The Lancet Commissions Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission Ann M Starrs, Alex C Ezeh, Gary Barker, Alaka Basu, Jane T Bertrand, Robert Blum, Awa M Coll-Seck, Anand Grover, Laura Laski, Monica Roa, Zeba A Sathar, Lale Say, Gamal I Serour, Susheela Singh, Karin Stenberg, Marleen Temmerman, Ann Biddlecom, Anna Popinchalk, Cynthia Summers, Lori S Ashford Lancet 2018; 391: 2642–92 Executive summary contraception. Each year worldwide, 25 million unsafe Published Online Sexual and reproductive health and rights (SRHR) are abortions take place, more than 350 million men and May 9, 2018 fundamental to people’s health and survival, to economic women need treatment for one of the four curable http://dx.doi.org/10.1016/ development, and to the wellbeing of humanity. Several sexually transmitted infections (STIs), and nearly S0140-6736(18)30293-9 decades of research have shown—and continue to 2 million people become newly infected with HIV. See Comment page 2583 Guttmacher Institute, show—the profound and measurable benefits of Additionally, at some point in their lives nearly one in New York, NY, USA investment in sexual and reproductive health. Through three women experience intimate partner violence or (A M Starrs MIA, S Singh PhD, international agreements, governments have committed non-partner sexual violence. Ultimately, almost all A Biddlecom PhD, to such investment. Yet progress has been stymied 4·3 billion people of reproductive age worldwide will A Popinchalk MPH, C Summers DrPH); African because of weak political commitment, inadequate have inadequate sexual and reproductive health services Population and Health Research resources, persistent discrimination against women and over the course of their lives. Center, Nairobi, Kenya, School girls, and an unwillingness to address issues related to Other sexual and reproductive health conditions of Public Health, University of sexuality openly and comprehensively. remain less well known but are also potentially Witwatersrand, Johannesburg, South Africa, Center for Global Health and development initiatives, including the 2030 devastating for individuals and families. Between Development, Washington, DC, Agenda for Sustainable Development and the movement 49 million and 180 million couples worldwide might be USA (A C Ezeh PhD); Promundo, toward universal health coverage, typically focus on affected by infertility, for which services are mainly Washington, DC, USA particular components of SRHR: contraception, maternal available only to the wealthy. An estimated 266 000 women (G Barker PhD); Department of Development Sociology, Cornell and newborn health, and HIV/AIDS. Countries around University, Ithaca, NY, USA the world have made remarkable gains in these areas (Prof A Basu MSc); Tulane School over the past few decades, but the gains have been Key messages of Public Health and Tropical inequitable among and within countries, and services Medicine, Tulane University, • Sexual and reproductive health and rights (SRHR) are New Orleans, LA, USA have often fallen short in coverage and quality. Moreover, essential for sustainable development because of their (Prof J T Bertrand PhD); Johns in much of the world, people have insufficient access to a links to gender equality and women’s wellbeing, their Hopkins Bloomberg School of full set of sexual and reproductive health services, and Public Health, Johns Hopkins impact on maternal, newborn, child, and adolescent University, Baltimore, MD, USA their sexual and reproductive rights are not respected or health, and their roles in shaping future economic (Prof R Blum PhD); Government protected. Acceleration of progress therefore requires development and environmental sustainability. of Senegal, Dakar, Senegal adoption of a more holistic view of SRHR and tackling of • Everyone has a right to make decisions that govern their (A M Coll-Seck MD); Lawyer’s neglected issues, such as adolescent sexuality, gender- Collective, Delhi, India bodies, free of stigma, discrimination, and coercion. (A Grover LLB); Early Signal based violence, abortion, and diversity in sexual These decisions include those related to sexuality, Foundation, New York, NY, USA orientations and gender identities. reproduction, and the use of sexual and reproductive (L Laski MD); Independent Progress in SRHR requires confrontation of the health services. Consultant (M Roa LLM, barriers embedded in laws, policies, the economy, and in L S Ashford MSc); Population • SRHR information and services should be accessible and Council, Islamabad, Pakistan social norms and values—especially gender inequality— affordable to all individuals who needthem regardless of (Z A Sathar PhD); World Health that prevent people from achieving