Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694818688619.pdf (Australia)
Submission to the Inquiry by the Joint Standing Committee on Foreign Affairs, Defence, and Trade into: The human rights issues of women and girls in the Pacific 1 Inquiry into the human rights of women and girls in the PacificSubmission 13 Summary: Health is a fundamental human right.

Women and girls in the Pacific face many challenges which impact on their ability to achieve their health and wellbeing potential.
This not only limits the individual and the community in which they live but has wider implications for the social and economic development of the region.

Investing in interventions to prevent gender-based violence, promote and protect sexual and reproductive health and advance gender equality are central to achieving sustainable and equitable health, social and economic development in the Pacific region.
Recommendations: • Australia prioritises funding for interventions grounded in human rights and gender transformation to prevent and manage gender-based violence in the Pacific.

• Australia meaningfully engages with all key stakeholders, especially women and girls in efforts to advance human rights at national, provincial and community levels.
Engagement must include with networks, organizations and civil society, to ensure efforts and response are not further discriminating and excluding those most in need.

• The Australian aid program should continue to make significant and sustained investments in integrated Reproductive, Maternal, Newborn, Child and Adolescent health in the Pacific.

Investment in RMNCAH is effective and essential for supporting the human rights of women and girls in the Pacific.
• Australia should continue to generously fund programs to reduce maternal mortality in the Pacific region, especially in Papua New Guinea and the Solomon Islands.

• Australian funded aid programs aiming to reduce maternal and neonatal morbidity and mortality should have clear strategies to address unsafe abortions.

In addition to family planning services, these programs should manage abortion complications, provide contraceptive counselling and services and, where legal, safe abortion services.
• Australian overseas development assistance invested in RMNCAH should target not only women and girls, but also men and boys, with efforts to address the fundamental gendered drivers of poor RMNCAH outcomes.

• The Australian aid program should maintain its 80% gender equality performance target and emphasise reporting indicators that support gender-transformative programming.
Additionally, the aid program should sustain its internal technical capacity in gender equality, women’s empowerment, diversity and inclusion in order to effectively support gender-transformative programming.

• The Australian aid program must ensure that during COVID-19 and in response to any future public health crises, essential RMNCAH services are prioritised and protected.

2 Inquiry into the human rights of women and girls in the PacificSubmission 13 1.
About Burnet Institute Burnet Institute welcomes the opportunity to make this submission to the Joint Standing Committee on Foreign Affairs, Defence, and Trade.

Burnet Institute is an Australian, unaligned, not-for-profit, independent medical research institute that links medical research with practical action to help solve devastating health problems.
Burnet’s mission is to achieve better health for vulnerable communities in Australia and internationally by accelerating the translation of research, discovery and evidence into sustainable health solutions.

The Institute is based in Melbourne, Australia, with offices in Papua New Guinea and Myanmar and active projects in over 20 countries internationally.

The Institute has an annual turnover of approximately AUD$55 million.

Further information is provided in Appendix 1.

2.


Health of women and girls in the Pacific Over 5 million women and girls live across the Pacific region.

These women and girls face significant challenges in achieving their health and wellbeing potential, often related to an inability to ensure protection of human rights.

Women and girls’ rights are human rights, as enshrined in the United Nations Universal Declaration of Human Rights.
In speaking about women and girls in the Pacific, it is important to recognise the heterogeneity that exists and that Pacific women are not seen as one homogenous group.

Sexual and reproductive rights are a key determinant of the health of women and girls.

Across the Pacific, up to 46% of women have an unmet need for modern forms of contraception.

The need for contraception is growing fast, and it is estimated that the 'unmet need' will grow by 40 per cent during the next 15 years.
As a region, the Pacific has a high proportion of young people, with over half (56%) of the population under the age of 25.

Young people face multiple barriers in accessing health care, especially sexual and reproductive health information and services.

Maternity mortality rates remain unacceptably high in the Pacific, especially Papua New Guinea (PNG), with rates of improvement lagging behind the rest of the world.

A significant but neglected contributor to maternal mortality is unsafe abortions.
Worldwide approximately 25 million unsafe abortions, over half of all induced abortions, occur each year, resulting in the deaths of 70,000 women.

The unique geography of the Pacific region with populations scattered over many small islands and difficult to access mountainous regions presents significant logistical challenges for the delivery of equitable healthcare.
Women and girls living in rural and remote communities are particularly affected by access issues and as a result, experience a disproportionate burden of ill health.

