Chapter 1. Introduction
Health system factors (1.3.3)
Within the health system, multiple actions are needed to realize human rights obligations. Actions to facilitate and strengthen abortion-related service delivery should be based on human rights, local health needs and a thorough understanding of the service-delivery system and the broader social, cultural, political and economic context. National standards and guidelines for abortion care should be evidence based and periodically updated, and should provide the necessary guidance to achieve equal access to comprehensive abortion care. Leadership should also promote evidence-based SRH services according to these standards and guidelines.
The right to the highest attainable standard of physical and mental health includes the right to respectful health care as well as the right to be free from violence and discrimination (73). The right to benefit from scientific progress and its realization entitles women to access to up-to-date scientific technologies necessary for women. This means States must ensure access to modern and safe forms of contraception (including emergency contraception), abortion medicines, assisted reproductive technologies, and other SRH goods and services, on the basis of non-discrimination and equality (49, para. 33). To achieve a high standard of respectful care, health systems should be organized and managed in a manner that ensures respect for people’s SRH and human rights (73). Respectful health care recognizes individuals’ rights, respects their agency and autonomy in decision-making, and incorporates their values and preferences into care.
In addition to policy and regulatory barriers, other barriers may further limit the availability of abortion services, including: stigma; formal and informal costs; lack of commodities, services, trained providers and information; and/or the unwillingness of some health workers to provide care. This leaves particular groups of people – such as those living in rural settings, those facing financial hardship, adolescents, unmarried, transgender or nonbinary individuals, those with less access to education and those living with HIV – disproportionately vulnerable to barriers to obtaining abortion care. As part of an enabling environment, a health system should be adequately resourced, meaning that resources (e.g. essential medicines, supplies, equipment, workforce, financial allocations) are available, fairly distributed and efficiently used. In this way, adequate and equitable access to quality-assured essential medicines and equipment should be assured. Relatedly, health financing policies should avoid making access to SRH services conditional on direct payment from patients at the point of service, and the health workforce should be skilled in providing evidence-based SRH services, including counselling.
Abortion stigma is common, and has negative psychological consequences for individuals seeking abortion and health workers providing abortion care (31, 74, 75), and can also be detrimental to health outcomes. Abortion stigma is a social process, and is dependent upon the context, but may be considered as an exercise of power and control of one group over members of a less powerful group, who are considered different, negatively stereotyped, discriminated against and marginalized within society (75, 76). Work is needed across sectors to counteract stigma; health systems should recognize the risks and effects of stigma, and implement solutions to not only ensure privacy and confidentiality, but also to support health workers. Care should always be provided respectfully and with compassion. In an enabling environment, communities are also engaged and supportive. Those who assist and support abortion seekers – their partners, friends, family members – also require support within the health system and broader environment.
More in-depth consideration of key health system factors is provided in section 1.4.