Commentaries Sexual and reproductive health and rights post 2015—challenges and opportunities P Allotey1, DD Reidpath1 The Millennium Declaration was an opportunity for UN member countries to reaffirm their ‘collective responsibility to uphold the principles of human dignity, equality and equity at the global level … recognising the duty to the most vulnerable’.[1] The Declaration reminded us of those things that we as a global community deem important. In championing these values, we as a global community, could address social justice and inequities, particularly in those areas where disadvantage is deliberately or inadvertently constructed by those with greater power or with greater access to resources. The intent of the Millennium Development Goals (MDGs), with targets to be achieved by 2015, was to provide a mechanism to operationalise and monitor strategies and interventions towards reducing poverty and addressing inequities.[2] To address issues related to gender equity for instance, MDGs 2, 3, 5 and 6 tackle challenges of access to universal primary education, greater gender equality and empowerment of women, reduction of maternal mortality and combating HIV/AIDS, respectively. Interventions to achieve these goals had the potential to also reinforce commitments that were made through the Convention to Eliminate all forms of Discrimination Against Women (Section V in ref. [1]) and the Beijing Platform of Action with a positive impact on sexual and reproductive health and rights.[3] Achievements in these gender‐related MDGs would effectively provide concrete proxy indicators of improvements in upholding the social values espoused in the Millennium Declaration.[4] The lead up to 2015 has seen a frenzy of activity to meet the MDG targets. Reviews of progress on these measures show that there have been significant gains—more in some countries than others—but there is a lot about which the global community can be proud.[5, 6] Although targets in others may not have been reached, the MDGs have made some impact by galvanising more effort than there previously had been. The numbers of people living in extreme poverty have almost halved, undernourishment and hunger have reduced. There have clearly been significant reductions in maternal mortality and morbidity; greater in some countries than others.[6] Within the Asia Pacific region for instance there are significant achievements in countries like Malaysia, Thailand, Singapore, China; not so much in Bangladesh, India, Nepal, Pakistan, Laos, Indonesia and Cambodia. Tangible indicators, such as the reduction in the numbers of people living in poverty or the reduction in women dying from pregnancy‐related causes, provide information on outcomes that could be a result of any number of complex interventions.[7] A maternal death for instance, is as much an outcome of poverty, rights violations, poor access, poor human resources for health and non‐existent transport infrastructure as it is an outcome of postpartum haemorrhage or eclampsia. An exclusive focus on clinical interventions, critical though these are, would certainly reduce deaths from cases that report successfully to the health services, but will do very little to prevent those cases that never reached the health services. It has been much easier, therefore to concentrate resources on the concrete interventions that have a tangible and short‐term impact than to invest in the translation and operationalisation of complex social phenomena such as changes in societal attitudes, values and protection of human rights.[4, 8-10] The critical point is that the focus on the endpoint has been at the cost of the importance of the route taken during the journey. Consequently, it is difficult to laud progress on gender equality and empowerment, when in spite of at least 15 years of concerted efforts, rights violations such as violence against women remain a significant global problem. Recent reports suggest that 35–38% of women worldwide have experienced either physical and/or sexual intimate partner violence or nonpartner sexual violence.[11] Further, globally, as many as 38% of all murders of women are committed by intimate partners.[11] The maternal health consequences of violence for women are wide ranging and include fetal loss,[12] low birthweight babies, likelihood of abortion, HIV infection, adolescent pregnancy, unintended pregnancy in general, miscarriage, stillbirth, intrauterine haemorrhage, nutritional deficiency, abdominal pain and other gastrointestinal problems, neurological disorders, chronic pain, disability, clinical depression, anxiety and post‐traumatic stress, musculoskeletal injuries and genital injuries.[11] There are several other forms of gender‐based violence based on enduring cultural practices that have been difficult to eradicate, despite recourse to human rights law. These include female genital mutilation,[13] injuries and deaths related to maltreatment of brides when in‐laws are dissatisfied with the amount of dowry paid[14](e.g. burns, acid throwing and suicide), honour killings where women are killed by their relatives because of a perception of dishonouring the family, sex‐selective abortion, abuse of elder women, female infanticide.