FEATURE

Embedding sexual and reproductive health and rights in a transformational development framework: lessons learned from the MDG targets and indicators Alicia Ely Yamin,a Vanessa M Boulangerb a Lecturer on Global Health, Harvard School of Public Health; Director, Program on Health Rights of Women and Children, François-Xavier Bagnoud (FXB) Center for Health and Human Rights, Harvard University, Boston, MA, USA. Correspondence: [email protected] b Program Manager, Program on Health Rights of Women and Children, FXB Center, Harvard University, Boston, MA, USA

Abstract: This paper explores the intended and unintended consequences of the selection of MDG 5 as a global goal, together with its respective targets and indicators, and places what happened to MDG 5, and sexual and reproductive health and rights more broadly, into the context of the development model that was encoded in the MDGs. Over the last decade, as the MDGs increasingly took centre stage in development and their use evolved, they were inappropriately converted from global goals into national planning targets. This conversion was particularly detrimental in the case of MDG 5. It not only created a narrowing in terms of policies and programming, but also had an enormous impact on the discourse of development itself, reshaping the field in terms of the organization and dissemination of knowledge, and underscoring that the process of setting targets and indicators is far from neutral but encodes normative values. Looking forward, it is not adequate to propose an MDG+ framework based on the same structure. Sexual and reproductive health and rights must be placed back into the global discourse, using development to empower women and marginalized populations, and to address structural inequalities that are fundamental to sustained social change. The new development framework should include a strong narrative of social transformation in which fit-for-purpose targets and indicators play a role, but do not overtake or restrict the broader aims of advancing social, political, and gender justice. © 2013 Reproductive Health Matters Keywords: Millennium Development Goals, reproductive and sexual health, human rights, human development, health policy and programmes The story of how the Millennium Development Goals (MDGs) reduced the broad sexual and reproductive health and rights agenda set out in the International Conference on Population and Development (ICPD) and the Fourth World Conference on Women (Beijing) to the relatively depoliticized domain of maternal health is now reasonably well known.1–5 After inroads initiated in Vienna in 1993, where women’s rights were declared human rights, the women’s movement achieved extraordinary, if not unprecedented, successes in advancing a progressive agenda at the ICPD and then built upon that broad agenda at Beijing.1,2,6,7 The swift backlash that ensued showed the ferocity with which women’s basic rights to control their bodies, and in turn their

lives, were and still are contested.3–5 Thus, the Millennium Declaration, which was adopted by 189 UN Member States, and is widely regarded as an otherwise “people-centred” document that attempted to incorporate human development concerns, did not contain a single reference to sexual and reproductive health and rights.8,9 In turn, the MDGs, which were created through a technocratic, top-down process as a road map for implementation of the Millennium Declaration, only included one Goal relating to sexual and reproductive health and rights – MDG 5, which called for improvement in maternal health.4,5,10 Less well recognized are the normative and empirical consequences of the choice of the goal, targets, and indicators for MDG 5, and

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Doi: 10.1016/S0968-8080(13)42727-1

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the relationship between what happened with MDG 5 and the vision for development that was encoded in the overall MDG agenda. Since they were set out in 2001, the MDGs have essentially become the blueprint for international cooperation.11 Although ostensibly intended to reflect the aspirational commitment of the Millennium Declaration to end global poverty, the MDGs ended up pasting a thin patina of human development on the continuing neoliberal organization of the world.12,13 Moreover, the reductionism of the MDGs, and the particular way in which goals, targets, and indicators came to drive the agenda, has had a complicated impact on development practice and discourse, not just with respect to sexual and reproductive health and rights, but with respect to other complex social issues as well. In looking ahead to the place of sexual and reproductive health and rights in a future development framework, it is essential not just to consider political aspirations for progress in the world, but also to reflect on the implications of structuring a development agenda through the kind of targetsetting that occurred with the MDGs. This paper explores both the intended and unintended consequences of the selection of MDG 5 as a global goal, together with Target 5A calling for the reduction of maternal mortality ratios (MMRs) by 75% from 1990 levels and the belated addition of Target 5B on universal access to reproductive health, with their respective indicators. In order to place some of the consequences that the MDGs have had on sexual and reproductive health and rights into a broader context, we draw on findings from a multi-author study on the MDGs by the Power of Numbers Project.14 First, we discuss the political context for how the MDGs were set and their inappropriate conversion from global goals to national planning targets. In the case of MDG 5 the choice of the target and principal indicator selected – MMRs – exacerbated the perverse consequences of that elision. Next, we explore the ambiguities around the highly touted successes of the MDGs in mobilizing attention and funding for “reproductive health”, pointing out that increased funding was directed at only a subset of issues, while other crucial areas were deliberately excluded or ignored, and that equity concerns were overlooked. We then turn to the unintended consequences of MDG 5 both in terms of policy/programming and knowledge/discourse effects, examining the largely technocratic and narrow programming that emerged as part of