It is this unique geography that contributes to the Pacific region being the most susceptible region in the world to the worst health effects of climate change.

National and regional efforts to improve sexual and reproductive health and rights will be jeopardized by the adverse effects of climate change.
It is critical that any efforts geared towards improving the attainment of human rights for women and girls in the Pacific also recognise and address the real and growing challenges related to climate change.

Violence against women and girls is not only physical, but also structural and therefore shaped by the distribution of resources and power.

Across the Pacific region, gender inequalities and systemic discrimination positions women and girls at greater risk of violence.
The Pacific has some of the highest rates of gender-based violence in the world, many Pacific Island countries report prevalence 3 Inquiry into the human rights of women and girls in the PacificSubmission 13 rates above 50 per cent and some as high as 80 percent.

Women often have little control of their fertility, sexual and marital choices.

In many countries, girls are less likely to be in school and women less likely to be in work.
Many women and girls have less control over income and assets, less access to public knowledge and information, less decision-making power within and outside their homes and reduced opportunities to participate in the workforce than their male counterparts.

Representation of women in government, leadership and decision-making positions is exceptionally low.

Clearly it is important for our Australian aid program to be agile and responsive in meeting the needs and priorities of communities in the Pacific.
This is particularly relevant with respect to public health crises, such as pandemics, natural disasters, cyclones and floods.

Natural disasters are already common in the Pacific and will become increasingly frequent due to climate change.

The COVID-19 pandemic has highlighted the importance of our aid program being adaptable and agile to meet the expected and unexpected health and economic needs of Pacific Islanders.
Achieving human rights for women and girls in the Pacific requires systemic changes at community, national and regional levels.

It requires changes to laws, policies and systems which inherently discriminate against women and girls because of their gender.

Australia is well positioned to play a leading role in advocating and supporting the attainment of human rights for women and girls in the Pacific, which is critical for sustainable social and economic development in the region.

3.
Response to the terms of reference Our submission will address the following terms of reference within the Inquiry: • The role of civil society groups in Pacific Islands in responding practically to domestic, family and sexual violence, and other human rights issues such as gender equality • The key figures and groups which advance the human rights of women and girls' in the Pacific context • The effectiveness of Australian overseas development assistance programs in supporting human rights of women and girls 1.
The role of civil society groups in Pacific Islands in responding practically to domestic, family and sexual violence, and other human rights issues such as gender equality Burnet Institute recognises the valuable role that civil society groups such as local non- government organisations play in addressing gender-based violence and gender inequality.
We welcome Australia’s focus on engaging local actors and civil society as key partners in responding practically to gender-based violence and gender inequality.

Burnet Institute has long standing experience and commitment to working in partnership with civil society groups and alongside communities, government and private sector.
We recognise the valuable role that civil society groups play in advocating for their communities, enabling social inclusion and gender equality, facilitating delivery of essential services to their communities and fostering government accountability.

We also recognise that engaging men and boys in the process of transforming attitudes around gender-unequal norms is critical, and interventions to improve outcomes for women and girls must include boys and men as an essential part of the solution.
Gender-Based Violence (GBV) including domestic, family and sexual violence exists at such a high rate across the Pacific, that it is often normalised in these communities.

In the Pacific, a women’s 4 Inquiry into the human rights of women and girls in the PacificSubmission 13 lifetime experience of violence ranges from 25 percent in Palau to as much as 76% in Samoa and 79% in Tonga.
Women and girls with disabilities experience are particularly vulnerable and experience up to 10 times more GBV than those without disabilities.

LGBTQI communities also experience disproportionate levels of violence and abuse throughout the Pacific.

Global studies show that in areas where there are high rates of GBV, children also experience high rates of violence.
There is also an intergenerational effect where children who have experienced violence are more likely to become perpetrators of violence (boys) and victims of violence (girls).

The current COVID-19 pandemic has exacerbated GBV.

Globally, it is anticipated that for every 3 months countries impose lock down measures, there will be an additional 15 million cases of intimate partner violence.
Violence against women and girls is a violation of human rights and has serious negative repercussions on physical, emotional and psychological health.

It limits the ability of women and girls to participate in social, political and economic life and, in turn, impacts on the development of communities and nations.

