Introduction
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‐
4].
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,
policy and
politics [
9]. 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,
13]. The discussion of the case studies will explore their linkages with the international literature on agenda setting and policy change.
Methods
This paper adopts a case study approach combined with a review of literature. The case study approach is used because not much is known about the ways that different stakeholders negotiate the challenges and dilemmas in operationalising SRHR in SSA, and the case study approach has been noted as being particularly appropriate for researching an area where few studies have been carried out [
14]. The international case study focuses on the progress made by African countries in implementing the African Union’s Maputo Plan of Action and the experiences of state and non-state stakeholders in this process. The case is developed from an evaluation report of the progress made by nine African countries (Botswana, Burkina Faso, Cameroon, Ghana, Ethiopia, Nigeria, Rwanda, Senegal, and Uganda) in implementing the Maputo Plan of Action (including the constitutional and policy environment), and analysis of qualitative interview data from the evaluation exploring stakeholders’ experiences and perceptions of the operationalisation of the plan in two countries (Botswana and Nigeria). The interviews in the two countries were purposively conducted to include stakeholders operating at different levels and with different interests and spheres of influence in relation to the operationalisation of the plan. Participants were identified at a regional level (e.g. African Union) , sub-regionally (e.g. SADC) and nationally, including both national government officials whose work focuses on the broad arena of SRHR (for example representatives from Ministries of Health, Finance and Women’s Affairs or Gender, donors and civil society organisations involved in SRHR-related activities). The first national case study explores the processes involved in influencing Ghana’s Domestic Violence Act passed in 2007 by the Ghanaian parliament. This case is developed from a review of scientific papers and organisational publications that detail the processes involved in influencing the Act, and a qualitative interview with one of the experts involved in influencing the Act. The second national case study examines the experiences with introducing the 2006 Sexual Offences Act in Kenya, and it is developed from organisational publications on the processes of enacting the Act and a review of media reports on the debates and passing of the Act. The authors draw on their experiences and reflections to complement the data from other sources since all five authors have been involved either in conducting the studies reviewed in developing the case studies or have been extensively involved in SRHR research and influencing SRHR policy processes in African countries. The authors also draw on media reports on contentious SRHR issues in SSA.
Why were these three cases selected? The international case study was selected because it examines the legal and policy environment as well as programme implementation for SRHR across SSA. The Ghana and Kenya cases feed into the international case study by providing examples of the legal and policy constraints and the legislating processes that bring about change on key SRHR issues.
Discussion
The three case studies described above offer experiences for reflection on operationalising SRHR in SSA. Drawing on the case studies, this section discusses the constraints, dilemmas, and strategies used by different groups to try to operationalise SRHR in SSA.
The constraints to the operationalisation of SRHR in Africa
The three case studies reveal three main constraints to formulating and operationalising SRHR policies and laws in SSA, namely, prohibitive laws and government’s reluctance to institute and implement comprehensive rights-based approaches to SRHR; lack of political leadership and commitment to funding SRH policies and programmes; and the dominant negative cultural discourses on SRHR.
Prohibitive laws and governments’ reluctance to embrace SRH rights
Prohibitive laws in most African countries greatly hinder the operationalisation of SRH and rights. For instance, the Maputo Plan of Action evaluation report noted that in most African countries abortion is prohibited except when a mother’s life is in danger [
4]. Further, sexual relationships among people of the same sex are often prohibited. Such laws hinder the realization of SRH rights such as access to safe abortion, and access to information and services by people in same-sex relationships. The international case study revealed the prohibitive legal and constitutional environment in which African countries operate, whereas the two national level case studies exemplified the difficulties in repealing the laws as they relate to sexual violence. Kenya and Ghana did not have an effective legislation against gender-based violence until 2006 and 2007, respectively; Kenya adopted one that only legislated against certain sexual offences and left out others such as marital rape and sexual harassment, whereas Ghana adopted one that failed to explicitly repeal section 42(g) of the Criminal Code 1960 (Act 29) that justifies the use of force in marriage.
