Management of the politics of evidence-based sexual and reproductive health policy.

The urgent need to address sexual and reproductive ill health is well established, and since the mid-1990s relevant policies and programmes have been expanded substantially. International commitment to improving sexual and reproductive health has been formulated in several forums, including the International Conference on Population and Development (1994) and the Millennium Development Goals (2000). Moreover, the cost-eff ectiveness of several interventions has prompted the World Bank to recommend that such interventions be provided as part of an essential package of health-care services—even in the most resource-constrained settings. Nonetheless, international commitment for the introduction or scaling-up of sexual and reproductive health interventions has generally been insuffi cient to guarantee policy change and implementation at the national level, despite evidence for the eff ectiveness of such interventions. For sexual health in particular, political and legal frameworks nationally have been largely determined by perceptions of cultural norms and moral standards. Such policies have met both passive and active resistance. We need to analyse the political dimensions associated with these policy processes, and to manage them strategically to counteract resistance to evidencebased policies from constituencies who might be more politically adroit. Political factors are often pivotal in the policy process. They can determine which sexual and reproductive health issues are included in national policy agendas, which evidence is examined (or excluded), which policy alternatives are considered (and ultimately adopted), and the degree to which they are implemented. Competition to include issues on political agendas can be strenuous. Opportunities can arise when problems become widely recognised and when decision-makers become aware of feasible solutions. But agenda items can be set only when the politics of the situation are right—ie, when decision-makers want to be seen to be taking action, and the probable political costs are much lower than the potential benefi ts. We might hope that health agendas would be set mainly on the basis of evidence. But experience shows that evidence has not always been suffi cient, especially if a subject is culturally taboo (eg, adolescent sexual and reproductive health services in Cameroon or the promotion of condom use in Indonesia); if an intervention could adversely aff ect some interest groups (eg, the restriction of the role of midwifery by obstetricians in rural areas in Latin America); if the intervention is perceived to be diffi cult to administer (eg, the complexity of sexual and reproductive health care services being used as an argument against integration of such services); or if the benefi ts would accrue mainly to those with little political infl uence, such as poor people, women, and girls. Evidence of the technical feasibility of aff ordable, costeff ective interventions to address a health problem might not be suffi cient to ensure that relevant policies are formulated or adopted. Indeed, in some cases policies have been adopted in the absence of suffi cient evidence, in contradiction to the evidence, or even when the data suggest that the proposed intervention might not work— because political factors have outweighed the available scientifi c evidence. For example, reviews of interventions that focus on the promotion of abstinence for reduction of unintended pregnancies, sexually transmitted infections, and HIV risk in young people have shown that when abstainers become sexually active they are less likely to use condoms than those who have not taken part in such programmes. Nonetheless, abstinence-only programmes have been widely adopted in international development cooperation—often as a result of infl uence and funding that stem from consideration of domestic political interests. Conversely, sexuality education has been stigmatised by the perception that it promotes early initiation of sexual behaviour—despite evidence to the contrary. Similarly, interest groups have also manipulated evidence about emergency contraception, and access to such contraception remains subject to legal and policy barriers in some countries. Implementation of policies can be hindered by costs or other barriers, religious or cultural norms, lack of political or commercial support, or inertia. For example, although the 1993 World Development Report recommended implementation of an essential package of services for sexual and reproductive health, many countries have been forced to sacrifi ce some components because of cost and other barriers to service delivery. As a result, some countries implemented maternal health policies such as antenatal care and family planning, but not delivery care or treatment for sexually transmitted infections. In another instance, although most countries in sub-Saharan Africa have adopted universal screening of pregnant women for syphilis, these policies have not been eff ectively implemented, and rates of congenital syphilis remain unacceptably high. The scarcity of champions or supportive coalitions for this feasible, cost-eff ective intervention has hampered implementation in settings where need is greatest. Similarly, magnesium sulphate, which is recommended to prevent and treat eclamptic seizures and which could prevent as many as 50 000 maternal deaths yearly at low cost, remains underused. Lancet 2006; 368: 2101–03