Prevention of GBV requires coordinated efforts across all sectors and at all levels.
Civil society organisations (CSOs) have a critical role in preventing and responding to violence against women and girls.

The most effective approaches to GBV engage multiple stakeholder groups and are community-led.

Services not only need to physically reach these groups, but must also be tailored to their needs, confidential, and free of judgement or coercion.

CSOs at a local level have a deep understanding of the socio-cultural factors that drive violence in the community.
This local knowledge is critical for identifying risk factors and informing interventions to ultimately change community norms and expectations around GBV, as well as increasing women’s status in society.

International evidence shows localised partnership approaches are more likely to drive sustainable development outcomes adapted to local community needs and values.
Engagement of local civil society actors in international development efforts is crucial to advancing the human rights of women and girls in the Pacific.

Recommendation: Australia prioritises funding for interventions grounded in human rights and gender transformation to prevent and manage gender-based violence in the Pacific.

2.
2.

The key figures and groups which advance the human rights of women and girls' in the Pacific context Burnet Institute emphasises the work of key figures and groups in advancing the human rights, of women and girls in the Pacific, particularly through the promotion and protection of sexual and reproductive health and rights.

Local, national and international organisations working on sexual and reproductive health and rights are critical to advancing the human rights of women and girls in the region.
These organisations and groups are diverse and include advocacy organisations, women’s rights organisations, research agencies, organisations delivering sexual and reproductive healthcare, community and youth groups, and community leaders.

The Burnet Institute works in partnership and collaboration with many of these groups across the Pacific.
5 Inquiry into the human rights of women and girls in the PacificSubmission 13 Local community leaders play a valuable role as ambassadors, role models and change agents in their communities to advance sexual and reproductive health and rights.

An example of a key figure and leader is Ms Maura Elaripe.

Maura was the first woman to publicly disclose her HIV status in Papua New Guinea and has become a strong and vocal advocate for the rights of people living with HIV in PNG and the Pacific.
Maura is a project officer with the Burnet Institute working on the 'Sustainability of HIV Services for Key Populations in Asia' program based in Port Moresby.

A study conducted by the Burnet Institute found that the level of drug-resistance in people recently infected with HIV — who had never been on medication — in Port Moresby and Mount Hagen were among the highest in the world.
One of the biggest drivers to drug-resistance in PNG is an inconsistent supply of medication and regular stock outs, which has been made worse during COVID-19 times.

Seventy percent of the global health workforce is female and healthcare workers, particularly those working in Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH), play a crucial role in advancing the human rights of women and girls.
However, the Pacific faces a chronic shortage in RMNCAH healthcare worker specialists, namely midwives/nurse-midwives, obstetricians/ gynaecologists and paediatricians.

The shortage is particularly acute in PNG, and unlikely to improve without major sustained investment.

The State of the Pacific’s RMNCAH Workforce (which Burnet was involved in writing) showed that the current workforce in PNG has the potential to meet less than 25% of the need for essential RMNCAH care.
An ongoing commitment to the RMNCAH workforce, especially the education and support of midwives, is critical.
In response to the RMNCAH workforce crisis in the Pacific region and in recognition of the vital role maternity care professionals play in improving outcomes and disparities in sexual and reproductive healthcare, Burnet Institute has become an implementing partner with UNFPA Asia Pacific (Pacific Sub-Regional Office (PSRO)) to support work on the Transformative Agenda for Women, Adolescents and Youth in the Pacific (The Transformative Agenda).
Burnet is assisting the PSRO in three vital areas that will significantly contribute to improving the sexual and reproductive health and human rights for women, newborns, children, adolescent and youth, as well as communities and societies.

The UNFPA PSRO work is focussed in three areas.

Firstly, improving quality midwifery care through the provision of technical support in improving midwifery education.
International evidence identifies significant improvements in outcomes for women and families, and in public health when quality midwifery and maternity care is available.

Improved outcomes include reduced maternal and perinatal mortality and increased uptake of contraception.

A second focus of the work with UNFPA is improving Health Management Information Systems (HMIS).
Strengthening HMIS will ensure the right sexual and reproductive health data is collected, reported on and used to inform and support system improvements and plans.

The third outcome for the partnership with UNFPA PSRO is strengthening country-specific Family Life Education (FLE).

Strong FLE programs can have an impact on reducing unintended and adolescent pregnancy rates.
FLE is designed to support young people in their physical, emotional and moral development and provide information and support for strong and functional family relationships.

