By Juan Carlos Rivillas, Raul Devia-Rodriguez, Gloria Song and Andréanne Martel
Generally speaking, equity in access to essential sexual, reproductive, and maternal health care services for Colombian women and girls has improved over time, but what about Colombian women and girls affected by armed conflict and forced displacement? These parts of the female population in Colombia tend to be invisible in data and are the hardest target group to reach with respect to basic health care services – and yet, these vulnerable groups require a people-centred care approach as much as the rest of the population, if not more, due to their needs, realities, and circumstances.
We - the four authors of this article - recently did a study that examined reproductive and maternal health care services in armed conflict and forced displacement settings in Colombia. Specifically, we looked at the patterns of inequalities in access to reproductive and maternal health care services, in order to better understand what works and why conflict settings reinforce already existing inequities.
We found that even though absolute health care-related inequalities have dropped over time, relative inequalities worsened or remain unchanged. In other words, this means the overall magnitude and size of inequality was reduced but the accumulation of inequality remained in the female population affected by conflicts in Columbia. The study suggests that for this particular vulnerable population, there is a pattern of increasing exclusion with respect to basic reproductive and maternal health care service provided to them.
Why does this matter? Good health for girls and women has been recognized as essential for the sustainable development of a country, and some aspects have substantially improved in past decades. In fact, worldwide priorities in women's health have shifted from a narrow focus on maternal and child health to the broader framework of sexual and reproductive health rights (SRHR). For the first time, member states of the United Nations have pledged to tackle the Sustainable Development Goals of gender equality, the empowerment of girls and women, the elimination of all forms of gender discrimination everywhere, healthy lives and well being for all at all ages, and the reduction of inequalities within countries, in the United Nations' ambitious Agenda 2030.
Nevertheless, there is still much work to be done to put girls and women first. Millions of people around the world are still caught in the vicious spiral of violent conflict and poor health. Within these complex and varied settings, access to basic services such as family planning, antenatal care, abortion, skilled births attendance, and emergency obstetric care can too easily be compromised or denied. As such, these health-related Sustainable Development Goal targets require a pro-equity approach that promotes accelerated progress for the poorest and most disadvantaged communities within any given country. This also means reaching the poorest and most vulnerable girls and women in conflict and post-conflict contexts, and putting them first when designing programs and agenda to tackle inequalities as urgently advocated for by the Global Strategy for Women's, Children's and Adolescents' Health.
Colombia faces huge challenges. Just after signing a historic peace deal to end more than 50 years of conflict, there was estimated to be over 8.1 million victims of armed conflict in Colombia, out of an estimated population of 45 million. The majority of victims (4.5 million) are females affected by forced displacement as well as sexual and gender-based violence, and are mostly female adolescents, single mothers, or widows with children affected by the war. Too frequently the effects of conflict continue to threaten sexual, reproductive, and maternal health care in Colombia, impeding progress towards universal health care while reinforcing already-existing inequities. It is this particular population that grapples with varying levels of social exclusion, particularly with respect to the access to sexual, reproductive and maternal health care at the primary health care level.
But there are solutions. In our study, we identify challenges and strategies into what worked for reaching girls and women who are the hardest to reach in conflict settings, and why. If we want to accelerate progress towards universal health coverage and meet gender equality by 2030, shaping people-centred health systems is key.
First, we need to understand and identify the distinct patterns of inequalities, in order to generally improve policy responses. Different types of inequality require different equity-oriented approaches and actions. Also we need to change the way we think about opportunities, reproductive and maternal health as a human right and inequalities and social exclusion undermining health's women and girls.
Second, addressing unmet needs in reproductive and maternal health requires supporting gender equality. Men play a pivotal role in achieving this, so we can't exclude them from equity-oriented approaches. It also means prioritizing girls and women in the regions with the highest rates of victims of armed conflict, if we truly want to leave no girl or woman behind.
Thirdly, as the World Health Organization calls for more inclusive engagement to design health care and systems that put people and their needs at the centre of care. People-centred care means ensuring that health services are tailored to people's needs and are provided in partnership with them, rather than simply given to them. Basic reproductive health care, for instance the family planning services, girls and female affected by armed conflict and forced displacement are respected, informed, engaged, supported and treated with dignity and compassion, moreover of being located in places physically close to them.
Finally, reducing inequalities in basic health care would not only promote equity, but also drive sustainable development for the country. When we ensure that the most vulnerable and marginalized populations of a country are not excluded from essential services such as family planning and maternal health care services, the whole country stands to benefit.
Juan-Carlos Rivillas and Raul Devia-Rodriguez are Colombian researchers committed to shifting health systems to meet real population needs, and work in the field of measuring social inequalities and their impacts in health outcomes. Juan Carlos has been Director of National Health Observatories and technical advisor health systems research of Ministry of Health and Social Protection in Bogotá. Juan Carlos recently joined the Association for the Well-being of the Colombian Family as the Director of Research.
Raul is an MD from Faculty of Medicine, University of Valle, Cali, Colombia, and Postdoctoral Fellow at the Center for Advanced Orthopedic Studies BIDMC, Harvard Medical School, Boston, United States of America.
Gloria Song is lawyer, researcher, and PhD candidate at the University of Ottawa.
Andréanne Martel is a collaborative research program officer for the Canadian Council for International Co-operation (CCIC) in Ottawa. Andréanne, Gloria, and Juan-Carlos are former research awardees from International Development Research Centre (IDRC).