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Ensuring that biomedical information about research procedures is adequately understood by participants and their communities is key for conducting ethical research. This article explores participants' understanding of trial procedures for an experimental vaccine against Ebola virus disease (EVD) in a West African context. We found that some trial participants believed there was a chance of contracting Ebola and other sicknesses from the vaccine, and others believed both the vaccine and the placebo control would be able to prevent other illnesses than EVD. While these beliefs might be understood as misconceptions about the vaccine trial, this paper shows that such a conclusion is problematic because it excludes local explanatory health models and logics of causality. The paper invites bioethicists to work with anthropologists to take seriously different models of health knowledge in global health research. Investigating and addressing such differences could be the key to understanding human subjects' motives for participation, and to creating space for studies of empirical ethics.

Sexual and reproductive health and rights (SRHR) are centrally important to health. However, there have been significant shortcomings in implementing SRHR to date. In the context of health systems reform and universal health coverage/care (UHC), this paper explores the following questions. What do these changes in health systems thinking mean for SRHR and gender equity in health in the context of renewed calls for increased investments in the health of women and girls? Can SRHR be integrated usefully into the call for UHC, and if so how? Can health systems reforms address the continuing sexual and reproductive ill health and violations of sexual and reproductive rights (SRR)? Conversely, can the attention to individual human rights that is intrinsic to the SRHR agenda and its continuing concerns about equality, quality and accountability provide impetus for strengthening the health system? The paper argues that achieving equity on the UHC path will require a combination of system improvements and services that benefit all, together with special attention to those whose needs are great and who are likely to fall behind in the politics of choice and voice (i.e., progressive universalism paying particular attention to gender inequalities).

Beginning with the demise of the socialist state system in 1990, Mongolia embarked on a process of neoliberal economic reform, initiating what is known among the Mongols as 'the Age of the Market'. The socialist health system has been replaced by a series of reforms initiated and substantiated by foreign donor organisations. This paper critically examines Mongolia's health system and discusses the extent to which this 'system', despite its provision of universal, accessible and essential primary health care services, is unable to accommodate the health needs of poor urban in-migrants and nomadic herders in remote provinces. With a particular focus on recurrent natural winter disasters (dzud) and an escalating rural to urban migration, the paper argues that the issues of access to health services and health system strengthening must be understood in relation to factors external to the health system. Ethnographic research highlights that despite a growing economy, considerable external aid and an established primary health care model, weak rural politics, environmental challenges and economic constraints create escalating health vulnerability among the poorest in Mongolia.

Kenyan sex worker-led organisations (SWLOs) often play a key role in the national HIV response. Accounts of these organisations frequently focus on their community-led approaches to promote sexual health. This paper addresses sensitisation, an underexplored but significant activity in the political agency of sex workers (SWs). Drawing on ethnographic fieldwork in a male SWLO in Nairobi, we examine how male SWs strategically use their position in the national HIV response to create spaces of police sensitisation. Taking police sensitisation as a manifestation of community-led advocacy and a ‘politics of small steps’, we examine how SWs respond to, resist and remake the political landscape of police violence. The strategy supports SWs in changing existing power relationships between themselves and the police, albeit within the confines of a criminalising legal system. The analysis of sensitisation practices supports a reimagining of SWLOs that stresses their political agency in the production of new political spaces and expands the focus on African SWLOs beyond HIV work to their political activities, which advance SWs’ health, rights and social justice.

This Global Public Health Special Issue ‘SRHR for the next decades: What's been achieved? What lies ahead?’ assesses progress 20 years after the 1994 International Conference on Population and Development (ICPD), which established the sexual and reproductive health and rights framework for population and health policy (United Nations [UN], 1995). Contributors from different regions demonstrate that the challenges recognised by the ICPD still stand, and that lessons learned provide a clear way forward for the world's governments as they convene at the United Nations (UN) to agree on priority actions, and a post-2015 global development agenda. Fulfilment of sexual and reproductive health and rights enables people to have a satisfying and safe sex life, to reproduce if and when they desire and to have access to the health services and information necessary to make informed decisions, free of discrimination, coercion and violence (UN, 1995). According to a recent UN Global Review Report, progress has been made in the implementation of the ICPD agenda, but we still fall short of the ICPD goal of sexual and reproductive health for all (United Nations, 2014). International and national commitments have not been matched with action to improve the lives of people, particularly women, across our one world. One of the starkest examples is the persistent pandemic of violence against women. Global and national indicators of progress are welcome, but mask harsh inequity, between and within countries (Barros et al., 2012). The better-off drive progress indicators upwards, while the marginalised and the underprivileged are left behind. The penalties for these shortfalls are heavy in terms of avoidable human suffering and lost opportunities for economic and human development. Health and rights in sexuality and reproduction are an integrated package (Fathalla, 2002), which, the ICPD agreed, includes sexual and reproductive health services (family planning, maternity care, safe abortion, prevention and treatment of sexually transmitted infections and HIV, among others); comprehensive sexuality education; and protection of sexual and reproductive rights. People cannot be healthy if they have one element of the package but miss others (Germain, Dixon-Mueller, & Sen, 2009). The papers in this Special Issue show that progress on the components of sexual and reproductive health and rights has been uneven. While acknowledging that certain components may be more difficult or more costly to implement, progress in many instances has been hindered on ideological, rather than scientific, public health and cost-effectiveness grounds. This Special Issue also considers the central role of addressing the underlying social and political determinants of sexual and reproductive health and rights, as well as work towards universal health coverage, currently facing an uphill struggle (The Lancet, 2012). Papers and commentaries stress that a human rights platform is essential for all of this work, along with strengthening of health systems, and design and delivery of comprehensive and integrated packages of health services and information. Sexual and reproductive health for all is an achievable goal (Fathalla, Sinding, Rosenfield, & Fathalla, 2006). Those of us who participated in the ICPD and have seen the paradigm shift from ‘counting people’ to ‘people count’ have no hesitation in giving credit to women who abandoned silence and made their voices loudly heard, then and now. They demand faster progress towards sexual and reproductive health and rights for all. Despite steep mountains to climb, make no mistake: women are not turning back.