the efforts to achieve MDG 5 outcomes, and the shift in discourse from sexual and reproductive health and rights to maternal-newborn-child health (MNCH), respectively. Finally, from the perspective of human rights, we consider lessons learned from the targets and indicators for MDG 5, and the MDGs overall, which should inform our thinking about any future development agenda, including the ongoing discussions on setting Sustainable Development Goals upon the expiry of the MDGs in 2015.

How the MDGs came to be – and came to be used: implications with respect to MDG 5 The MDGs introduced a new model of development, which according to prevailing consensus, has been a great success.11,15 They presented a nested structure of goals, targets, and indicators in which the goals were intended to be normative and aspirational; the targets were to assign numerical, time-bound objectives to each goal; and the indicators were the data to be used in monitoring progress toward the targets. The broadly worded goals that appeared in the Millennium Declaration in 2000 were converted into the MDGs and first introduced in 2001 in a ‘Road Map’ document, which was initially intended simply to facilitate reporting on progress.7 The MDGs were conceptualized as global goals to signal priority to long-neglected areas.11 John Ruggie, the chief architect behind the Millennium Declaration, has argued that the list of goals needed to be both simple and memorable in order to garner consensus and attention.16 Michael Doyle, who authored the Road Map document, sought to replicate the impact on funding that the time-bound targets of the 1996 International Development Goals had effected among OECD countries.16 The simplicity and reductionism of the MDGs were understood as critical to using these global goals as communications devices. They were, however, entirely inappropriate for the complexities of national planning. Nevertheless, the MDGs quickly came to be used in precisely that way, as technical guidelines for the allocation of resources and policy design.16,17 Indeed, as the MDGs increasingly took center stage in development over the last decade their intended use and interpretation evolved. The UN Secretary General’s 2005 report, “In Larger Freedom: Towards Development, Security and Human Rights for All,” explicitly discusses the goals 75

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as national planning targets.18 The report “Investing in Development”, also published in 2005, further shifted understanding of the MDGs, setting out country level processes and recommendations for achieving “the quantitative targets set out in the MDGs.”19 Some countries developed their own planning targets and went through a process of national adaptation of the MDGs.20 However, especially in highly aid-dependent countries, including virtually all countries with high burdens of maternal mortality and morbidity, where donors showed resistance to national adaptation and ownership, the global targets were no longer treated merely as “benchmarks” for measuring progress, but rather had come to drive policy planning.21,22 MMRs are a leading indicator for maternal health, which may have been appropriate for the goal of mobilizing attention to a long-neglected priority, but they are inappropriate measures for assessing progress on whether or not strategies and interventions are effective at the national level. Consequently, the conversion of targets from global mobilization tools to national planning tools was particularly detrimental in the case of MDG 5. As a result of the lack of investment in adequate vital registration systems, estimation exercises had to rely heavily on statistical modelling to produce results. Due to poor data quality and availability, as well as the relatively small number of occurrences at the population level, most estimates have large confidence intervals producing inconclusive results and complicating the interpretation of changing trends. Even at the time, the statisticians involved in selecting the MDG indicators recognized the need for supplementing MMRs with process indicators to measure MDG 5A.23,24 Emergency obstetric care, widely recognized as critical to saving women’s lives and the only leading maternal health indicator tied to the functioning of the health system, was discarded in favour of skilled birth attendance, in large part due to data availability arguments. Complete emergency obstetric care data are still not collected at the national level in most countries with high burdens of maternal mortality and morbidity.5 However, skilled birth attendance is also problematic in light of survey methodology used to record rates at the national level and the consequent difficulty in comparability across contexts.25 In the absence of adequate vital registration, many high-burden countries relied heavily on less direct and less effective methods to monitor maternal mortality. For example, the 2008–2015 76