sexual and their age, marital status, socioeconomic status, race or Organization, Geneva, reproductive health. Improvement of people’s wellbeing ethnicity, sexual orientation, or gender identity. Switzerland (L Say MD, depends on individuals’ being able to make decisions K Stenberg MSc); International • The necessary investments in SRHR per capita are modest Islamic Center For Population about their own sexual and reproductive lives and and are affordable for most low-income and Studies And Research, Al Azhar respecting the decisions of others. In other words, middle-income countries. Less-developed countries will University, Cairo, Egypt achieving sexual and reproductive health rests on face funding gaps, however, and will continue to need (Prof G I Serour MD); and realising sexual and reproductive rights, many of which Department of Obstetrics and external assistance. Gynaecology, Aga Khan are often overlooked—eg, the right to control one’s own • Countries should incorporate the essential services defined University, Nairobi, Kenya body, define one’s sexuality, choose one’s partner, and in this report into universal health coverage, paying special (Prof M Temmerman PhD) receive confidential, respectful, and high-quality services. attention to the poorest and most vulnerable people. Correspondence to: The evidence presented in this report reveals the scope • Countries must also take actions beyond the health sector Dr Susheela Singh, Guttmacher of the unfinished SRHR agenda. Each year in developing Institute, New York, NY 10038, to change social norms, laws, and policies to uphold USA regions, more than 30 million women do not give birth human rights. The most crucial reforms are those that [email protected] in a health facility, more than 45 million have inadequate promote gender equality and give women greater control or no antenatal care, and more than 200 million women over their bodies and lives. want to avoid pregnancy but are not using modern 2642 www.thelancet.com Vol 391 June 30, 2018 The Lancet Commissions die annually from cervical cancer even though it is almost Introduction entirely preventable. Men also suffer from conditions, For too long sexual and reproductive health and rights such as STIs and prostate cancer, that go undetected (SRHR) have been treated as a narrow set of siloed health and untreated because of social stigma and norms issues, with little recognition of their centrality to people’s about masculinity that discourage them from seeking overall health and wellbeing. This approach is rooted in health care. cultural and political sensitivities related to sexuality, This report proposes a comprehensive and integrated reproductive choice, and gender inequality. For all definition of SRHR and recommends an essential individuals to live healthy and satisfying lives and to package of SRHR services and information that should achieve their full potential, their SRHR must be fulfilled be universally available. The package is consistent with, and respected. Substantial health gains have been achieved but broader than, the sexual and reproductive health since world leaders reached landmark agreements targets of the 2030 Agenda for Sustainable Development. defining sexual and reproductive health almost 25 years Our recommended package includes the commonly ago at the International Conference on Population and recognised components of sexual and reproductive Development (ICPD; Sept 5–13, 1994, Cairo, Egypt),1 but health—ie, contraceptive services, maternal and new- full attainment of SRHR remains elusive for many people. born care, and prevention and treatment of HIV/AIDS. Now is the time to embrace SRHR in its totality. Additionally, the package includes less commonly SRHR have far-reaching implications for people’s health provided components: care for STIs other than HIV; and for social and economic development. Unintended comprehensive sexuality education; safe abortion care; pregnancy, complications of pregnancy and childbirth, prevention, detection, and counselling for gender-based unsafe abortion, gender-based violence, sexually trans- violence; prevention, detection, and treatment of in- mitted infections (STIs), including HIV, and reproductive fertility and cervical cancer; and counselling and care for cancers threaten the wellbeing of women, men, and sexual health and wellbeing. Recognising that many families. Therefore, SRHR “are essential for the achieve- countries are not prepared to provide the full spectrum ment of social justice and the national, regional and global of services, we recommend that governments commit to commitments to the three pillars of sustainable develop- achieving universal access to SRHR and to making ment: social, economic and