Because HIV and AIDS key populations share common social-cultural factors challenging their sexual health and rights (e.g. stigma, criminalisation), there is an assumed benefit of collaborative programmes where various key populations work in solidarity. In this paper, we reflect on how partners collaborated in a complex alliance of over 100 different NGOs, representing and supporting three key populations - lesbian, gay, bisexual and transgender (LGBT) people, sex workers and people who use drugs - working across 16 countries. We used a multiple-method approach of participant observation, qualitative interviews, and a survey to explore the benefits, facilitators and challenges of collaboration. Results show that motivators for collaboration included being part of the larger funding structure with applied impacts, a repressive human rights context, and intersectionality. Barriers for collaboration included identity politics, stigma, and constraints regarding the appropriate timing of new collaborations. Finally, facilitators include practical support for engagement, the framing of human rights in a medical agenda, and recognition of implicit differences. We conclude that for building the capacity for collaboration among socially marginalised groups it is important to develop trust and the ability to recognise strength in difference beyond the initial identification of shared norms and common goals.

Improving on previous social protection schemes, in 2000, policy-makers created the Mexican Social Protection System in Health (SPSS), an insurance scheme to expand financial coverage for health care, and especially to reduce and eliminate out-of-pocket health expenditures by the poorest households. Mexico has been widely applauded for achieving universal health coverage, meaning financial coverage, in 2012. However, such an achievement does not, by itself, result in adequate services for women's sexual and reproductive health and rights (SRHR; see paper by Sen & Govender, 2014). Following the reform of the National Health Law in 2004, policy-makers began to work on harmonising health standards across all states in terms of selected aspects of service quality and efficiency. By 2012, more than 52 million people were enrolled in the SPSS, and the total health expenditure increased from 5.1% to 6.3% of GDP between 2001 and 2010 (Knaul et al., 2012); these are considerable accomplishments. Nonetheless, the per cent of GDP allocated to health is low compared to other countries in the region (World Bank, n.d.), and significant gaps remain in securing SRHR, particularly for rural, poor and indigenous women and adolescents. What has SPSS contributed to meeting women's SRHR and what still needs to be done to ensure the universal access commitment of the International Conference on Population and Development (ICPD)? The SPSS is based on a paradigm shift from disease-specific treatment to provision of care across the life cycle. Thus, in theory, the SPSS covers comprehensive SRH services, including maternity care, STI and HIV prevention and treatment, safe abortion services where legal and contraception (including female condoms, emergency contraception and the sub-dermal implant, among others). Two key SPSS programmes prioritise SPSS enrollment for pregnant women and their families, and send out mobile units to work with rural midwives. SPSS also provides financial support for the treatment of cervical cancer, breast cancer and mental health, as well as other services that are critical over a woman's lifetime. While the SPSS has helped reduce the risk of crippling health costs for many of the poor, only limited information is available on the percentage of SPSS coverage that applies to SRHR services, and the impact on SRHR has been inadequate. For example, if the pace of the decline in the maternal mortality ratio, from 56.1 in 2002 to 43 in 2013, continues, Mexico will not meet its Millennium Development Goals (MDG) 5 goal of 22.2 (Government of Mexico, Office of the President, 2013). The unmet need for contraception is nearly 27% among adolescents and over 21% among indigenous women (Mexican Association for Family Planning [MEXFAM], n.d.), and adolescent pregnancy rates remain high: adolescents account for 6 out of every 10 births (National Institute on Statistics and Geography, 2013). Furthermore, one in four people living with HIV are women (UNAIDS, 2010). Particular services such as maternal health programmes do not provide the information on allocation and expenditure of resources needed for accountability, often leaving key decisions in the hands of certain decision-makers alone. These indicators demonstrate that despite ‘universal health coverage’, SRHR still lags behind. At least three factors inhibit progress and must be improved in the years ahead. First, the SPSS emphasis on financing has meant that the following key aspects of care have been neglected: improving the quality of services; strengthening and modifying the distribution of services within the health infrastructure; developing effective referral systems; increasing the number of skilled health workers, especially midwives and other primary- and mid-level providers; and ensuring access to translation for indigenous women in order to facilitate their effective use of services (CIDE & CONAPRED, 2012; GIRE, 2013; Zamarron, 2012). Areas of focus must be changed. Second, Mexico is a Federal Republic, and meeting the right to health for all is the responsibility of 32 states, posing some major challenges for quality assurance and the efficiency of resource spending, among other areas. Third, many women face other significant barriers to accessing SRHR services, including low levels of education; subordination within families and communities; lack of transportation; violence; as well as stigma and discrimination based on ethnicity, sexuality, race and age; all of which require stronger multi-sector policies and programmes to overcome. It is critical for the SPSS, and similar initiatives in other countries, to reduce and eliminate profound inequalities affecting women's access to health services, especially those that are based on income, age, ethnic origin and geographical residence. This requires allocating the maximum available resources, a human rights standard, to public health financing, particularly for SRHR. Finally, the international right-to-health standards for the availability, accessibility, acceptability and quality of goods, services and facilities need to be central to the next stages of health services development. This requires transparency in health sector budgeting and expenditures, effective accountability mechanisms and data collection and monitoring systems that, among other things, enable programme managers, policy-makers and others to track quality of care and individual health outcomes, not just services provided. It further requires mechanisms through which redress can be sought when human rights are abused or the government does not live up to its obligations under international human rights law.