Negotiating sexual and reproductive health
The United Nations Population Fund (UNFPA) and other organisations working to achieve the goal of universal access to reproductive health have to negotiate highly sensitive and embedded beliefs and practices. In certain contexts challenging female genital cutting, child marriage and instituting gender equity, access to contraception, sexual and reproductive health and information are highly contentious issues. Rather than perceiving cultural perspectives to constrain positive social change, UNFPA’s Culture Matters approach illustrates how development actors might work sensitively with the dynamics of culture to enhance the achievement of development objectives and human rights within a variety of social, cultural and spiritual settings.
The promotion of sexual and reproductive health (SRH) presents a variety of sensitive and contentious issues, particularly in settings where there may be discord between cultural tradition and social change. Initiatives to promote SRH can be enhanced by taking socio-cultural realities into account to harmonise a range of views within a society and to strengthen ownership. Since 2002 the Swiss Agency for Development and Co-operation (SDC) has supported UNFPA to develop such an approach whereby cultural issues are regarded to be challenges and opportunities rather than obstacles to rights-based SRH development. This article examines the socio-cultural approach to SRH programming, reviews UNFPA’s work towards this goal and considers operational aspects of this process.
Pivotal role of culture in effective development approaches
Ownership of interventions and empowerment of stakeholders are widely acknowledged to be fundamental to the success of development activities. Given that people, from individuals and communities, their representatives and institutions are the main agents of change, it is crucial that international organisations facilitating social and economic transformations adopt approaches that include community structures and embrace cultural awareness and sensitivity. Increasingly the development community is acknowledging the pivotal role of socio-cultural dynamics in mediating sustained positive change and the promotion of human rights. In its 1995 report the United Nations’ World Commission on Culture and Development highlighted the need for a clearer, expanded understanding of the relationship between culture and development to enhance practical, harmonised and sustainable interventions. A decade later, the Paris Declaration further emphasised the role of including religious and cultural perspectives in improving the efficacy of development initiatives. Throughout this process the World Bank held a Conference on Culture and Public Action, UNESCO in 2001 adopted the Universal Declaration of Cultural Diversity and UNDP’s 2004 Human Development Report focussed on the importance of understanding cultural issues in effectively tackling poverty and development.
Cultural context and sexual and reproductive health
Social and cultural issues influence and mediate the efficacy and appropriateness of policies and approaches to SRH in different social, economic and religious settings. In order to reduce harmful traditional practices, legislation and beliefs and to support equitable, rights-based development in some of the most intimate and sensitive domains of human life, it is fundamental that international agencies strive to understand, appreciate and include the cultural context in strategic development and action planning to connect social realities to SRH and wider development goals. Rather than attempting to impose alien views and cultural values from above, agents of change can be more effective and appropriate by listening and learning from communities. On this basis they can engage in dialogue and work in partnership with communities to determine ways of supporting positive change and knowledge-sharing. In this way cultural issues can be viewed in a positive relationship to development, providing entry points and opportunities rather than obstacles to be surmounted.
The “Culture Matters” initiative
One example of such an approach is that developed by UNFPA to promote understanding of human rights relating to SRH, gender and wider development issues in settings where tension may exist between aspects of cultural tradition and social change. Guided by agreements reached at Cairo during the 1994 International Conference on Population and Development (ICPD) that focus on sexual and reproductive health and gender equity as human rights, UNFPA in 2002 began to develop an approach to systematically institutionalise and mainstream culturally sensitivity in its programming and practice to be shared with development partners. The Swiss Agency for Development and Co-operation was the first donor to provide financial support to UNFPA to develop the Culture Matters initiative.
At the outset UNFPA reviewed its effectiveness in identifying and optimising opportunities and entry points to implement ICPD goals and address points at which these appeared constrained or opposed by traditionally-embedded attitudes and practices. Assessment was made of culturally sensitive approaches and partnerships with existing secular and spiritual institutions and their outcomes in implementing rights-based family planning, reproductive health and broader development initiatives. Case studies from nine of its country programmes in Asia, Africa, the Middle-East and Latin America were published in full in the 92 page, 2004 UNFPA report Culture Matters and in a briefer overview format in Working from Within. The exercise provides a resource-base of knowledge on cultural issues relating to development, particularly on the potential enabling role of local-level power structures and religious institutions in promoting SRH health and rights-based approaches to development.
Operational approaches emerging from UNFPA’s case studies
Cultural Sensitivity: In spite of the wide socio-cultural diversity of the case studies and variations in scale and modes of implementation of UNFPA Country Programmes, a number of common themes emerged. Cultural understanding and awareness were found to be essential in establishing the prerequisite trust between communities, their leaders and agencies implementing initiatives related to SRH. The development and use of culturally-sensitive language was highlighted to be fundamental to effective implementation, as was avoidance of judgemental and negative language concerning accepted attitudes. A prime example is use of the value-laden terminology “female genital mutilation” as opposed to “female genital cutting”. The latter describes the procedure without implying value judgement and facilitates discussion within communities of the consequences for female health that form the basis for change. It became clear from the case studies that by clarifying that UNFPA makes no value judgement on cultures, but takes a strong position on traditional practices such as female genital cutting and early marriage that breach human rights and impact negatively on maternal and child health.
