual health in the recent decade – she acknowledged the gradual progress that has been made.

Yet progress has been extra slow for the most vulnerable people. These populations around the world have often either been misrepresented or forgotten about completely in global health statistics. They are also often left out of discussions around SRHR programmes, interventions and policies; despite having some of the largest burdens of disease. The symposium made good use of a pre-recorded video segment from a panelist based in Kenya who was unable to attend in person; in the future, techniques such as this could be used to expand participation. While some panelists used their platform to advocate on behalf of rural populations and amplify their needs, others focused mainly on their own organisations’ projects and priorities. We would have liked to see a deeper focus on fewer cases in the available time, to help achieve a more nuanced understanding of the complex issues at play.

We believe that labelling a group the “hardest-to-reach” risks placing a level of blame on them; rather than seeing the problem as lying within the programmes attempting to reach out (or lack thereof). We therefore suggest using under-served as a more appropriate term.

As was correctly noted by Risha Hess, the users of the health interventions in the case studies tend not to be invited “to conferences like these”. According to her, this absence leads to development of projects like the female condom, “which is a good example of something that was pushed by the public health community, rather than based on actual needs”. Adopting a business-perspective, she underlines the importance of a needs assessment, “starting with the users and bringing them together”. Only then, she argues, will the outcomes of these conferences be valuable.

“We come up with solutions and expect them to be able to be copy-pasted in all communities. Forgetting that they need to be adjusted” Bidian Okoth

Bidian Okoth, medical student at Kenyatta University and youth advocate for peer-to-peer education and empowerment, shared the importance of focusing on the “end users” as the fundamental means of addressing challenges in SRHR. He shared that only when individuals can make meaning of their own perceptions of SRHR and communicate it among themselves in a “safe space”, can we begin the process to ensure these communities get their rights, access and care services.

“People need to talk about it among themselves … if people are not aware of the available contraceptive options, cost or not willing to use certain services, there would be no use of having stocks of products or various services available when people are not going to use it or not know how to use it.”

We asked Bidian about the difficulties in empowering individuals, specifically young people, to speak about sexual and reproductive health. He shared that it’s crucial to never stop investigating the reasons behind the reasons, while ensuring that the discussion is headed by individuals themselves:

“…why do young girls or boys, for example, not want to talk about sex? … if about stigma, ask why? … if stigma related to family/friends, ask why? … if scared to ask boyfriend to use condom, ask why? … keep asking why? … then, you can begin with some idea of what’s happening … all you do in between is to make sure everyone is heard and no major arguments happen but also to correct any false factual information like spread of HIV … What is important is that they have to lead themselves to their problem and how to solve it”

SRHR panel
Courtesy of School of Global Health

When Risha Hess was asked about the future in SRHR, she replied: “I am horrible at predicting the future and usually when anyone tries they are wrong. There are a lot of variables in play. Political stability is one … What I want most are more options for women. … I would like to see that, and of course on delivery (birth) we need to make sure that there are safer options. A big issue I find with deliveries is that we don’t listen to women. We ignore their pain, we ignore their complaints and then we miss really big issues.” 

We were inspired by our conversations with Bidian and Risha, and believe their respective focuses on community-based approaches and adopting a user perspective were key contributions to the discussion. However, we felt that the event as a whole did not achieve meaningful interactions with the people labelled “hard to reach” and “most in need”, but acted more as a forum for the mostly-Western intellectuals and world-changers-to-be in attendance. This is a recurring problem when hosting such events so far away from the people they are meant to serve; how can their voices be represented? Is it ethical to fly people to Denmark to share their experiences? Is it ethical not to?

SRHR is not a field for the faint hearted. It is an area entangled with conflicting values and agendas, and there is simply no way to succeed in improving SRHR by shying away from the political side. The symposium brought to light several issues and themes, with vocal perspectives offered by the panelists. There are no easy answers, and we left the event with a greater understanding of how complex this area really is. Reaching under-served populations – and organising conferences about them – requires a blend of user-driven solutions, community-led advocacy, and leveraging resources and power to ensure that the subjects in question get a seat at the table.



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