Tanzanian National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn, and Child Deaths reports using Health Management Information Systems data, annual Reproductive and Child Health reports, and DHS data, as well as other facility and household surveys, to monitor levels of maternal mortality and morbidity in the country. Multiple shortcomings in the data are freely acknowledged, including “incorrect and incomplete recording, proper case definition, data management, source of information, and methods of estimation”.26 Neither MMRs nor skilled birth attendance address fertility levels, much less the spectrum of sexual and reproductive health needs. It was not until 2005, as a result of strong lobbying by UNFPA and others that Target 5B was added, while the indicators for Target 5B were not established until 2007. Target 5B called for achieving by 2015, “universal access to reproductive health” and four health service coverage indicators (contraceptive prevalence rate, adolescent birth rate, antenatal coverage, and unmet need for family planning) were added to the official list of MDGs. 27,28 Although the combination of indicators can be seen as an effort to arrive at a sense of women’s agency in controlling their reproduction, they are not unproblematic. For example, “unmet need for family planning” is based upon surveys of married women, and omits girls and women not in couples.29 MDG 5B was adopted against the strong political opposition of the Bush administration, among others, and was given little priority until 2012 when the issue of contraception, or “family planning”,* re-emerged at the global level.30

Mobilizing attention and funding: spotlights and shadows The overarching objective of the MDGs was to mobilize funding from North to South, and there is no doubt that donor assistance to health increased dramatically during this period. While maternal, newborn, and child health (MNCH) obtained only half as much funding as HIV/AIDS in 2008, total official development assistance (ODA) to MNCH activities more than doubled from *This terminology is problematic because many people have a need for contraception outside of the context of “planning families”; we use it only in reference to the London Summit on Family Planning 2012 and Family Planning 2020 Initiative.

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$2.56 billion in 2003 to $6.48 billion in 2010.31–33 ODA to MNCH activities for the 74 Countdown countries increased from $1.96 billion in 2003 to $3.46 billion in 2006 to $4.99 billion in 2010. Of the $3.46 billion disbursed in 2006 for MNCH to Countdown countries, 68% was spent on child health and 32 % was spent on maternal and neonatal health.31 From 2003-2010 ODA to “reproductive health” (antenatal, delivery and postnatal care; infertility, consequences of unsafe abortion, and safe motherhood activities) more than doubled, from $305 million to $863 million (Figure 1).34 Although funding for health sector support increased significantly from $0.144 billion in 2000 to $1.234 billion in 2009, the increase in funding has not yet permeated narrow, vertical approaches to programming.35 While certain aspects of reproductive health have unquestionably received increased attention and funding during the MDGs, this was not the case for contraception, or “family planning,” as the financing rubric is defined, until 2012. Indeed, from 2000–2007, Nguyen et al. state that donor assistance for family planning decreased in both absolute terms, from $518 to $462 million, and proportional terms, from 30% to 5% of total “population assistance” (which includes contraceptives; basic reproductive health services consisting of maternal health, abortion, information, education, and communication about reproductive health, among other services; sexually transmitted infections, HIV/AIDS; and basic research, data, and