The case studies also illustrate African governments’ reluctance to embrace the rights approach to SRH despite the fact that many of them have signed up to the Maputo Plan of Action and, in regard to gender violence, many have ratified the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). The reluctance is as a result of the controversy that surrounds SRHR issues and political climates that do not support SRHR because of ideological opposition from key stakeholders. For instance, although Kenya’s AG played a key role in facilitating the development of the sexual offences bill, he was reluctant to present the bill in parliament for debate when the civil society groups initially submitted a draft to him [
25]. Respondents in Botswana and Nigeria in the international case study indicated that their respective governments were often reluctant to discuss or pursue rights issues in SRH.
Lack of political leadership and commitment to funding SRHR policies and programmes
The international case study found that although countries had SRHR policies, these did not translate into programmes and service provision partly because of lack of funding for the implementation of policies. The evaluation found that most African governments either did not fund SRH issues or only allocated very limited resources to aspects of SRHR. Such neglect and lack of prioritisation of SRHR issues by politicians and policymakers indicate the lack of political leadership in tackling these issues. This challenge is made worse by the fact that only a handful of donor organisations still focused on funding SRH; while others had shifted their focus to funding disease specific issues such as HIV/AIDS, tuberculosis, and malaria [
27]. This challenge has resulted in not only few SRH programmes, but also in inadequate staffing for handling SRHR issues, and existing staff’s lack of skills and capacity to deliver SRHR services. Family planning commodity shortages have also been common occurrences in many African countries because of limited funding and ineffective logistical systems [
27]. Given the low priority accorded SRH by donors, the programmes and activities of CSOs have also been constrained.
Dominant negative cultural framing of SRHR
Many African societies are patriarchal and so powerful actors such as religious, political and community leaders frame women and SRHR issues in ways that perpetuate male dominance. The way issues are framed is important in operationalising SRHR because it influences the level of priority they receive [
28]. The three case studies reveal the negative cultural framing of women’s SRHR issues (e.g. giving men the ‘right’ to discipline their partners), the acceptable cultural norms pertaining to SRHR (e.g. sexual harassment as a way of courting), and the framing of SRHR as ‘unAfrican’, ‘modern’ or as alien to Africans’ way of life. This framing has greatly hindered the operationalisation of SRHR policies and laws as seen in the Ghanaian and Kenyan experiences with legislating against sexual violence.
The challenge of conceiving SRHR issues as acceptable cultural norms is perhaps best captured in Kenya’s experiences. For instance, the parliamentarians argued that rape in marriage was acceptable. Similarly, in a notorious case, a secondary school deputy principal, making a statement after boys from his school raped and killed 19 school girls and injured another 71 in 1993, said that ‘the boys did not mean any harm, they only wanted to rape’ [
7].
On the framing of SRHR as alien to Africa, some studies have noted that efforts to reform SRHR policies and laws in Kenya have often been thwarted by this [
29]. Thomas [
29] found that debates that saw the repealing of the Affiliation Act in Kenya in 1969 (a short-lived law enacted in 1959 and which granted all single women the right to sue the fathers of their children for paternity support), and other later debates opposing the marriage, divorce and inheritance bills, used the duality of the ‘modern’ versus ‘traditional’ as a powerful framing for safeguarding Kenyan men’s privileged legal position and sabotaging efforts to empower women through the law. Thomas [
29] argued that ‘modern’ versus ‘traditional’ framings of women’s issues are grounded in particular visions of gender and reproductive relations which emphasise men’s dominance over women and safeguard men’s privileged legal position. These ways of framing SRHR in SSA influence not only the public, but also the attitudes of healthcare providers towards providing certain SRHR services.
The dilemmas
The contentiousness of controversial SRHR issues presents stakeholders with dilemmas when it comes to operationalisation. From the international case study, respondents in Botswana (from the SRH department, MoH) indicated that there were SRH services provided in prisons, but such services did not provide condoms since same-sex relationships were illegal in the country. But if prisoners were presenting with STIs, it meant they were sexually active. How can they be reached with services to protect themselves? This is the case in many African countries where same-sex relations are prohibited, and therefore no targeted services are provided to people in these relationships, apart from the SRH services provided for everyone else.
