Urbanisation and Sexual and Reproductive Health and Rights (SRHR)

The 21st Century is the century of the city. Today, more than half of humanity lives in cities and by the year 2030 this will have risen to about 60%. The urban population will then stand at almost five billion. While the global population growth rate is estimated at 1.1% per year, the rate of urban growth will be double this, at 2.2%.This expansion, which is caused both by the migration of those hoping for better working and living conditions, and by natural population developments, is occurring mainly in developing countries. It is having an enormous impact on population dynamics. On top of this the size of cities will increase steadily, bringing a rise in the number of mega-cities: by 2020 eight cities will exceed 20 million inhabitants, six of them in developing countries.

Urbanisation of poverty

Urban growth is accompanied by the growth of slums and informal settlements. Today, 40% of the population in developing countries lives in poor urban settlements. In many cities in the countries of sub-Saharan Africa which find themselves on the threshold between rural and urban culture, 90% of city dwellers live in slum areas. Examples of this include Ethiopia, Uganda, Sierra Leone and Tanzania.

Cities in developing countries are characterised by a variety of problems such as air pollution, noise, high-density and inadequate housing, insufficient water supply and sewage disposal, fragmentary waste disposal and overburdened public transport. These all constitute serious health hazards, especially for the urban poor. In slums and informal settlements, children, women and elderly people suffer particularly from the poor conditions. Nevertheless, the lack of possibilities for development in rural areas as well as insufficient infrastructure and working opportunities still force more and more people to migrate to cities that are ill-prepared for the influx and are unable to supply necessary services and facilities. For example, Lagos, in Nigeria, grows by over 5% each year. In the face of such rapid expansion, city councils in developing countries are overburdened. They fail to plan urban development or make the necessary infrastructure available.

Sexual and reproductive health is a critical factor for sustainable urban development

Sexual and reproductive health and rights (SRHR) are central to health and development as a whole. Accessibility and availability of quality sexual and reproductive health services are a part of the human right to the highest attainable standard of health as well as a critical factor of utmost importance for poverty reduction and sustainable development

Sexual and reproductive health is a human right.Health is a basic need of all human beings and a precondition for any kind of development. Sexual and reproductive health (SRH) includes all aspects of physical, mental and social well-being with regard to sexuality and reproduction and is thus a core element of the right to the highest attainable standard of health. The right of the individual to decide freely and responsibly the number and spacing of their children, and the right to adequate access to information, education and services, form part of internationally recognized human rights. At the 2005 World Summit, world leaders committed themselves to the goal of universal access to reproductive health by the year 2015, thereby confirming the centrality of SRH to the Millennium Development Goals.

Feminisation of poverty

The proportion of households headed by women is increasing, especially in urban slums. More than half the families in some informal settlements do not have a male head of family. Many children grow up without their biological father.

Women are often at a worse disadvantage than men regarding education, income and living conditions. They are more likely to work in the informal sector or in unsafe working conditions, and they have considerably less access to financial loans. The insufficient urban services and the lack of infrastructure affect women particularly hard, because their domestic responsibilities include caring for the health of their children, ensuring access to clean water and disposing of waste water and household refuse. Women are exposed to insecurity and danger in public spaces, and are often treated badly in their private environment. Because of gender-related attitudes, violence, and harmful traditional practices, women are increasingly affected by HIV/AIDS. HIV-positive women and AIDS widows suffer stigmatisation and live in fear of expulsion from their communities.

The birth rates in urban slums exceed those of rural areas. Poor urban women lack access to services and information, to modern means of contraception, to skilled attendance at birth. They are exposed to an extremely high risk of HIV/AIDS, and teenage pregnancies are putting poor urban women at risk.

A lack of social networks and the pressure to nourish their families force girls and women into transactional sex or prostitution, which increases the risk of HIV/AIDS and other sexually transmitted infections. A high percentage of children living in poverty in the cities of many developing countries die of pneumonia, diarrhoea, malaria, measles and HIV/AIDS. The spread of these diseases is exacerbated by unclean water, dirty conditions, overcrowding and the lack of sanitary facilities.

Sustainable urban development with women

The concept of sustainable development includes measures that affect future generations, long-term health and the protection of the environment. It also encompasses quality of life, equal opportunities and other social and cultural dimensions of human wellbeing.

Places like urban slums – where ownership of property is insecure, where people live in constant fear of being displaced, where a correlation between gender and poverty exists, and where infrastructure is inadequate – pose a serious threat to people’s health and wellbeing. Although health is both a basic need and a precondition for every aspect of development, women, adolescents and children living in slums suffer a high risk of sexual and reproductive ill-health.

A gender-balanced policy of urban sustainable development has an important role to play in integrating women more closely into the planning process and assuring that various aspects of sexual and reproductive health are addressed. There is a high need for family planning and sexual and reproductive health services specially adapted to women in poor urban areas. Even though many urban settlements do provide basic health services, poorer girls and women often can not get access to them. Services around family planning, safe pregnancy and delivery, violence against women and safe sex counselling are examples. In order to make these accessible and effective, the participation of men is also extremely important. The framework of Local Agenda 21 action programmes is an important platform for integrating topics like sexual and reproductive health into urban planning. In ideal, the programmes are developed in a participative manner, at city council or municipal level, and include under-represented social groups, like women, slum dwellers and minorities.

Sexual and reproductive health and urban management

City councils are responsible for a long list of services, such as business development, law and order, estates management, waste disposal, the fire brigade, urban planning, transport, traffic, construction (housing and infrastructure), social services and environmental protection. They also play an important role in culture, education, youth issues, sports, employment, social welfare, health and consumer protection. All these areas of work are reflected in corresponding municipal departments. Some cities also maintain full departments for women or gender issues, but sexual and reproductive health services are usually neglected.

Challenges and opportunities

In the future municipal administrations will have to adjust their planning and health services to better meet the needs of the poor urban population. Urban planning, for example, must address issues which are of specific interest to slum inhabitants, such as violence, risk of injury, sexually transmitted infections, HIV/AIDS, mental well-being, and sexual and reproductive health. The collection of disaggregated data will be of crucial importance.

Urban health services will need to cover fields of sexual and reproductive health: family planning, prenatal and postnatal care, safe childbirth, breast-feeding, health care for women and infants, prevention and treatment of infertility, unsafe abortion, prevention and treatment of sexually transmitted infections. This includes the right to contraception as well as information and counselling about sexuality and infertility. It is possible to incorporate measures for improved sexual and reproductive health in almost all fields of the city council’s responsibility, for example:

Transport: addressing violence prevention in street design and urban planning; raising awareness on topics of SRHR on public transport and in public spaces.

Water/Sewage: improvements to the infrastructure of poor urban settlements so that the right to a standard of living adequate for the health and wellbeing of citizens is realised, with particular attention to women and children.

Estate management: fostering pro-poor, equitable policies; sensitising the administration to the housing problems of poor and marginalised citizens, including women and people living with HIV/AIDS; supply of appropriate support services.

*The Fact Sheet was written by Joanna Kotowsi, SUM Consult and edited by Inge Baumgarten and Ulrich Knobloch from “Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ)”. German development cooperation has a long-standing experience in urban health promotion in Latin America, Asia and Africa. Special features of its strategy are a comprehensive approach, promoting the integration of issues like sexual and reproductive health, youth promotion, addiction and drug control, violence prevention; and facilitating participatory, gender-sensitive development and good governance. Examples from practice reveal numerous linkages and intersections for the efficient promotion of sexual and reproductive health and rights in urban development.