population and development policy analysis).36 The lack of adequate funding for contraception, however, cannot all be attributed to the lack of attention to sexual and reproductive health and rights under the MDGs. For example, the US government’s de-funding of UNFPA contributed enormously.37,38 The absence of adequate donor funding for contraception was devastating in terms of its effects on women’s sexual and reproductive health and rights. For example, a 2013 study looking at contraceptive prevalence from 1990 to 2013 found that of the 26 countries with the lowest contraceptive prevalence in 1990 (lower than 10%), the absolute increase by 2010 was less than 10% for 16 African countries.39 In terms of unmet need for family planning, the values estimated for middle and western Africa in 2010 were nearly identical to those in 1990.39 The 2012 London Family Planning Summit has to date promised substantial new aid commitments, including from the Bill and Melinda Gates Foundation. However, the outcome document of the UN Conference on Sustainable Development, Rio+20, as well as both public and scholarly discourse, suggest that concerns over “sustainable development” and economic growth, rather than sexual and reproductive health and rights, may have been the real motivation for the recent resurgence in attention to “family planning” and contraception.40–43 Other concerns in sexual and reproductive health and rights, such as the fact that 13% of

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global maternal deaths could be addressed by providing access to safe and affordable abortion services, have often been explicitly excluded from the funding provided to maternal mortality reduction.5,44 It would be fair to say that the power exerted by well-known donors, conservative religious views against abortion, and the unwillingness or inability of many Southern governments to discount these forces, are responsible for this exclusion.45 Significant gains have been made in international human rights oversight bodies on abortion rights, and there have been sites of resistance through courts, as well as social mobilization, though certainly there have also been backlashes.38,46 Further, there were many issues highlighted at ICPD and Beijing that transcended health sector interventions, such as gender-based violence, that were left off the MDG agenda and pushed to the periphery of global discourse.47 It was only in 2013 that the Commission on the Status of Women, together with the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda and the UN Secretary-General, came out with reports strongly underscoring the need to treat gender-based violence as a violation of human rights and to position its elimination as a priority for global development.48–50

Aggregate advances—persistent inequities The highly-touted success in reducing the global MMR by 47% and global maternal deaths from 543,000 to 287,000 51 also masks inequalities and potential patterns of discrimination, which are critical from a human rights perspective. Countries such as Thailand, which have made remarkable progress in reducing inequities in reproductive health utilization and outcomes, have done so through substantial and sustained investments in health systems.52 However, as the MDG targets focused on aggregate advances, rather than disparities, many countries aiming to be ranked as “on track” opted to focus not on marginalized or remote populations, but on larger urban and peri-urban areas in order to get the “best value for money” in terms of reproductive and other health investments.53,54 The MDGs as a whole have been widely criticized for their focus on aggregate advances, without regard to equity. The Power of Numbers Project found inattention to equity across water and sanitation, as well as education and child sur78

vival. For example, Unterhalter argues that the failure to address equity in the primary school enrolment goal (Goal 2) perpetuated the marginalization of children from the lowest socio-economic groups, and the most subordinated ethnic groups, generally living in areas that have not benefitted from social development programmes.55 Data disaggregation is vital to detecting disparities within and across countries and identifying potential patterns of discrimination across populations. In the case of MDG 5, disaggregation of MMRs exacerbates the issues discussed above on data interpretation because of small sample sizes and large confidence intervals.23 Thus, for example, the optimistic narrative of India’s declines in MMR are undermined upon attempting to look state by state or at income quintiles, despite the quality and availability of the data itself.56 Nevertheless, if the selection of MMRs unintentionally masked the equity impacts of the MDGs, they were nonetheless alarmingly evidenced in data on skilled birth attendance. A comparative study published in 2012 of 12 MNCH interventions in 54 countries demonstrated that skilled birth attendance was the MDG indicator that reflected the greatest inequity, subject to significant variations by wealth quintiles and geographical distribution.57 Of the 54 countries, average skilled birth attendance coverage was 54%, but the average coverage in the poorest quintile was only 32%, compared with 84% in the wealthiest quintile.57

