Family Planning NSW SDG Inquiry 28 March 2018

28 March 2018 Senate Foreign Affairs Defence and Trade References Committee [email protected] Re: Senate Foreign Affairs Defence and Trade References Committee Inquiry into the United Nations Sustainable Development Goals

Dear Sir/Madam, Thank you for the opportunity to provide a written submission to the Senate Foreign Affairs Defence and Trade References Committee Inquiry into the United Nations Sustainable Development Goals (SDG). Family Planning NSW is the leading reproductive and sexual health (RSH) agency in Australia with over 90-year’s history and an in-depth understanding of where Australia sits in terms of key RSH goals outlined in the agenda. Family Planning NSW provides RSH services, professional education and training, and research and evaluation in Australia, focusing in NSW. We are DFAT accredited and provide international development activities in RSH across the Indo-Pacific region. The Pacific has some of the worst RSH indicators globally, with high rates of unintended and teenage pregnancies, sexual violence and unacceptably high rates of cervical cancer deaths. Our international projects closely align with the United Nations’ SDGs and in particular: • Goal 3: Ensure healthy lives and promote well-being for all at all ages • Goal 5: Achieve gender equality and empower all women and girls Across Australia, there is a lack of national co-ordination on key RSH issues and no recognised national data collection on related 2030 RSH agenda indicators. Available evidence indicates that vulnerable populations including Aboriginal and Torres Strait Islander people, young people, culturally and linguistically diverse people, people with disability and those living in rural or remote areas are left behind the general population on key RSH action items. These facts present ample opportunity to respond and prioritise improvements in this area.

Our submission spans key targets and we are delighted to provide this submission via your online portal and cc’d here. I would welcome any inquiries you may have and have no requirement for any part of this submission to be kept confidential. Kind regards

Adj. Prof. Ann Brassil CEO Family Planning NSW

Sustainable Development Goal 3 – Good Health and Well-Being

3.7 By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes.

The unmet need for family planning remains unacceptably high, especially in disadvantaged populations and in under- developed and developing countries, including in the Pacific region. In the Solomon Islands, for example, population increases are expected to outstrip food and water supply within ten years. Neighboring Papua New Guinea is experiencing similar critical sustainability issues in relation to its current population projections. These parts of the Indo-Pacific are faced with limited and unreliable contraceptive supply, with some of the most under-resourced reproductive health services in the world.

A. The understanding and awareness of the SDG across the Australian Government and in the wider Australian community; In Australia both within government and the wider community there is good understanding and awareness of the importance of access to family planning and contraception for overall health and wellbeing and there is broad access to sexual and reproductive healthcare. Sixty-eight per cent of partnered women in Australia used contraception in 2015 (i).This proportion has remained relatively stable over the past 20 years and is consistent with other more developed countries. There has been a rise in the prevalence of contraceptive use in less developed (44% to 53%) and least developed countries (21% to 63%) over the same period (i).

B. the potential costs, benefits and opportunities for Australia in the domestic implementation of the SDG; Reproductive and sexual health and rights save lives, empower women and lift women and their families out of poverty. Family planning is one of the most cost-effective investments in global health and development. Every one dollar invested in reproductive health generates up to 120 times its value in economic and social benefits (ii). This includes reductions in unintended pregnancy and maternal and infant mortality, improved health and wellbeing, increased educational attainment for women and children, and greater female labour force participation. Australia has good quality reproductive health services, however, there is a significant opportunity to improve access for high need populations including Indigenous communities which have lower use and access rates to contraception than the broader community (iii).

C. What governance structures and accountability measures are required at the national, state and local levels of government to ensure an integrated approach to implementing the SDG that is both meaningful and achieves real outcomes; There are significant gaps in knowledge regarding contraceptive prevalence and choices in Australia, including methods and products used, and how this varies by geographic, social and other factors. The National Aboriginal and Torres Strait Islander Health Survey (NATSIHS), conducted by the ABS in 2012, found 49.4 per cent of Indigenous women reported currently using contraception (iii). This is lower than the national average of 60 per cent who were currently using contraception as reported in the HILDA 2015 survey (iv). Facilitating greater education about, as well as access to, contraception among Indigenous and other priority populations is crucial to reducing rates of unintended pregnancy, reducing maternal and infant mortality, and thus increasing educational attainment and increasing labour force participation. These are critical in ‘closing the gap’ in Aboriginal and Torres Strait Islander health and well-being, as well as that of other priority populations including youth, culturally and linguistically diverse populations, people living with disability, lesbian, gay, bisexual, transgender and intersex (LGBTI) people and people from rural and remote communities.

