'We need to put the S back into sexual and reproductive health': HRP and WHO SRHR Director

Dr. Pascale Allotey began her career helping mothers give birth in her native Ghana. Several decades later, The Lancet described her as a "global health supremo. "

It's no exaggeration: Dr. Allotey, the director of the UN’s Special Programme on Human Reproduction (HRP) and the World Health Organization’s (WHO) Department of Sexual and Reproductive Health, has become one of the world's most important advocates for sexual and reproductive health and rights (SRHR) and gender equality in global health. She has been hailed as a champion of women and girls everywhere.

Dr. Allotey, who was born in Morocco and spent her childhood in Ghana and the United Kingdom, has spent over three decades working as a nurse, midwife, researcher, and global health leader, including serving as director of the United Nations University’s International Institute for Global Health in Malaysia, before taking up her role at HRP and WHO in 2022. Her research has covered health equity, health and human rights, gender, and social determinants of health, forced migration and marginalization, infectious diseases, and non-communicable diseases.

To mark this year's International Women's Day, Exemplars News spoke with Dr. Allotey about how her experiences in Ghanaian communities shaped her approach to global health, the need for global health professionals to be future-focused, and the path to achieving universal access to comprehensive sexual and reproductive health.

How did your career in sexual and reproductive health and rights get started?

Dr. Allotey: I'm from Ghana and I absolutely loved doing community-based midwifery in my country. That work also provides the lens I bring to my work – always from the understanding of the realities on the ground in communities. My first degree was a double major in nursing and psychology. I then did a triple professional certificate, so I'm a nurse, midwife, and public health nurse. I was fortunate to be a recipient of what was then the Australian Special Commonwealth African Assistance Plan to support postgraduate studies in public health – a post-graduate diploma, Master’s, and a PhD. It was such an exciting time and a privilege to take the time to learn. For my PhD, I chose to combine medical anthropology and epidemiology focusing on tropical diseases in pregnancy. The community in Ghana where I was working had endemic lymphatic filariasis, schistosomiasis, onchocerciasis, and malaria. I was one of the few midwives working in the district hospital, so the opportunities and the responsibilities were significant, with real-life experiences to understand the challenges of traditional and government health systems and health-sector reform from both the supply and demand sides.

Having come from that kind of situation, everything I've done since then, whether research or clinical practice or whatever, has been embedded in the need to understand the context. When you have a patient in front of you who is also part of a family and a community, you cannot break up their body into different parts or different functions or provide effective care and support in isolation. You have to understand and treat the person.

What are currently the main opportunities and challenges for achieving universal access to sexual and reproductive health services, especially in low- and middle-income countries, and how can they be overcome?

Dr. Allotey: It's shocking that around 800 women still die from preventable pregnancy-related causes every day and that these numbers have not moved significantly for a decade. Abortion care remains a neglected issue. Almost half of the 73 million induced abortions carried out each year are unsafe, putting women at risk of infection and death and less than half of all countries provide people with safe abortion care services. Programs to deliver comprehensive contraceptive services face bureaucratic and staffing bottlenecks that need to be overcome.

An ongoing lack of access means that many women in low- and middle-income countries cannot be confident of receiving safe, respectful care when pregnant and giving birth. One million sexually transmitted infections are acquired every day. Most adolescents and young people do not receive comprehensive sexuality education, a known way to set them up for a healthy relationship. We still dismiss menstrual disorders and severe dysmenorrhoea as ‘normal’ for women, resulting in significant loss of quality of life and in productivity.

Despite a challenging legal and policy environment that exists around SRH in many countries, I have the privilege, as director of SRH/HRP at WHO to work with an amazing team that continues to generate new knowledge, provide evidence- backed guidance and work with dedicated professionals in partner countries and organizations to contribute to supporting SRHR.

It is clear to me that the scientific research and evidence-backed norms and standards provided by HRP are as important as ever. But I think what can do better by being more futures-oriented in the way we work. In the global public health space, we're still reacting to things we know from the past, rather than trying to plan and implement with a sense of what will be relevant for the future. How do we project a little bit of what's happening with changes in the population, or political, physical and social environment and so on? Whatever the futures-related interventions are – whether it's training or capacity building or technologies – we need to make that more embedded in our planning.

You recently wrote that there is 'no reproductive health without sexual health.' What did you mean by that and why does it matter?

Dr. Allotey: We should live in a world in which the productive years, right from childhood, hold boundless opportunities for all. This includes the option to be reproductive at an age when the choice can be autonomous, with an expectation to prevent unwanted pregnancies, survive and thrive through a desired pregnancy, childbirth, parenthood, and beyond, with access to high quality, patient-centered promotive, preventive, and curative care.