Vertical programming, silos, and short-term objectives A number of assessments of Road Maps regarding progress on the MDGs have shown little positive impact on services for women.58 One reason is the existence of vertical programming and a lack of multi-sectoral planning at the national level, which ultimately impedes progress towards a comprehensive approach to maternal and newborn health services, and sexual and reproductive health more broadly.58 The structure of the MDGs themselves, with their focus on quantifiable outcomes, encouraged short-term and often vertical, narrow programming. Connections were not drawn between and among the MDGs, even the health MDGs. In the case of HIV/AIDS, strong advocacy from the HIV/AIDS community on separating the sexual and reproductive health and rights narrative from HIV/AIDS, claiming “exceptionalism” and citing threats to national

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security, also had enormous consequences for funding and programming during the MDG process.59–61 Further, the MDGs’ focus on short-term outcomes, rather than systemic change, may have exacerbated a trend in development funding for health, which came to be dominated by thinking about “results-based management” and “value for money” approaches, which were often associated with calls for or promises of “greater accountability”. 62 The World Bank’s Poverty Reduction Strategy Papers had promoted this focus on results-based financing, and evidence suggests that after the introduction of the MDGs, many of these Poverty Reduction Strategy Papers were simply modified to include the MDG targets, as both consensus objectives and planning targets, without adapting them to local conditions and priorities.63 For example, rather than addressing the broader macro-economic issues regarding women’s access to resources and productive employment generally, especially in reproductive health, vouchers and cash transfers took on an increasingly prominent role during the 2000s. Such schemes in effect provide women with resources to make pre-selected “choices” about their reproductive health care, rather than focusing on broader economic empowerment, which underlies gender equality and also impacts upon sexual and reproductive health. Despite the popularity of reproductive health voucher schemes with donors and international organizations, with some exceptions in Latin America, there have been few rigorous evaluations of these programmes, and evaluations that have been done have used differing methodologies.64 The MDG approach to development focused on narrow interventions and concrete outcomes, sharply contrasted with a recognition that had grown out of the international conferences of the 1990s with respect to the interdependence of progress in various social and economic domains, and the need not to neglect civil and political freedoms.1,2,6 These conferences were remarkable for their inter-sectoral approaches. Not just ICPD and Beijing, but also the 1990 World Summit for Children in New York, the 1990 Jomtien Conference on Education, the 1992 Earth Summit at Rio, the 1994 World Social Summit on Social Development in Copenhagen, the 1996 World Food Summit in Rome, and the 1996 Conference on Human Settlements in Istanbul explicitly recognized the crosscutting nature of the complex social issues they attempted to address and almost all also noted

the importance of gender equality to development (reduced to MDG 3, measured by gender parity in education, and only later by some measures of female political participation). Although the MDGs were intended to encode the more “people-centred” model of development from the Millennium Declaration, in actuality they reflected a shift backwards to the narrower development approaches of the 1980s, in which health, education and the like were not seen as rights, but as basic needs.62 The Power of Numbers Project found that MDG 5 was not the only domain affected by this shift in the development model. For example, Fukuda-Parr and Orr’s analysis of MDG 1 on hunger shows that the MDGs have encouraged measures to achieve shortterm improvements through feeding and nutritional supplements, rather than sustained change as outlined by the broad approach of the 1996 World Food Summit, which identified food security as a human right.65 Similarly, Unterhalter shows that the education goal reduced the comprehensive “Education for All” agenda of Jomtien to universal primary education, marginalizing equity, quality, and gender issues, among others, by replacing them with short-term, measurable outcomes.55 Cohen found that Goal 7, Target 7D – a significant improvement in the lives of at least 100 million slum dwellers – reduced the broader economic, social, governance, and environmental goals set in the 1996 UN Conference on Human Settlements, to counting houses and bathrooms, and thus utterly failed to address the structural challenges of urbanization, such as climate change, economic growth, and employment creation.66 Sen and Mukherjee found that the MDGs took up only one of the 13 points of action on gender equality from the Beijing Conference.67