The Kenyan case showed just how influential individuals in patriarchal societies can frame sexuality and women in ways that perpetuate and legitimize gender inequality and deny women opportunities to realize their human rights. This issue is compounded by the fact that since women are part of these cultures, many have internalized their rightlessness [
30] and often have limited agency. To respond to this challenge, stakeholders struggle with the question: how do we counter negative framings of women and promote more positive ones that can raise the profile of women’s rights? More importantly, stakeholders struggle with how best to involve men in such efforts, because for the efforts to succeed, men have to be involved and appreciate the value of gender equity and equality.
Related to this is the problem of the language of SRH rights with policymakers. Policy-making is arguably male-dominated in most African countries and given the cultural context, the language of SRH rights evokes negativity and often closes doors to influencing policy. In the international case study, respondents from both Botswana and Nigeria indicated that their government was not supportive of the SRH rights based approach.
Another dilemma relates to compromise. In the Kenyan case study, the proponents of the Sexual Offences Act had to make considerable compromises by deleting several sections of the original bill for it to be accepted and passed in parliament. These changes have been argued to have ‘watered down’ the bill considerably [
24]. The question here is: How much should stakeholders compromise in their efforts to operationalise SRHR?
What strategies have different stakeholders used to operationalise SRHR in Africa?
Despite the constraints and the dilemmas, the three case studies also reveal a number of strategies that stakeholders can take advantage of in their efforts to operationalise SRHR in African countries. We have classified the strategies in four broad categories namely, strategic framing of SRHR issues, forging of strategic alliances, working with the government, and strategic opportunism.
Strategic framing of SRHR issues
‘Strategic framing’ is defined as ‘a way of selecting, organizing, interpreting and making sense of a complex reality to provide guideposts for knowing, analysing, persuading and acting’ [
31]. Strategic framing, which draws on concepts from discourse analysis, has been applied in eliciting support for public issues that are often not a priority for governments or are controversial. In SRHR, strategic framing is often used to get issues onto the government’s agenda as well as to influence decision-making. For instance, to gain support for the gender mainstreaming agenda in various African governments, bureaucrats have strategically framed gender analysis and mainstreaming as important for better and more efficient health systems as opposed to framing it as important for the realisation of equity and rights [
32]. The latter framing risked being counterproductive as it was likely to be seen as a threat to the power of decision-makers (who are pre-dominantly male). Also, it has been noted that advocacy efforts that led to the Kenyan government initiating budgetary allocations for family planning framed family planning as critical for ‘development’ as opposed to ‘population control’ [
33].
In our case studies, the power of framing is evident in the dominant cultural discourse that has worked against women realizing their SRHR in SSA. But this, as already seen, presents the opportunity for stakeholders to identify and nurture alternative discourses that not only construct women as important and equally deserving human beings, but also highlight the role of men in promoting SRHR in the African society. This suggestion is not new as such alternative framings have been employed by human rights activists for the rights of women, children and sexual minority groups. However, there is scope for stakeholders to make greater use of positive framings of women that are protective of their entitlements that are already present in African communities. For instance, Izugbara and Undie [
34] noted that in the Ubang community of Nigeria, women, whether married or unmarried, remain ‘daughters’ to their natal communities, which reflects their natal communities’ role in protecting their rights regardless of their age or (marital) status. In many African cultures, the extended family and community are expected to intervene in cases of gender violence [
35]. Crichton [
35] found that in a few cases of intimate partner violence in Kenya, relatives-in-law intervened to stop the violence. Although these existing protective cultural and social norms may not adequately prevent rights violations, they could be drawn on in efforts to change attitudes. They could also help to persuade community or religious leaders to speak out on issues such as domestic violence.
As seen in the three case studies, framing was used to get the support of opponents for SRHR policies, legislations and programmes (i.e. support of parents and adults for youth sexuality programmes in Botswana and Nigeria, and support of parliamentarians and public for sexual violence legislation in Ghana and Kenya). This attests to the power of framing, which has been shown to play a key role in influencing policy change [
12]. The cases also revealed that reframing SRH issues involves processes of contestation between proponents of different narratives and that different narratives represent certain interests and marginalise others [
13]. In our national case studies, three strategies stood out as effective for supporting strategic framing. One is the use of stories of people’s experiences with sexual violence to shape and support the framing and draw attention to sexual offences. The second is the focusing of attention on the rape of young girls and grandmothers as opposed to the rape of ‘generic’ women in Kenya to indirectly challenge some of the arguments of the opponents and appeal for their support. And, the third is the use of the mass media not only in drawing attention to sexual violence but in propagating positive narratives that counter negative ones. The mass media have the power to set agendas and focus public attention on important issues [
36].