The need to put the S back in sexual and reproductive health comes out of the unfortunate politicization of our work because there is such a strong and increasing resistance to SRHR. Reproduction does not occur without sex, and sex occurs much more frequently for reasons other than reproduction – what a revelation! It stands to reason that we have to ensure that this major part of our lives is safe, consensual, healthy, and fulfilling for all.

You’ve also said that a comprehensive approach to sexual and reproductive health is essential for gender equality. How are sexual and reproductive rights fundamental to achieving gender equality and universal human rights?

Dr. Allotey: The Harvard economist Claudia Goldin, who recently won the Nobel Prize, noted that the single most transformative intervention both for economies and gender equality is the control women have over their fertility. Even though that doesn't always necessarily translate into better access to contraception, it is the empowerment of women to decide not to be purely reproductive, but also productive beings beyond motherhood, that has enabled economies to grow. The whole idea of ensuring sexual health, which means that women can choose the nature of their relationships, when to have children, and space those children, is absolutely fundamental. It's so fundamental I find it difficult to even think about why this argument still needs to be made.

Gender inequalities prevent women and girls from practicing safer sex, limits their use of contraceptives, increases their risk of acquiring STIs including HIV, and underpins violence and harmful practices. Gender inequalities intersect with other socioeconomic inequalities and discrimination on the basis of class, race/ethnicity, sexual orientation, gender identity, among others to shape inequities in SRH outcomes.

Women, newborns, and children face distinct risks from climate change-related health impacts. How can hard-won advances over the past decades in women's health and wellbeing, including SRHR and maternal, newborn and child survival, be protected?

Dr. Allotey: When we look at the different crises the world faces, it becomes too easy to almost dehumanize these crises or make them gender blind. It's easy to focus on the issues instead of the people. But once you really break it down into specifics, it provides a much stronger way of finding the solutions we need. For instance, we need to very explicitly think about maternal health issues within the context of a climate crisis. There's evidence we'll need to generate to understand more about the impact of the changing environment on sustaining maternal health and maternal health outcomes and so on.

We need to be a little bit more analytical about the changes to the environment and how vulnerabilities – as well as solutions – will shift. And we need to frame climate change as a health and human rights issue with a human capital approach.

There are obviously issues around health systems and making sure they are still fit for their purpose. We also need to remember that people will continue to have sex regardless. People will continue to have children regardless. And that a whole lot of problems, including sexual health problems, will continue to persist. I don't think we're sufficiently worrying about the issues around sexually transmissible infections and how those will relate to antimicrobial resistance, which is very much a part of climate change. More than any other time, it's an opportunity to continue to prioritize multi-sectoral approaches, but very much with a gender lens to ensure that we keep SRHR issues at the fore as well.

Exemplars in Global Health is preparing to launch a new area of work focused on exploring global health, racism, and structural discrimination. Can you talk about the intersections you see between racism, structural discrimination, and SRHR?

Dr. Allotey: This question sets up classic examples of intersectionality and power analyses. Let's start with access to health care. Racial minorities and marginalized communities often face barriers to accessing quality health care, including SRHR services. This can be due to factors like geographic inaccessibility, lack of culturally competent care, discrimination by health care providers, and lack of insurance coverage.

Socioeconomic status is an intersection. Structural racism has contributed to disparities in income, education, and employment opportunities, which can lead to poverty, poor living conditions, and limited access to resources. This, in turn, can negatively impact SRHR by making it more difficult to afford health care, contraception, and other services.

Reproductive justice is another. The reproductive justice framework recognizes that the ability to control one's reproductive life is closely tied to issues of social, political, and economic power. Racism and structural discrimination have historically limited the reproductive autonomy of certain racial and ethnic groups through forced sterilization, lack of access to contraception and abortion, and other means.

Yet another intersection is disparities in maternal health – racial minorities experience significantly higher rates of maternal mortality and morbidity compared to their more privileged counterparts. This disparity is driven by a complex web of factors, including systemic racism, implicit bias in health care, and social determinants of health.

We can also look at sexual health and HIV/AIDS. Racism and discrimination can contribute to higher rates of HIV/AIDS and other sexually transmitted infections in certain communities due to factors like lack of access to prevention and treatment services, stigma, and limited health education. Finally, mental health and trauma is another intersection. Experiences of racism and discrimination can lead to increased stress, anxiety, and trauma, which can have negative impacts on overall health and wellbeing, including SRHR.

To address these intersections, it is essential to adopt a multifaceted approach that addresses structural racism and discrimination, as well as improving access to high-quality, culturally competent SRHR services and information. This includes policies that promote racial equity, social determinants of health, and reproductive justice.