UNFPA is a key group in the Pacific Region with sexual and reproductive health (SRH) programs across 14 countries and territories.
The Burnet and UNFPA collaboration will result in significant improvements in sexual and reproductive health rights and outcomes in six of these countries with potential for outputs to be replicated and utilised across the region.

6 Inquiry into the human rights of women and girls in the PacificSubmission 13 Key figures and groups (particularly women and girl-focused groups) are well positioned to effectively respond to sexual and reproductive health challenges in the Pacific.
Key community leaders and civil society organisations can provide healthcare and information not otherwise accessible in government or church-run settings.

We need stronger mechanisms for supporting community leaders, through skill development and capacity building as these individuals can be major drivers of change within a community.

Investment in and support of local groups is critical to changing community attitudes and improving sexual and reproductive rights as human rights for women and girls.
Recommendation Australia meaningfully engages with all key stakeholders, especially women and girls in efforts to advance human rights at national, provincial and community levels.

Engagement must include with networks, organizations and civil society, to ensure efforts and response are not further discriminating and excluding those most in need.

3.
3.

The effectiveness of Australian overseas development assistance programs in supporting the human rights of women and girls Burnet Institute recognises that Australian overseas development assistance, particularly in maternal and newborn care and sexual and reproductive health services, has been critical in improving the human rights of women and girls in the Pacific.

Over the last three decades, there has been a substantial decline in maternal deaths globally.
Since 2000, the number of women who die during pregnancy or childbirth has decreased by around 38% —from 529,000 deaths to around 295,000 in 2017.

Despite these improvements, some Pacific countries continue to have very high rates of maternal death.

In PNG, official estimates of the maternal mortality ratio vary widely and range from 170 to 730 deaths per 100,00 live births, for facility and community-based births.

However, some local estimates report even wider ranges and higher numbers, from 68 to 900.
This is 80 times the rate of maternal death in Australia.

Rates of maternity mortality globally are set to worsen as a result of COVID-19 and the Johns Hopkins Bloomberg School of Public Health estimates that globally there may be as many as 57,000 additional maternal deaths from preventable causes.

We recognise that reducing maternal deaths is already a high priority of the Australian aid program and we applaud this position.
However, there is one aspect of maternal mortality that is neglected – unsafe abortions.

Unsafe abortions account for 4.7 to 13.2% of maternal deaths globally.

The Inter- Agency Group for Safe Motherhood states that: ‘Unsafe abortion is the most neglected—and most preventable—cause of maternal death.’ Worldwide approximately 25 million women and girls undergo unsafe abortions each year, 3 million of these unsafe abortions are in girls aged 15 to 19 years.
Almost half of all induced abortions are unsafe and result in the deaths of 70,000 women and girls.

Almost all deaths occur in low- and middle-income countries with highly restrictive abortion laws.

Countries with restrictive abortion polices have much higher rates of unsafe abortion and maternal mortality.

For example, the average unsafe abortion rate is four times greater and average maternal mortality ratio three times greater in countries with restrictive abortion polices.
These deaths can be virtually eliminated by improving access to family planning and ensuring all women have access to comprehensive abortion services (including safe abortion and post-abortion care for women who experience complications).
7 Inquiry into the human rights of women and girls in the PacificSubmission 13 In addition to investments in maternal and newborn health, it is imperative that Australian aid continues to invest in sexual and reproductive health to achieve other global development priorities such as women’s empowerment and poverty reduction.
Reducing unmet need for modern contraceptives and preventing adolescent pregnancies has profound benefits in terms of increasing educational attainment of girls and improving women’s economic and political participation.

It can also result in large public sector savings and increased productivity.
Modelling conducted by Burnet Institute in 2012 estimated that for every US$1 invested in family planning to reduce unmet need in the Pacific, between US$9-16 would be saved in health and education costs – equivalent to over US$112 million in the next 15 years.

The ability of women and girls in the Pacific to fully realise their human rights is unacceptably curtailed by gender inequality.
Gender inequality is a fundamental driver of violence against women and girls, maternal mortality, neonatal mortality, poor sexual and reproductive health outcomes, and other RMNCAH outcomes.

Gender-unequal outcomes for individual women and girls are caused by unequal gender norms, roles, and relations.

Effectively addressing these requires addressing the social, structural, and relational drivers of gender inequality.

