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2017 Country Assessment on Sexual Reproductive Health Rights (SRHR) in Timor- Leste

Since its independence in 2002, Timor-Leste has made significant progress in social and economic development. The country achieved lower middle-income status in 2011 and has ambitions to reach upper middle-income status by 2030. As the country continues to experience socio-economic and security-related advances, the situation for women, men, girls and boys in Timor-Leste has also improved. However, major challenges remain in the area of sexual and reproductive health and rights. The Country Assessment on Sexual and Reproductive Health and Rights (SRHR) in Timor-Leste is a partnership initiative between the Office of the Ombudsman for Human Rights and Justice (Portuguese abbreviation − PDHJ) and the United Nations Population Fund (UNFPA). The Country Assessment provides an overview of challenges in the areas of maternal and child health, family planning, comprehensive sexuality education, HIV and sexual health, and gender-based violence. The key findings in these thematic areas are as follows. Maternal and child health: Since independence, Timor-Leste has made great gains in this area by significantly reducing maternal, infant and child-under-five mortality. However, maternal deaths remain a challenge, despite the majority of deliveries being attended by skilled personnel. Pregnant women and mothers have difficulty accessing adequate antenatal and post-natal care, and children are still dying from preventable causes. Inequalities in access to maternal health care are evident nationwide, with rural women and girls facing particular challenges in accessing sexual and reproductive health services, especially skilled care at birth, emergency care, and antenatal and post-natal care. The Government of Timor-Leste is committed to addressing these issues and the National Health Sector Strategic Plan 2011−2030 identifies maternal and child health as the two highest priorities of the national health programs. Key recommendation: Strengthen measures to ensure that all women – including young women and rural women − have timely access to quality antenatal and post-natal care, emergency obstetric and newborn care in line with the Emergency Obstetric and Newborn Care Plan of Action. Family planning: Since independence, the modern contraceptive prevalence rate (mCPR) in Timor-Leste has increased more than three-fold—from 7% in 2003 to 24% 2016. Though the use of family planning continues to rise, one out of four (25%) married women still has an unmet need for family planning. Timorese people, especially adolescents and unmarried people, have difficulty accessing contraceptive information and services. This has contributed to women having unwanted pregnancies and large numbers of babies. There are a high proportion of adolescent pregnancies and early marriages, with adolescent pregnancies contributing to higher rates of death and disability for adolescent mothers and their children. Abortion is restricted to protection of the life of the mother. Key recommendation: Provide to all Timorese people access to family planning services and effective modern contraception to reduce the incidence of unintended pregnancies and unsafe abortions in TimorLeste. Reproductive health education: Reproductive health education, or comprehensive sexuality education (CSE) as it is known globally, is recognized as an age-appropriate, culturally relevant approach to teaching about sexuality and relationships, providing scientifically accurate, realistic, non-judgmental information. In general, Timorese people – particularly young people – have a poor understanding of sexual and reproductive health, including knowledge about modern contraceptive methods, how to get pregnant and Human Immunodeficiency Virus (HIV) prevention. The lack of sexual and reproductive health education has contributed to the incidence of unwanted pregnancies, early marriage and other consequences. While the Timorese law and policy environment is broadly supportive of reproductive health education, cultural taboos make it difficult to implement. The prevailing cultural view is that young unmarried people should abstain from sexual relations and should not be taught about sexual and reproductive health. However, global evidence shows that CSE has a positive impact on sexual and reproductive health, notably contributing towards reducing sexually transmitted infections (STIs), HIV and unintended pregnancy, and delaying sexual debut. For married people (young or not), the lack of 6 sexual reproductive health education has significant consequences with couples unable to plan their families effectively or take proper care of family health. Key recommendation: Ensure universal access to comprehensive sexuality education – both in school and out of school – that is age-appropriate, unbiased, scientifically proven and gender sensitive. HIV and sexual health: The fight against HIV and STIs in Timor-Leste has to date focused on key populations, including sex workers and their clients, men who have sex with men, transgender persons, uniformed personnel and the partners of these key populations. While Timor-Leste is a low-prevalence country, with 711 cases identified up to 2017, there are concerns that transmission is occurring in the general population which requires close monitoring. STIs, on the other hand, are very high with rates of 16.1% in clients of sex workers. Despite the prevalence of STIs and HIV in Timor-Leste, the population generally has a low knowledge of and access to STI and HIV prevention, testing and treatment. Young people, who are globally recognized as particularly vulnerable, have especially low levels of knowledge about comprehensive methods of preventing HIV and STI transmission and are not specifically targeted by information campaigns. Key recommendations: Increase HIV and STI prevention through non-discriminatory, comprehensive voluntary counseling, testing and treatment for the most at risk populations. Improve HIV testing in the general population, targeting women through routine antenatal care, for people identified with STIs and other routine service delivery modalities. Moreover, increase non-discriminatory HIV and STI prevention efforts with specific education and messaging targeting young people. Gender-based violence: Gender-based violence is widespread in Timor-Leste. Intimate-partner violence is one of the most pervasive types of violence, but there is also prevalence of sexual violence, child abuse and trauma. Particularly vulnerable groups include lesbian, gay, bisexual and transgender people, and people living with disabilities. Factors contributing to the high incidence of gender-based violence include unequal gender norms, attitudes that justify violence and other manifestations of male dominance over women. The physical and mental health consequences of gender-based violence can be serious for women, and may include injury, disability, unintended pregnancy, depression, suicidal thoughts, and impacts on sexual and reproductive health. Children are also affected both as victims and as witnesses. Yet few survivors of gender-based violence seek help from health authorities for these conditions. Timorese laws and policies prohibit gender-based violence, but there is low accountability due to a low reporting rate, and insufficient investigations, prosecutions and convictions. Key recommendation: Strengthen awareness-raising and educational activities targeted at men and women, traditional leaders, health-care and social workers, with support from civil society, to eliminate prejudices related to violence against women. Conclusion: The Country Assessment on SRHR acknowledges vulnerable groups of people who have particular difficulty accessing sexual and reproductive health and rights, identifies the context of and challenges in each of the five key areas, and makes specific recommendations for improvements in every one of them. These suggestions feed into Timor-Leste’s overall plan to achieve the SDGs on health and well-being (SDG 3) and gender equality (SDG 5) before 2030. General recommendations: Proposals to develop systems within the Ministry of Health and its programs, particularly SISCa, to improve service delivery, and ideas to share information on SRHR in the broader community will expand general understanding and achievement of reproductive health rights.