Accessing Transport and Transporting Access:
Healthcare and Mobility among Youth in Developing Countries
Deladem
Kusi-Appouh[1]
Following strong and persistent
pressure from concerned organizations, a new target was finally incorporated to
Goal 5 of the Millennium Development Goals (MDGs) in 2006: that of
universal access to reproductive health by 2015.[1] Even though theoretical frameworks and
empirical studies had already established linkages between reproductive health
(RH) and MDGs, the United Nations General Assembly’s adoption of the target represented
official recognition that the MDGs (eradicating poverty, promoting gender
equality, reducing child mortality, improving maternal health, combating
HIV/AIDS) cannot be achieved without paying particular attention to
reproductive health.[1]
Another area awaiting explicit recognition
is the indispensable role of transport in achieving the MDGs. In addition to enhancing a country’s physical
infrastructure, transport design has a qualitative impact on general economic
and social welfare. Indeed, transport
plays pivotal role in stimulating economic growth and poverty reduction as well
as assisting the poor in gaining access to services and employment
opportunities.[2, 3] Current literature shows that a wide range of
studies have been undertaken to underscore the importance of the role of
transport in achieving all the MDGs.
This
paper proposes to examine the relationships between (i) access to reproductive
health – particularly sexual health services, (ii) transport/mobility and (iii)
achieving the MDGs. There is undoubtedly an interplay between multiple factors regarding mobility and the accessibility to
all health resources, both at macro and micro levels and especially so in low-income
countries.[4] Still, this paper focuses on youth in developing countries[2]
and posits that for this subgroup of the population, there are added levels of
complexity at the nexus of all three elements.
In other words, as a result of their age group, gender, and/or marital
status, youth (defined here as those between 15-24 years) are faced with challenges
beyond those already facing people living in poverty and resource-poor areas.
These challenges are influenced by social, cultural, political and economic
norms and practices.
The first section of the paper will discuss aspects of youth sexual/reproductive
health and the MDGs; the second will look at the role of transport/mobility as it
relates to health and achieving the MDGs; the third section will examine
factors to consider when access to sexual and reproductive health, transport
and the MDGs intersect, for 15-24 year-olds seeking healthcare.
1. Youth Sexual and Reproductive
Health and the MDGs
The
right of youth to access reproductive health services and information as well
as privacy, respect, confidentiality and informed consent was endorsed several
years before the MDGs were created. In 1999, such a plan was ratified as
a follow up to the 1994 International Conference of Population and Development
(ICPD) held in Cairo.[5] Nevertheless, in many parts of the world, the
sexual and reproductive health needs of adolescents are only minimally
appreciated or poorly understood.[6] A quick glance suggests that every MDG contains
targets that would greatly benefit from a healthy youth population whose
education and livelihoods should be drastically improved.[5]
Half of
the world’s population is made up of youth below the age of 25, with
approximately three billion children and youth of, or soon to be, reproductive
age.[7] In some countries – usually the poorest – youth
make up 30 to 40% of the entire population.[5] The realities of youth today include a rapidly
changing world confronted by urbanization, HIV/AIDS, changing family structures,
and migration, among others.[5]
Youth
generally face markedly higher sexual and reproductive health risks compared to
any other age group for a variety of reasons.
One is that they are more likely to engage in (risky) sexual behavior. The consequences of this behavior include early
pregnancy, sexually transmitted infections (STIs) including HIV, unsafe
abortions with associated complications as well as sexual pressure, violence
and coercion.[5, 6] Issues of gender equity, poverty, lack of
education and inadequate livelihood skills also adversely impact the youth.[5] Youth who are poor are disproportionately
affected by the reproductive health issues mentioned above, but also early
marriage, unmet need for contraceptives, and lack of access to reproductive
health services.[5]
If the
age profile of new HIV infections is any indication, the reproductive health
needs of youth have yet to be met effectively. Worldwide, there are
about 1 billion youth between 15-24 years and of the latter, about 10 million
are living with HIV and an estimated 6,000 youth are infected with HIV daily.[7] Among the infected youth, 63% come from
sub-Saharan Africa and 21% from Asia.[7] At the global level, women 15-24 years are
almost twice more likely to be living with HIV than their male counterparts.[8] Other more common STIs – including chlamydia,
gonorrhea, syphilis and trichomoniasis – dramatically increase the risk of HIV
transmission. More than 100 million of
curable STIs are contracted by young men and women under 25 years. Young
women, however, suffer more serious consequences of STIs because of their
asymptomatic nature before the disease advances.[5] Clearly, Goal 6 of the MDGs cannot be
attained given the current situation, and immediate efforts to improve youth sexual
and reproductive health are imperative. Moreover,
with economic, social and biological factors undermining women’s capacities to
protect themselves,[9] it is evident
that MDG Goal 3 of promoting gender equality and empowering women is also
important in combating HIV/AIDS.