Discourse: from sexual and reproductive health and rights to maternal newborn and child health? Not only did the MDGs create a narrowing in terms of policies and programming, but they also had an enormous impact on the discourse of development itself. No Goal illustrates this more powerfully than MDG 5, where the MDGs led to a reshaping of the field, not just in terms of funding, policies, and programming, but also in terms of the organization and dissemination of knowledge. By 2005, when the MDGs had already become the consensus framework driving policies for international cooperation,19 there was also a growing 79

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sense that the dispersal of MNCH efforts, which itself may have been exacerbated by the structure of the MDGs, was counter-productive in terms of achieving MDGs 4 and 5. One major effort to address this compartmentalization was the creation of the Partnership for Maternal, Newborn and Child Health and the launch of the “continuum of care” approach, which was meant to bring the research and practice communities together. The continuum of care model was not itself new, but drew together the dimension of linkages between health facility levels, as well as the dimension of linkages of interventions from prepregnancy through pregnancy and the postpartum period to early childhood. Even if it did not remedy the fragmentation at the national level in some of the highest-burden countries, the Partnership for Maternal, Newborn and Child Health was instrumental in establishing this approach as the way forward in the UN SecretaryGeneral’s 2010 Global Strategy on Women’s and Children’s Health.68 In underscoring the role of women as childbearers, the continuum of care approach both reflected and contributed to a significant shift during the MDGs that places women’s roles as child-bearers and caretakers at the centre of the agenda rather than their empowerment as independent social citizens with rights. This was a major change from the transformative understanding of sexual and reproductive health and rights that came from ICPD, which was reaffirmed at Beijing, which recognized women as agents of social change, and the subjects of rights, and called for action across an array of issues that transcended both the health sector and women’s full life cycles, and was not just limited to their pregnancy status. That earlier agenda called for subverting entrenched relations of power, from the most macro-level of economic models that contributed to the feminization of poverty to the most micro-level of intimate partner violence – and consequently was inherently politically contested.69 With the focus on maternal health, debates over women’s socially ascribed roles were displaced from mainstream development discourse, and many issues, such as gender-based violence and gender identity expression, faded from view in both research and discourse. The programmes of some of the principal global conferences during this period, such as Women Deliver and the Global Maternal Health Conferences, which garnered millions in funding and generated atten80

tion through special Lancet journal issues, both reflected and may in some ways also have contributed to this shift. Notwithstanding these developments, it is crucial to underscore that the women’s health and rights movement has continued to push for a broader sexual and reproductive health and rights agenda throughout the 2000s, as evidenced by, among other things, the successful incorporation of MDG 5B despite enormous political resistance, the ongoing use of sexual and reproductive health and rights paradigms in national and international spaces, and the Langkawi meeting in 2010. Most recently, the creation of networks and advocacy for sexual and reproductive health and rights in a post-2015 development agenda, and the progressive Montevideo Consensus document that emerged from the ICPD+20 regional review in Latin America are promising indications of continuing political traction regarding sexual and reproductive health and rights in future development frameworks.15,47,49,69,70

Implications for agenda setting in the future development agenda The world’s attention is now focused on setting a post-2015 development agenda, which will include a new set of goals, likely Sustainable Development Goals, as well as perhaps others, with accompanying targets and indicators.42,49 The sexual and reproductive health and rights community has been increasingly visible in advocating that broader claims to sexual and reproductive health and rights are incorporated into the post-2015 agenda and linked with the ICPD+20 process. However, less attention has been paid to the structure of the future development framework, and its implications for sexual and reproductive health and rights. The findings of this analysis of MDG 5, and the overall Power of Numbers Project suggest that the fundamental dilemmas inherent in elaborating goals and targets based on the kinds of criteria used for the MDGs must be considered. Establishing universal and inter-related goals It is absolutely essential that sexual and reproductive health and rights be embedded across goals and that their connections to both gender and economic justice be contemplated in the future development framework. Sexual and reproductive health and rights is relevant to many of