D. How can performance against the SDG be monitored and communicated in a way that engages government, businesses and the public and allows effective review of Australia’s performance by civil society; In Australia, a consistent, national approach to the collection of data on contraceptive use, either through routine data collection and reporting by Medicare, or through regular, population-based survey research, is required to provide the level of information needed to ensure a robust understanding of our immediate priorities in RSH, supported by effective health service provision and cost-effective policy in this area.

Internationally, the populations of the Pacific Island nations are very small, which means that sales of contraceptives will never be large on any world standard. The pressing impact of this is that both the corporate (including pharmaceutical companies) and significant international donors do not focus on the Pacific as they cannot achieve the requirements of their business models for economies of scale and size in achieving a significant return on investment. While many industries stand to gain from a population with good RSH and rights, such as Australia itself, those companies and services reaping the profits are not those working at the forefront of RSH. It is therefore beholden on governments, including the Australian Government, to provide the safety-net so that Pacific Island nations can access goods and services at the level of developed nations and therefore develop the capability to compete on the world stage.

E. What SDG are currently being addressed by Australia’s Official Development Assistance (ODA) program? A greater unmet need for family planning can be seen among less developed (16%) and least developed countries (22%). Globally, 214 million women and girls have an unmet need for modern contraception (v), and more than 800 women and girls die every day from preventable pregnancy and childbirth-related causes (vi). Australia’s investment in family planning within the aid program has halved between 2013/14 and 2015/16 to AUD 23.7 million; accounting for just 0.6% of ODA. Australia’s commitment to family planning now falls far below global comparisons (vii). We urge the Australian Government to increase this investment to AUD $50 million per annum for family planning assistance. Disbursement of these funds should not just focus on big multilateral organisations, but include significant allocations to NGOs and civil society who have a proven track record on the ground to provide capacity-building of service providers at the country level. We call for a broad multi-country commitment, investing in aid and development organisations that focus on communities in the Pacific. Communities across the Pacific are at crisis point with rapidly growing populations .Unsurprisingly, these communities have concomitant high levels of maternal and infant mortality, lower levels of educational attainment, lower levels of sustainable workforce participation and limited and unreliable access to RSH services, including family planning and contraception (viii).

G. How countries in the Indo-Pacific are responding to implementing the SDG, and which of the SDG have been prioritised by countries receiving Australia’s ODA, and how these priorities could be incorporated into Australia’s ODA program; To implement sustainable change in the Pacific health sector, long term investment is required to build the capacity of Pacific communities to implement change themselves. Investment in infrastructure to provide appropriate health facilities is essential. Critical to achieving improved health outcomes is training of clinicians, community workers and teachers, trialing and implementing customised programs, and ensuring that they continue by embedding teaching in schools and universities. Community education involving men, women and youth about family planning education and ensuring a reliable supply of modern contraceptive methods are also essential. Alongside this, it is crucial that Australia’s ODA program improves the poor RSH data

collection across the Pacific so a fuller understanding of need can be gained. ODA Program reporting from NGOs, linked to the objectives of the SDGs, is required.

Abortions within a reproductive health context A. The understanding and awareness of the SDG across the Australian Government and in the wider Australian community; There is no standardised national data collection or overarching policy on abortion in Australia. It remains the case that in some states universal access is impossible with abortion still falls under the Crimes Act in some states. In many parts of Australia access to abortion is affected by socioeconomic status as private clinics and some NGOs charge high fees for services in areas where publicly-funded services are scant. The impact of this is an overwhelming inequality in access to abortion services in Australia, linked entirely to the capacity of the individual to pay for the service. It is arguable that this is the only critical health care service in Australia where this inequality exists on the basis of socioeconomic status.

Despite a Termination of pregnancy policy being released in 2005 and reviewed in 2016, by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), Australia has failed to align a national strategy on this issue.

In 2004, most abortions were carried out in major cities and very few were carried out in rural and remote areas of Australia (ix). The number of induced abortions was around 58,000 in major cities and was only 251 in very remote areas. The lower abortion rate in rural and remote areas may reflect issues regarding access to abortion services and/or that women from rural and remote areas have to travel unacceptably long distances to other centres where facilities are available.

C&D. What governance structures and accountability measures are required at the national, state and local levels of government to ensure an integrated approach to implementing the SDG that is both meaningful and achieves real outcomes; how can performance against the SDG be monitored and communicated in a way that engages government, businesses and the public and allows effective review of Australia’s performance by civil society; There is no recognised national Australian data collection on reproductive health care services and this should be a focus point for governments as we aim to meet the sustainable development agenda by 2030. Issues accessing abortions in remote and regional areas also need to be addressed, as do issues of socio-economic barriers.

Australian governments need to support national consistency in relation to abortion law and timely, mandatory, national data collections in relation to abortion services. This will bring Australia into line with the SDG of integrating reproductive health into national strategies and programs.