This includes addressing relations between women and girls and men and boys.
Programs to support the realisation of women and girls’ right to health should therefore engage men and boys as partners and agents of change in changing the gendered drivers of poor health outcomes.
Previous ANCP-supported programs implemented by Burnet Institute have engaged men in transforming the gendered drivers of poor health outcomes for women and girls – for example by: questioning gender norms supportive of violence against women in PNG; providing financial, instrumental, and emotional support to female partners to create an enabling home environment for health care-seeking for essential MNCH services in PNG, Myanmar and Zimbabwe; and participating in antenatal care as a partner/expectant father in Myanmar and Zimbabwe.
These programs have been evaluated to demonstrate the effectiveness of a gender-synchronised approach in tackling gendered drivers of poor health outcomes for women and girls.

The Australian aid program is to be commended for its strong commitment to addressing gender inequality through the 80% gender equality performance target, clear programming guidance, and building and maintaining strong internal technical capacity in gender equality, women’s empowerment, diversity, and inclusion.
This is a strength of the Australian aid program that enables it to effectively support women and girls in the Pacific to fully realise their human rights and should be maintained.

Recommendation: The Australian aid program should continue to make significant and sustained investments in integrated Reproductive, Maternal, Newborn, Child and Adolescent health in the Pacific.

Investment in RMNCAH is effective and essential for supporting the human rights of women and girls in the Pacific.
Recommendation: Australia should continue to generously fund programs to reduce maternal mortality in the Pacific region, especially in Papua New Guinea and the Solomon Islands.

Recommendation: Australian funded aid programs aiming to reduce maternal and neonatal morbidity and mortality should have clear strategies to address unsafe abortions.
In addition to family planning services, these programs should manage abortion complications, provide contraceptive counselling and services and, where legal, safe abortion services.

8 Inquiry into the human rights of women and girls in the PacificSubmission 13 Recommendation: Australian overseas development assistance invested in RMNCAH should target not only women and girls, but also men and boys, with efforts to address the fundamental gendered drivers of poor RMNCAH outcomes.
Recommendation: The Australian aid program should maintain its 80% gender equality performance target and emphasise reporting indicators that support gender-transformative programming.

Additionally, the aid program should sustain its internal technical capacity in gender equality, women’s empowerment, diversity and inclusion in order to effectively support gender-transformative programming.
Recommendation: The Australian aid program must ensure that during COVID-19 and in response any future public health crises, essential RMNCAH services are prioritised and protected.
9 Inquiry into the human rights of women and girls in the PacificSubmission 13 Appendix 1: Further information about the Burnet Institute: Burnet Institute is the only Australian medical research institute to be accredited as an international development agency by the Department of Foreign Affairs and Trade, and the only Australian non- government organisation (NGO) to also be accredited as a Medical Research Institute by the National Health and Medical Research Council.
Maternal, child and adolescent health; health security; disease elimination; and behaviours and risks are key programmatic priorities of the Institute, with a geographical focus on the Asia Pacific region.

Our staff includes medical scientists, clinical researchers, clinicians, epidemiologists, public health professionals and educators.

Recognising that health is a fundamental human right.
Burnet is engaged in a broad range of research, development and policy activities focused on improving the health of women and girls in the Pacific.
Some of our work includes: laboratory-based research and clinical trials of new diagnostic and prevention technologies to address the high burden of sexually transmitted infections (including HIV) among young women; public health research to better understand and respond to the sexual and reproductive health needs of adolescent girls in the Pacific; community-based trials of interventions to improve the quality of maternal and newborn care; information, education and communication research and interventions in the Pacific to raise awareness of gender based violence, education and training of healthcare workers to improve knowledge and skills in providing routine and emergency maternal and newborn care; and technical support to UN agencies and other stakeholders to improve policy and programs aiming to address the sexual and reproductive health and rights of women and girls in the Pacific and working with local level governments and local communities.
Burnet also engages in evidence-informed advocacy at national, regional and global levels to support equitable progress towards universal access to sexual and reproductive health.
We are a member of the Asia Pacific Alliance for Sexual and Reproductive Health and a founding member of the International Sexual and Reproductive Health and Rights Consortium through which we advocate for sexual and reproductive health and rights of women and girls to be recognised as a critical global health and development priority.

10 Inquiry into the human rights of women and girls in the PacificSubmission 13