Each year, 529,000 women die from causes related to childbirth or pregnancy and 99% of them are from developing countries.[9, 10] Not only do about 20% of women give birth before the age of 18, but also young mothers are twice as likely as older women to die from pregnancy-related causes, facing a greater risk of obstructed labor, damage to the reproductive tract and of unsafe abortions.[5] In sub-Saharan Africa, for instance, young women under the age of 25 account for nearly 60% of all unsafe abortions.[6] Early pregnancy is also directly associated with higher infant mortality, which is highest in countries with the largest proportion of adolescent births.[5]
Many married young women also report that their first birth was unplanned or unwanted, attesting to the unmet need for contraception among this group. Serving this need in developing countries would prevent about 52 million unintended pregnancies a year and circumvent maternal deaths.[5] In short, the education of young girls/women; an increase in age at marriage and at first birth; reduced adolescent fertility; improved livelihood skills; increased contraceptive prevalence; reduced HIV prevalence among 15-24 year olds; proportion of births attended by skilled birth attendants; proportion of met for family planning needs; and availability of emergency obstetric care are all closely tied to effectively accessing sexual and reproductive health information and services, which in turn contribute to attaining MDGs 2, 3, 4, 5 and 6.[9, 10]
2. Transport/Mobility,
Health and MDGs
A major hindrance to some factors
listed above is that existing health systems in the majority of developing
countries are not adequately equipped to handle issues related to adolescent
sexual and reproductive health.[6] Many health centers lack related and/or
specific services and even where such services are available, restrictive laws
and policies based on age and marital status may prevent services from being
accessed.[6, 9] Still, in areas where no such restrictions exist at all, youth may
not always be able to take advantage of these services due to issues of
transport or mobility, cost, perceived hostile and judgmental attitude of
service staff, lack of confidentiality and embarrassment at needing services in
the first place.[6, 9] While some health service providers are
unaware of the youth-friendly laws, others apply their own cultural and/or
religious beliefs when dealing with young clients.[8, 9] A study of young women in
The role of transport becomes very apparent when marrying sexual and
reproductive health with the MDGs because transport connects the built
environment with the social environment.
Improved transportation and mobility are likely to directly improve access to
health services and indirectly enhance aspects of social and economic
development that impact positively on health..[4] Transport, however, has been associated with
two harmful health-related effects in developing countries: (1) a
predominant vector for the spread of HIV/AIDS, where improved access to
transport increases mobility between regions and countries leading to an increased
geographic reach of the virus. Moreover, transport sector workers
including truck drivers and migrant workers tend to exhibit high-risk behaviors
and tend to engage in relations with sex workers, and thus, the probability of
infection is very high[3, 8] and (2) an increase
in road accidents, becoming the second leading cause of death among young
people, most of them from poor households.[3] These negative consequences notwithstanding,
the positive aspects of transport are still worth emphasizing.
3. The nexus considered
While youth may face barriers to accessing sexual and reproductive health services that others may also face, poor/(un)married/rural/urban youth face additional psychosocial, cultural, and economic challenges existing outside their geographical/physical terrain. Aside from fulfilling the infrastructural access to quality, safe, cost-effective and timely transport, transport can also serve to broaden information/service networks available to youth, both by accessing these outside of their community, and by bringing the information to the community.[9] In so doing, though, transport and mobility must recognize their potential not only as agents of social change in unlocking poverty traps, but also in altering the landscape of deeply-rooted norms and practices of a given area by affecting the ways in which health care needs, including supplies and personnel are transported (i.e. delivered) to meet the needs of specific subgroups of the population (many of which overlap). Although certain services relating to youth sexual and reproductive may not always be an emergency as it is with saving a (young) mother or child’s life, accessing information and services on prevention, diagnosis, counseling, treatment and care are essential in order to circumvent potentially fatal situations clearly articulated in the Millennium Development Goals.
References
1. Griffin, S., Universal access to sexual and reproductive health services, in www.eldis.org/health/Universal/index.htm. 2007, ELDIS & PANOS & Realising Rights Consortium.
2. WB, Social Analysis in Transport Projects: Guidelines for Incorporating Social Dimensions into Bank-Supported Projects. 2006, The World Bank: Washington, DC. p. 1-43.
3. GTZ, Why Transport Matters: Contributions of the Transport Sector towards Achieving the Millennium Development Goals. 2005, Deutsche Gesellschaft fur Technische Zusammennarbeit (GTZ). p. 1-13.
4. Molesworth, K., Mobility and Health: The impact of transport provision on direct and indirect determinants of access to health services. 2006, Swiss Tropical Institute. p. 1-27.
5. Zwicker, C. and K. Ringheim, Commitments: Youth Reproductive Health, the World Bank, and the Millennium Development Goals. 2004, Global Health Council. p. 1-30.
6. WHO, Promoting and safeguarding the sexual and reproductive health of adolescents, in Policy Brief 4: Implementing the Global and Reproductive Health Strategy. 2006, World Health Organization: Geneva.
7. UNFPA. Youth and HIV/AIDS Fact Sheet. 2007 [cited; Available from: http://www.unfpa.org/swp/2005/presskit/factsheets/facts_youth.htm#ftn1.
8. Mendoza, A., Relevance of population aspects for the achievement of Millennium Development Goals 6 and 3: Combating the spread of HIV/AIDS. 2004, UNAIDS. p. 1-10.
9. UNFPA, The Millennium Development Goals: Why Every Woman Counts. 2005.
10. Haslegrave, M., Mainstreaming Gender into National Development Policies. 2005, www.srh-mdgs.org. p. 1-3.
[1] Deladem is a graduate student in the Department of Development
Sociology and in the Population and Development Program at
[2] Although, youth in developed countries face remarkably similar issues (youth-friendly health centers, access to appropriate services, confidentiality and cost), this topic is beyond the scope of this paper