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the potential goals being considered for the post2015 development agenda, not just health, but also employment (and women’s unremunerated work), education, nutrition and food security, democratic governance, and climate change, access to water and sanitation. Sexual and reproductive health and rights are fundamentally tied to both poverty and inequality, especially gender inequality. Moreover, the central involvement of rights must be included across these goals. Sexual and reproductive health and rights also illustrates the importance of a universal set of goals. Issues such as gender-based violence affect countries with radically differing development levels.71 Additionally, achieving universal access to quality, comprehensive, and integrated sexual and reproductive health information, education, and services also raises issues of inequalities between and within countries. As Sumner and Gentilini note in their study for the Power of Numbers Project, 72% of the world’s poor now live in middle-income countries, dramatically illustrating the need to address equity and potential patterns of discrimination within countries in the future development agenda.72 Setting differential targets One significant lesson to be drawn from the MDGs is the need for graduated targets that account for development level, as had been done in UN Conferences previously, which at least acknowledges that each country has improvements to make and does not inherently disadvantage the countries that are furthest away from achieving a specified goal. It is essential that the process for setting numerical targets balances participation of and input from national governments in setting their own targets, in order to promote local ownership, with rigorous standards of justification, including comparisons with countries having similar GNIs and demographic situations, so that target setting is sufficiently ambitious. The approach offered by the Human Rights Treaty Monitoring Committees provides one example of the relationship between international normsetting and a subsequent process of national benchmarking through which it is possible and appropriate to hold governments accountable. Selecting indicators for human rights In a human rights framework, some indicators will not and should not be quantitative. For example, a target that calls for “universal recognition

of sexual and reproductive rights” would necessarily rely upon indicators related to legal and policy frameworks. The fact that these are not quantitative does not mean that they cannot be time-bound aspirations, with tangible institutional and policy efforts during that time. For example, the ICPD+20 High Level Task Force recommends: immediately “criminalizing sexual violence and ending impunity for perpetrators and eliminating early and forced marriage and female genital mutilation within a generation”.73 Looking ahead, it is particularly essential that quantitative indicators be subject to meaningful disaggregation to demonstrate potential patterns of discrimination. As has been recognized, data availability cannot automatically preclude the selection of some indicators, as was done in the MDGs.74 For example, investment in vital registration systems will be critical for generating data that underpin the ability to track many sexual and reproductive health issues, but also issues such as child marriage. Further, indicators should be relevant to policy making and sensitive to policy interventions.5 This implies the need for process indicators as well as outcome indicators, such as emergency obstetric care. In human rights, indicators are used to measure compliance with international obligations and without such measures of conduct it is impossible to hold governments accountable for adopting “appropriate measures” on a non-discriminatory basis, as is required by human rights law.

Conclusions The story of what happened to sexual and reproductive health and rights during the MDGs can be used for many lessons with respect to the future development agenda. It is clear that advancing sexual and reproductive health and rights will require changes in the global economic architecture and global institutional arrangements, affecting a range of issues from financing for development to trade agreements, as both the vicissitudes of aid and global economic arrangements have dramatic impacts upon sexual and reproductive health and rights. We have described the effects of the MDGs’ emphasis on quantified, time-bound targets and indicators that came to define social goals. While simplicity was a key strength of the MDGs in terms of raising awareness, the selectivity inherent in reducing a development agenda to 81

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a “set of goals” was far from a neutral process, and excluded many critical dimensions of each and every goal. Similarly, while quantified targeting was another strength of the MDGs, in terms of communicating complex concepts, a key finding of the Power of Numbers Project was that an exclusive focus on “measurable” targets can divert policy attention from structural human rights concerns, which require legal, political, and institutional changes, which are not well-suited to quantifiable measurement. Although concrete, outcome-focused targets were effective in achieving consensus on the MDGs as a development framework, this drove short-term interventions that did not address the root causes even of maternal mortality, much less violations of sexual and reproductive health and rights more broadly. Across the MDGs, the concern with meeting basic needs strengthened financial support for national and global health initiatives that invested in vertical, top-down programming. This represented a marked shift away from the development discourse of the 1990s, which had included concern for social change and shifts in power relations. Further, in a rights-based approach to development, the process of development must involve people not only as the passive beneficiaries of progress,