[15] In the first 4 months of 2014 alone, major news feeds from the BBC, Associated Press and Reuters ran stories on the mass abduction of more than 200 girls in Nigeria some of whom have been reportedly sold into marriage or slavery;[16] fatal gang rapes in India;[17] reports of high prevalence of sexual violence within the EU[18] and increasing sexual violence in schools in the USA.[19] The media is undoubtedly likely to report on the most extreme, ‘newsworthy’ cases and one could argue that these are isolated incidents. One could also argue that several of these events relate to conflict and civil unrest and are therefore not normalised in society. However, the use of gender violations as a strategy in conflict highlights the underlying gender power imbalance that needs to be addressed.[20] Furthermore, research in this area consistently highlights the hidden nature of sexual and other forms of gender‐based violence.[21, 22] A fraction of cases are brought to public attention; many more never reach an administrative system in order to contribute to the statistics.[11] It is also important to note that on the basis of available data, there is no clear economic or development‐based protection against gender‐based violence.[23] In other words, violence against women occurs in both high‐ and low‐income countries. The absence of trends may be an indication of the quality of the data. There is also a lack of data on the wealth quintiles of women who report violence across the different countries where data are available. Nonetheless, the need to address the gravity of violence against women has gained some traction independent of MDG‐related programmes[24, 25] and highlights that there remain significant rights‐related issues that have not been and cannot be addressed within the MDG targets. These also suggest that in spite of any extant data on achievements in gender and sexual and reproductive health and rights, initiatives addressing the structure and values on which these are built are not sufficiently robust to sustain progress or to address those areas that have hitherto been ignored. In a post 2015 shift in focus from poverty to sustainability, the foundation on which we expect the enjoyment of sexual and reproductive health and rights to be sustained needs to be strengthened by ensuring that the values they embody are upheld. Opportunities exist through the various grass roots, civil society and other social movements that have evolved out of the necessity to address ongoing injustice.[3] With the development of new sustainable development targets, there is a need to build the capacity of grass roots organisations that work directly on rights‐based and social justice programmes to compile and present the evidence that demonstrates the success of interventions. The experience of working directly with communities places them in an ideal position to capture the ‘softer indicators’ of change in attitudes, of empowerment, of support and those attributes of societies and relationships that strengthen communities to protect rather than victimise. In recognition of the growing need for the development and synthesis of robust evidence on social issues and interventions to inform policy development and best practice, the Campbell Collaboration was created in 2000 as a sister organisation of the Cochrane Collaboration.[26, 27] Reviews through the Campbell Collaboration and qualitative systematic reviews are beginning to develop evidence that attempts to identify process and non‐traditional health indicators that can inform ways of achieving sustainable equity. There has also been a gradual recognition of the value of evidence generated by grass roots organisations in a range of high impact publications.[28-30] There have also been concerted efforts to prioritise the inclusion of sexual and reproductive health and rights in sustainable development goal setting.[3, 31, 32] Early discussions highlight a revisit of sustainable population level debates from three decades ago on the one hand,[32] and the desire to ensure population growth to maintain economic development on the other.[33] Both of these positions have implications for reproductive health and reproductive choices. Ongoing gender‐based violence, whether associated with conflict and civil unrest or otherwise needs to be addressed and much can be achieved through greater integration of efforts towards the Committee on the Elimination of Discrimination against Women, the Beijing Platform of Action, work on social determinants of health and other global health initiatives.[10]Significantly, joint efforts across UN agencies with agendas relating to gender, sexual and reproductive health and rights would provide critical mass in terms of global networks and expertise, and efficiency given limited resources. Disclosure of interests We declare no conflicts of interest. Contribution to authorship Both authors contributed to the manuscript. PA wrote the initial draft. Ethics approval Ethics approval was not required for this manuscript. Funding No funding was required for this manuscript. Acknowledgements This paper follows on from discussions with colleagues in Global Public Health particularly Dr Sharuna Verghis, colleagues involved with the Rights‐Oriented Research and Education (RORE) network, with Julia Hussein and Tikki Pang and youth committed to social justice particularly Caitlin Allotey‐Reidpath.