Engagement of Religious Institutions: In the range of socio-cultural and spiritual contexts of UNFPA’s Country Programme case studies it was apparent that the engagement and incorporation of local power structures and faith-based institutions was decisive in operational success. In all settings the use of Islamic, Catholic, Buddhist and Hindu institutions and leaders in advocacy campaigns proved effective both in terms of ownership and efficacy. A number of important issues emerged surrounding the mode of engagement of religious leaders and institutions. Religious organisations and power structures in the case study settings were prepared to work in partnership with UNFPA when they were actively engaged and presented with non-judgemental, evidence-based information relating to health. By taking a culturally-informed and sensitive approach and identifying common objectives, UNFPA was able to develop partnership strategies that clearly addressed the needs of communities served by local secular and religious leaders as well as UNFPA themselves. In this way, both local and international parties worked towards common goals.
Accentuation of Agreements: Early identification of potential opposition and allies in realising the ICPD goals was also found to be indispensable. By identifying potential areas of contention and agreement enabled pre-emptive inclusion of concerned groups and incorporated their views in planning processes. This minimised conflict points and enhanced effective partnerships and co-operation. In this way advocacy campaigns were designed that avoided reinforcing differing values and optimised consensus existing between religious texts and development goals. For example, in Yemen and among Uganda’s Muslim community, early research in partnership with Islamic scholars highlighted a convergence of views in certain messages in the Koran and ICPD goals. This proved to be influential in gaining project entry into these Muslim communities and promoting reproductive rights and access to services.
First Achievements: In all the case study settings, partnerships with faith-based organisations succeeded in integrating rights-based reproductive health into the public arena and religious agendas. In this way these issues could be addressed and communities themselves mediate tensions between the dynamics of social change and cultural traditions. This approach provided a positive and supportive position for both ICPD advocates and religious leaders who have come under increasing pressure within their congregations to provide spiritual solutions to concerns over family size, maternal and child health and other SRH health. Even where religious institutions are in opposition to particular aspects of the ICPD Programme of Action, the UNFPA experience shows that selective collaboration with faith-based organisation can enable valuable partnerships towards common objectives where differences in positions on issues are respected. For example, even though the Church of Uganda takes a strong view on contraception, UNFPA engaged the Church in dialogue and developed a selective partnership on natural birth spacing. In the course of this collaboration, advocacy among the clergy and congregation was enabled regarding the negative health impacts of early marriage and the positive outcome of women receiving access to reproduce care and young people being HIV-aware.
Capacity building: UNFPA applied the knowledge base and lessons learned from the case studies to devise training to capacity-build cultural awareness and sensitivity into approaches of programme staff. Among the capitalisation documentation resulting from the case studies, were a trainer’s guide entitled “Mediating Change Through Culturally Sensitive Approaches” and the brochure “Guide to Working From Within: 24 Tips for Culturally Sensitive Programming.” The scope of the ICPD+10 survey conducted in 165 countries in 2004 was also broadened by UNFPA conducting a detailed analysis of data concerning cultural issues 10 years after the Cairo Conference. With the objective of identifying regional trends to assist programming, it explored the relationship between cultural issues and initiatives in the areas of reproductive health and rights, adolescent reproductive health, HIV/AIDS and gender, equity and equality.
UNFPA advocates the use of the “Culture Lens” as a programming tool that facilitates policy makers and development practitioners to explore and understand cultural values which can be used as entry point and facilitating structures in programme implementation to realise ICPD and wider development goals. In this way initiatives can be designed to work within the socio-cultural context and by cementing local partnerships, identifying common objectives and establishing ownership, promote rights-based approaches to SRH within a wider development context that engenders community empowerment and sustainable local solutions to local development concerns.
*Kate Molesworth works in public health specialising in integrated health and social development with the Reproductive Health and HIV/AIDS unit of the Swiss Centre for International Health at the Swiss Tropical Institute (STI/SCIH). She provides regular technical advice to the Swiss Development Co-operation under the SDC/SCIH Backstopping Mandate. Contribution on behalf of the Swiss Agency for Development and Co-operation. Contact: email@example.com
- UNFPA (2004) Culture Matters: Working with Communities and Faith-based Organization: case Studies from Country Programmes. New York: UNFPA
- UNFPA (2004) Working from Within: Culturally Sensitive Approaches in UNFPA Programming. New York: UNFPA
- UNFPA (2005) Mediating Change Through Culturally Sensitive Approaches: Trainer’s Guide. Training Workshop SDC, Bern 19 August 2005.
- UNFPA (2004) Guide to Working From Within: 24 Tips for Culturally Sensitive Programming. New York: UNFPA
- UNFPA (2005) Culture in the Context of UNFPA Programming: ICPD+10 Survey Results on Culture and Religion. New York: UNFPA
- UNFPA, the 2005 World Summit and the Millennium Development Goals, www.unfpa.org/icpd