Australia does not have, and requires, a nationally agreed position in relation to sexual and reproductive health and rights. Government continues to be challenged by loud, conservative minorities who do not represent prevailing attitudes in the community at large about sexual and reproductive health and rights. Government needs to develop and rigorously support a nationally agreed position on sexual and reproductive health and rights that it promulgates in Australia and on the international stage. The imperative for this is even greater given Australia’s recent appointment to the International Human Rights Council.

3.8 Achieve universal health coverage, including financial risk protection, access to quality essential

health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all A&B. The understanding and awareness of the SDG across the Australian Government and in the wider Australian community; the potential costs, benefits and opportunities for Australia in the domestic implementation of the SDG; An area of great impact in Australia has been the implementation of the National Cervical Screening Program (NCSP), which has been successful in reducing cervical cancer cases, as well as illness and death from cervical cancer in Australia, through an organised approach to cervical screening aimed at detecting and treating high-grade abnormalities before possible progression to cervical cancer. The target group for this is women aged 25 to 74 years. Because of the implementation of this program, cervical cancer cases and deaths are low by international standards.

However, the incidence of cervical cancer in Aboriginal and Torres Strait Islander women is more than twice that of non-Indigenous women, and mortality is four times higher (x). This is a national disgrace. Addressing the continuing disparity in the cervical cancer mortality rate between Aboriginal and Torres Strait Islander and non-Indigenous women remains a key element to the overall success of the cervical screening program, because this would immediately reduce the high rates of unnecessary deaths from cervical cancer by Aboriginal and Torres Strait Islander women.

The ability to address this issue has been hampered, in part, by incomplete data on Aboriginal and Torres Strait Islander participation in cervical screening, as Indigenous status has not been collected fully by cancer screening registries. There is a need to collect additional demographic characteristics of women attending for cervical cancer screening to ensure participation rates and follow-up of subgroups is monitored.

E. What SDG are currently being addressed by Australia’s Official Development Assistance (ODA) program; F. Which of the SDG is Australia best suited to achieving through our ODA program, and should Australia’s ODA be consolidated to focus on achieving core SDG; G. How countries in the Indo-Pacific are responding to implementing the SDG, and which of the SDG have been prioritised by countries receiving Australia’s ODA, and how these priorities could be incorporated into Australia’s ODA program; H. Examples of best practice in how other countries are implementing the SDG from which Australia could learn. Cervical cancer screening is far less available throughout the Pacific region. For example, in the Solomon Islands women are dying up to eleven times the rate of women in Australia (Australia 1.6; Solomon Islands 18 per 100,000 women). In PNG this is nearly 14 times higher than the Australian rate (xi).

The World Health Organization supports a range of cervical cancer screening programmes, including HPV DNA testing, Pap Tests and Visual Inspection with Acetic acid (VIA). Implementation of HPV DNA testing, whilst unquestionably the most effective, is beyond the capacity of most Pacific Island Nations at present. Alternate low resource cervical cancer screening, such as VIA and treatment with cryotherapy, would immediately and dramatically reduce the unconscionably high death rates from cervical cancer in the Pacific. The Pacific Island Forum has already made cervical cancer screening a priority. Recognizing this through support for capacity building in VIA and cryotherapy through already established programmes would be a great win in saving women’s lives. Reporting, evaluating and measuring this work is also crucial.

Sustainable Development Goal 5 - Gender Equality 5.1 End all forms of discrimination against all women and girls everywhere 5.2 Eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation. 5.3 Eliminate all harmful practices, such as child, early and forced marriage and female genital mutilation.

A. The understanding and awareness of the SDG across the Australian Government and in the wider Australian community; In Australia, two in five people (39 per cent, or 7.2 million) aged 18 years and over have experienced an incident of physical or sexual violence since the age of 15, including 42 per cent of men and 37 per cent of women. Four in 10 men and three in 10 women have experienced physical violence, and one in five women and one in 20 men have experienced sexual violence. Approximately one in four women have experienced violence by an intimate partner (xii). Reproductive coercion, where women are denied basic access to contraception by their sexual partners, is a recognised and prevalent form of sexual violence, however there is little to no data available on this in the Australian context.

B. the potential costs, benefits and opportunities for Australia in the domestic implementation of the SDG; Domestic Violence screening was introduced in NSW in 2003 as part of antenatal, child and family health services, mental health services and alcohol and other drug services. In 2012 Family Planning NSW implemented domestic violence routine screening through its clinics and has achieved an organisational average screening rate of 64 per cent. Across Australia domestic and sexual violence is recognised as a significant public health concern. There are known links between domestic violence and sexual and reproductive ill health. Routine screening for these issues in appropriate settings is an important intervention and should be mandated.

