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Addressing the second ‘R’ in sexual and reproductive health and rights: why norms and values matter for development cooperation
  1. Jesper Sundewall1,2,
  2. Karin Båge3,
  3. Anna Mia Ekström3,
  4. Bi Puranen4,
  5. Helena Litorp3,
  6. Olalekan A Uthman5,
  7. Anna Kågesten3
  1. 1HEARD, University of KwaZulu-Natal, Durban, South Africa
  2. 2Department of Social Medicine and Global Health, Faculty of Medicine, Lund University, Lund, Sweden
  3. 3Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
  4. 4Institute for Future Studies, Stockholm, Sweden
  5. 5University of Warwick, Coventry, UK
  1. Correspondence to Dr Jesper Sundewall; Jsundewall{at}

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Summary box

  • The gendered impact of the COVID-19 pandemic and associated mitigation measures have exposed and deepened existing inequalities related to sexual and reproductive health and rights (SRHR).

  • This is especially true for adolescent girls and young women in low-income countries who face increased SRHR risks, as a result of interrupted health services, education, financially insecure households and unsupportive social norms and values regarding their rights to bodily autonomy and integrity.

  • To mitigate the backlash in achievements and ensure that no one is left behind, it has never been more crucial to collaborate and invest in SRHR for all—a key target of the 2030 Agenda. Development assistance is one such collaborating actor.

  • To be effective, however, development assistance for SRHR must consider and address discriminatory social norms and values, as part of a human-rights-based, collaborative agenda.

  • Grounded in findings from a recent survey on social norms and values linked to SRHR in low-income countries, as well as data on development assistance for SRHR, we present five recommendations that we argue should guide development cooperation for SRHR going forward.

  • We make the case for a more informed, long-term approach in development cooperation that explicitly considers and addresses social norms and values to achieve SRHR for all.

  • Such an approach must be contextually grounded and developed in close contact with community stakeholders to be effective and to avoid generalising values and norms to specific groups.


By now, it has become obvious that the COVID-19 pandemic and associated mitigation measures have (just like the HIV pandemic) exposed and deepened existing inequalities related to both human rights and health.1 Not only have the all-too-familiar inequitable sexual and reproductive health outcomes been exacerbated by the additional strain placed on already underfinanced health systems, but the interruptions in education and concurrent loss of family incomes due to pandemic restrictions have further marginalised those already at risk of poor health. The impact of COVID-19 can be noted for women of all ages and across generations. However, the impact is particularly clear for adolescent girls and young women in low-income countries who face increased risks of sexual-based and gender-based violence, child marriage and unwanted pregnancy in light of disrupted sexual and reproductive health services, together with restrictions on movements and school closures.1–6

As a result, investing in sexual and reproductive health and rights (SRHR) for all—a key target of the 2030 Agenda—has never been more crucial. Yet, in a time of limited growth in domestic funding for health, as well as stagnating development assistance for reproductive health,7 a key source of funding for SRHR interventions in low-income countries, advancements of the SRHR agenda are proving difficult. And while strengthening resource-weak health systems and ensuring equity and quality of care are essential,8 moving toward SRHR for all will not be possible without simultaneously addressing crucial context-specific factors, including discriminatory social norms and values that often underpin these challenges. Such discriminatory norms vary over time and localities but are grounded in societal control of individuals’ human rights to decide about one’s own body and fertility regardless of gender, sexual orientation, gender expression or marital status.9 Their implications may be clear when framed in a human-rights-based approach emphasising the agency and autonomy of the individual. However, discriminatory SRHR norms can themselves often be rooted in other norms that reflect different ways of understanding identity, community and belonging,10 which contributes to making them complex, layered and difficult to address.

To date, there are limited data on norms and values related to SRHR and gender globally but especially in low-income countries. It is also unclear whether official development assistance (ODA) for SRHR in a systematic, structured, inclusive and equitable way considers these normative challenges and opportunities in strategies and activities.

In a recent report for the Swedish Expert Group for Aid Studies,11 a government committee to evaluate Swedish development cooperation, we set out to examine this gap in the available evidence. We collected and analysed nationally representative data on norms and values in three sub-Saharan African countries—Ethiopia, Nigeria and Zimbabwe—collected via the World Values Survey ( In addition, we analysed data on all ODA for SRHR from the Swedish International Development Cooperation Agency (Sida) between 2010 and 2018 to better understand the level of overall alignment of Sida’s SRHR ODA with prevailing norms and values for SRHR. To link SRHR norms and values with Sida’s SRHR ODA, we were guided by the comprehensive definition of SRHR set forth by the Guttmacher-Lancet Commission.12 We sought to operationalise this definition through analysing both norms and values in relation to ODA. Furthermore, we developed a framework (figure 1) to help us understand how norms and values can be understood in the context of SRHR ODA.

Figure 1

Conceptual framework linking SRHR norms and values to SRHR development assistance.9 LGBTQ, lesbian, gay, bisexual, transgender and queer; SRHR, sexual and reproductive health and rights.


Based on the results, the report11 proposes five key recommendations that we believe can guide development cooperation investments to better consider, navigate, and address SRHR norms and values.

  1. Systematic assessments of norms and values should underlie any development cooperation effort to advance SRHR. Norms and values remain more discriminatory related to sexual and reproductive rights (such as the right to abortion or the rights of lesbian, gay, bisexual, transgender and queer populations) than to sexual and reproductive health aspects (eg, contraception or institutional delivery services). That said, access to sexual and reproductive health services is intimately linked to rights and thereby with values and norms. Therefore, development cooperation actors should consider a systematic assessment of values and norms when initiating new and following up on existing SRHR investments. This can include a description of existing knowledge of relevant SRHR values and norms as a part of the process of planning and appraising development interventions. We noted that while development cooperation actors are often aware of the normative context in which they operate, their preferred approach tends to aim for improvements in access to SRHR within the existing norms and values, rather than actively trying to change them.