Forging strategic alliances
Networks and coalitions play an important role in bringing about policy change [
11]. Kingdon [
9] has argued that different policy actors play different roles in bringing about policy change. As seen in both the national case studies, effective networking and drawing on the expertise of different stakeholders can greatly contribute to bringing about policy and programme reform in the area of SRHR. In Ghana, the INDEPTH Network, a research organisation, worked very closely with a renowned human rights lawyer to bring about change in the country’s Domestic Violence Act. Also in Kenya, alliances between parliamentarians, human rights lawyers, scientists and child and women rights activists were instrumental in the development and passing of the Sexual Offences Act. Furthermore, identifying and working with champions such as sympathetic parliamentarians was instrumental in moving forward the sexual offences legislative processes in both countries.
Reaching out to opponents through multiple avenues is also useful in soliciting their support for contentious SRHR issues. In the Kenyan case, Onyango-Ouma et al. [
24] noted that the proponents of the bill reached out to parliamentarians opposed to the bill through fellow members of parliament supporting the bill, church leaders, and parliamentarians’ spouses. The successes realised in Ghana and Kenya reveal the constellations of policy actors that make change in SRHR laws possible.
Working with the government
Governments are charged with making and implementing policies and legislation. Even where a government shies away from taking public action on controversial issues, it does not necessarily mean individual government actors are not sympathetic to the issue. In many cases, individual policy actors play a key role in facilitating policy change within their political, bureaucratic and economic constraints, as revealed in the work of Grindle and Thomas [
10]. In Kenya, the AG was reluctant to present the sexual offences bill in parliament, but when an MP proposed to move a similar bill in parliament as a private members’ bill, the AG provided important support throughout the legislative process [
24].
Strategic opportunism
Policy processes are not straight forward and there may be sudden points of opportunity to influence decision making [
8]. This necessitates identifying and taking advantage of any opportunity that may arise. In Kenya, the parliamentarian who was leading the motion on the sexual offences bill noticed one day that most of the parliamentarians opposed to the bill were not in parliament. She therefore took the opportunity to have the motion and votes cast, and this may be perhaps what saw the bill pass through parliament as, after this stage, parliamentarians could only amend the bill but not reject it [
24]. This supports Kingdon’s [
9] element of chance in aligning the three streams of
problems,
policy and
politics to elevate an issue onto the policy agenda. In Ghana, INDEPTH took advantage of the parliamentary debates on the domestic violence bill to gain attention for its research findings.
Also, an important strategy that emerges from the three case studies is taking advantage of entry points provided by government policy frameworks. In most African countries, national plans for education and health provide entry points for partnering with the government in improving access to SRHR information and services to marginalised groups such as adolescents.
Conclusion
The discussions in this paper attest that there are still huge challenges in the operationalisation of SRHR in SSA. Prohibitive laws and governments’ reluctance to institute and implement comprehensive rights approaches to SRH, lack of political leadership and commitment to funding SRHR policies and programmes, and dominant negative cultural framing of women’s issues present the major obstacles to operationalising SRH rights. But these challenges are not insurmountable as revealed by the successes that stakeholders have realised in their efforts to operationalise SRHR. For instance, stakeholders in Ghana and Kenya have countered the strong opposition to legislate against various forms of sexual violence. In Botswana and Nigeria, progress has been made in enabling young people to access SRH information and services. To achieve these successes, stakeholders have formed and worked through strategic alliances and coalitions, employed strategic framing of SRHR issues to counter opposition and gain support, collaborated with individuals within government, and employed strategic opportunism. The use of evidence in the strategies especially highlighting the extent of the issues (e.g. the magnitude of rape incidents) as well as capturing people’s experiences with these issues, has helped galvanise support. These strategies point to the pathways through which SRH policy and programme change can be realised in African countries.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
RNO, JC and ST participated in the conception of the paper. RNO led in drafting the paper. JC, ST, NOL and LI reviewed and contributed to the revising of the manuscript. All authors have seen and approved the final version.