Australia requires a nationally consistent approach to the implementation of comprehensive sexuality education (CSE). This remains a highly fraught area in Australia and requires national leadership. The discussion around CSE is strongly influenced by a loud minority of highly conservative lobbyists whose goal is to reduce community knowledge and awareness in line with highly conservative, far- right and non-representational religious positions. Australia should immediately consider adoption and implementation of the UNESCO Comprehensive Sexuality Education guidelines, to ensure the optimal sexual and reproductive knowledge and health of our communities.

Consistent national domestic violence screening similar to the NSW model should be established across the country. This screening, in appropriate settings, would allow women and girls greater access to support services, and provide a basis for meaningful public reporting of the issue annually.

Likewise, in Australia there is no national information or reporting on the number of women who have experienced female genital mutilation, or the psychosocial, health or workforce impact for these women and their families. Understanding the localities where the prevalence of female genital mutilation is concentrated is essential for community engagement, policy development, health system planning for primary prevention of the issue and the management and support of women living with female genital mutilation.

Health professionals should undertake continuing professional development around female genital

mutilation to be more effective in communicating with women. Education will allow health workers to understand the health consequences and management of female genital mutilation, and to accurately collect information.

Appropriately skilled and confident health professionals should contribute to mandatory collection of robust and reliable national and state-based data on female genital mutilation. Funding and mandating the institution of mandatory collection and reporting of female genital mutilation data to territory and state health departments, will support the development of services required to support women who are affected by, or are at risk of, mutilation.

G. How countries in the Indo-Pacific are responding to implementing the SDG, and which of the SDG have been prioritised by countries receiving Australia’s ODA, and how these priorities could be incorporated into Australia’s ODA program; In the Pacific, rates of sexual and domestic violence are significantly higher than in Australia, with, for example, up to 67 per cent of women in Papua New Guinea and Kiribati reporting experiencing physical and sexual violence in their lifetime (viii) Effective, evidence-based programs targeting cultural attitudes to reproductive and sexual rights and gender-based violence are needed. It is crucial men and boys are involved in RSH programs as the role and attitudes of men are critical to addressing the broader issues and gender equality. It is crucial that ODA funding is tasked for ongoing gender equity work across this region. However, meaningful and consistent data collection across the Pacific on matters of gender equality is scant and this makes tracking performance difficult. ODA funded NGOs should report to DFAT on the people reached and programs implemented with a view that an annual, public report that is accountable, transparent and capable of tracking this total ODA effort against the SDGs be implemented.

i United Nations, Department of Economic and Social Affair, Population Division (2015). Trends in Contraceptive Use Worldwide 2015 (ST/ESA/SER.A/349). ii Kohler, Hans-Peter and Jere R. Behrman (2014). Population and Demography Assessment Paper: Benefits and Costs of the Population and Demography Targets for the Post-2015 Development Agenda: Copenhagen Consensus Center. (This calculation focuses on investments in family planning commodities, information, education and services). iii Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Survey 2012 , customized report. 2017 iv Melbourne Institute of Applied Economic and Social Research. Household, Income and Labour Dynamics in Australia (HILDA) Survey. Melbourne, Australia 2015 v Guttmacher, 2017. Adding it Up: Investing in Contraception and Maternal and Newborn Health, 2017. Available online: https://www.guttmacher.org/fact-sheet/adding-it-up-contraception-mnh-2017 vi WHO, 2016. Maternal Mortality Fact Sheet, November 2016. Available online: http://www.who.int/mediacentre/factsheets/fs348/en/ vii The UK Department for International Development’s investment in family planning support accounted for 1.4% of ODA in 2015/16. viii UNFPA. World Population Dashboard . Available online: https://www.unfpa.org/data/world-population- dashboard

ix Data for 2003: Grayson N, Hargreaves J, Sullivan EA 2005. Use of routinely collected national data sets for reporting on induced abortion in Australia. AIHW Cat. No. PER 30. Sydney: AIHW National Perinatal Statistics Unit (Perinatal Statistics Series No. 17). Data for 2004: Laws PJ, Grayson N & Sullivan EA 2006. Australia’s mothers and babies 2004. Perinatal statistics series no. 18. AIHW cat. no. PER 34. Sydney: AIHW National Perinatal Statistics Unit. x Cancer Institute NSW (2016). NSW Cancer Plan. Available online: https://www.cancerinstitute.org.au/cancer- plan/Focus-areas/Aboriginal-communities xi Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, et al. GLOBOCAN 2012 v1.0. Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11. 2013. Available from: http://globocan.iarc.fr. xii Australian Bureau of Statistics (2013). 4906.0 – Personal safety, Australia, 2012 . Canberra: ABS.