but as subjects of rights who can voice their concerns, claim their entitlements, and participate in transforming the structures and institutions that perpetuate their disempowerment. We have argued that the narrow and depoliticized approaches to maternal health that have taken over as a result of the MDGs should be understood within the larger context of the shift in development thinking that occurred during the first decade of the 2000s. Placing sexual and reproductive health and rights back into the global discourse captures the perpetual challenges of using development to empower women and marginalized populations, and address structural inequalities that are fundamental to sustained social change. Experience with the MDGs underscores that the process of setting targets and indicators is far from neutral, encoding normative values and having far-reaching policy and programme effects. In looking forward, it is not adequate to propose an MDG+ framework based on the same structure. The new development framework should include a strong narrative of social transformation, including with respect to sexual and reproductive health and rights, in which fit-for-purpose targets and indicators play a role, but do not overtake or restrict the broader aims of advancing social, political, and gender justice.

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Résumé Cet article examine les conséquences prévues ou non du choix de l’OMD 5 comme objectif mondial, conjointement avec ses cibles et indicateurs respectifs, et place l’évolution de l’OMD 5, et plus largement de la santé et des droits sexuels et génésiques, dans le contexte du modèle de développement qui a été encodé dans les OMD. Ces dix dernières années, à mesure que les OMD occupaient une place de plus en plus centrale dans le développement et que leur utilisation évoluait, il est regrettable qu’ils aient cessé d’être des objectifs mondiaux pour devenir des cibles de la planification nationale. Cette transformation a été particulièrement néfaste dans le cas de l’OMD 5. Elle a non seulement restreint les politiques et la programmation, mais a eu d’importantes répercussions sur le discours du développement lui-même : elle a transformé ce domaine du point de vue de l’organisation et de la diffusion des connaissances, et a montré que la définition des cibles et des indicateurs n’est pas neutre et qu’elle véhicule des valeurs normatives. S’agissant de l’avenir, il n’est pas judicieux de proposer un cadre des OMD+ reposant sur la même structure. La santé et les droits sexuels et génésiques doivent être replacés dans le discours mondial, utilisant le développement pour autonomiser les femmes et les populations marginalisées, et corriger les inégalités structurelles, ce qui est fondamental pour un changement social durable. Le nouveau cadre de développement devrait inclure une solide description de la transformation sociale dans laquelle des cibles et des indicateurs adéquats jouent un rôle, mais sans dépasser ni circonscrire les buts plus larges du progrès de la justice sociale et politique et de l’égalité des sexes.

Resumen En este artículo se examinan las consecuencias deseadas y no deseadas de la selección del ODM 5 como meta mundial, así como sus respectivas metas e indicadores, y se pone en el contexto del modelo de desarrollo codificado en los ODM lo que sucedió con el ODM 5 y con la salud y los derechos sexuales y reproductivos en general. En la última década, a medida que los ODM cobraron cada vez más importancia en desarrollo y su uso evolucionó, inapropiadamente pasaron de ser metas mundiales a ser metas nacionales de planificación. Esta conversión fue perjudicial en el caso del ODM 5 en particular. No solo creó un estrechamiento con relación a las políticas y los programas, sino que también tuvo un gran impacto en el discurso del desarrollo en sí, ya que reestructuró el campo en términos de la organización y difusión de conocimientos y recalcó que el proceso de establecer metas e indicadores dista mucho de ser neutral pero codifica valores normativos. Con miras hacia el futuro, no es adecuado proponer un marco de ODM+ basado en la misma estructura. La salud y los derechos sexuales y reproductivos deben incluirse nuevamente en el discurso mundial, utilizando el desarrollo para empoderar a las mujeres y a las poblaciones marginadas, así como para abordar las desigualdades estructurales que son fundamentales para el cambio social sostenido. El nuevo marco de desarrollo debe incluir una narrativa influyente sobre la transformación social en la cual las metas y los indicadores adaptados al propósito desempeñen un papel, pero no superen ni limiten los objetivos generales de promover la justicia social, política y de género.

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