  2. Contextual knowledge is essential to effectively target discriminatory norms. While SRHR may be conceptualised as a package, supporting one aspect of SRHR (eg, freedom from gender-based violence) does not mean that individuals agree with other areas (eg, choosing when and whom to marry).11 We also observed that the same aspect of SRHR can gain different degrees of support depending on the wording of the survey question. For example, while only 17% of respondents in the three countries in our study said that abortion is ‘justifiable’ to some extent, 50% agreed that women should have access to safe abortion services. Given this complexity, development actors need to ensure that there is sufficient capacity among their staff to effectively understand, assess and navigate norms and values related to both the broader concept of SRHR and its specific components. Furthermore, the contextual knowledge of key local stakeholders should be better leveraged, and perspectives of local and community level actors must be considered. All development interventions aiming to address discriminatory values and norms should be grounded in an analysis of the specific context in which it operates, including the social structures and relations that shape this context. Such understandings need to take into consideration the relations and dynamics of power; both those that continuously shape, contest and negotiate the local meaning of norms and values that may influence SRHR outcomes, as well as those that the development actors themselves, contribute with through their resources, privilege and power in light of colonial histories and postcolonial perspectives. Development interventions should follow a human-rights-based approach and be carefully adapted to the local context in close dialogue with community level stakeholders to avoid generalising certain values to specific nationalities or groups.

  3. Explicitly including SRHR norms and values in official development cooperation strategies can set priorities and guides project logic and evaluation processes. In our study, we found little specific emphasis on the importance of values and norms in relation to SRHR in strategies and policies guiding Swedish development cooperation, even though Sweden is one of the most important actors for SRHR on the global scene, guided by a feminist foreign policy.13 We, therefore, stress the need for development actors to explicitly mention the importance of addressing discriminatory values and norms related to SRHR in strategies for development cooperation and to provide staff with tools to include norm assessments and adaptations in their activities. When positions and intentions are made explicit, mutual reflection and reciprocal learning can begin to take place, informing a process that is likely more efficient in making progress on SRHR in line with local voices and a human-rights-based approach.

  4. SRHR values and norms are complex and require long-term investments. Efforts to actively influence and change broader social norms and individuals’ personal beliefs or values take time.14 This requires investing in programmes beyond the often short-term ODA strategies and funding cycles (generally 2–5 years). Our analyses showed a large complexity and incongruence between SRHR norms and values. Somewhat surprisingly, there was no consistent association between sociodemographic factors such as educational level and age and SRHR-related norms and values. This corroborates recommendations that multilevel interventions are needed to reach a ‘tipping point’, where people and communities abandon discriminatory norms and adopt new ones.15

    As has been made clear in the decolonisation debate,16 addressing discriminatory norms and values as a donor organisation external to a context is a very complex challenge. We want to emphasise that any attempt to ‘changing norms’ is not about assimilation into another (the donor) country’s culture, but to ensure universal access to SRHR in accordance with internationally recognised human rights conventions and global goals. Avoiding addressing these issues is not an option. However, in a development context, it must be done in an equitable and inclusive way, where partners from relevant communities play a central role in framing priorities and ways forward to create the conditions necessary to reach a tipping point.17 To guide and evaluate ODA, development actors thus need data on SRHR norms and its drivers to best target programming. The World Values Survey is one of several useful tools for collecting such information.

  5. Increasing the quality and granularity of development assistance data would allow for better understanding of the extent to which SRHR ODA is targeting values and norms. While SRHR is a prioritised area of ODA, the quality and granularity of data on SRHR ODA are often limited. The current reporting method for ODA (through the Organisation for Economic Cooperation and Development) does not allow for quality, transparency and detail in line with the Guttmacher-Lancet Commission’s comprehensive definition of SRHR. This makes it difficult to analyse which areas SRHR ODA is effectively targeting. To be able to follow-up on SRHR ODA and to what extent it targets social norms and values, development actors should consider improving the reporting of SRHR ODA data.


Development assistance for SRHR grounded in justice and a human-rights-based approach has never been more critical to mitigate both the backlash and the lost momentum against SRHR-related morbidity and mortality in the wake of COVID-19, particularly in low-income countries. We present a conceptual framework that can help improve understanding of SRHR ODA and how it relates to SRHR norms and values. Furthermore, we argue for a more informed, long-term approach in development cooperation, that actively considers and addresses social norms and values, grounded in local and contextual analyses, needs and expertise, to achieve SRHR for all as part of the 2030 Agenda. This also requires sustained commitments from development actors and more robust data and methods for follow-up of how SRHR ODA is allocated and to what extent social norms and values are targeted. Such an approach would enable more contextually grounded, and effective SRHR development cooperation.

Data availability statement

Data are available in a public, open access repository through the World Values Survey website (

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  • Handling editor Seye Abimbola

  • Twitter @jsundewall

  • Contributors JS, KB and AK drafted the manuscript. BP, AME, HL and OAU provided feedback and participated in revisions of the manuscript. All authors contributed to the study on which the commentary is based and have seen and approved the final version of the manuscript.

  • Funding This study was funded by the Swedish Expert Group for Aid Studies.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.