Cross-sectoral integration can support reproductive choice, violence reduction and social cohesion: experiences from a climate-stressed district of rural Uganda.

Introduction: Climate and environmental stresses have a disproportionate impact on women and girls, acting as a trigger for intimate partner violence (IPV) and compromising access to needed sexual and reproductive health and rights (SRHR) services. Little is known about the impact of cross-sector programmes and services, and programmes responding to these linked crises remain siloed. This paper examines the effect of a novel partnership between environmental protection and livelihoods NGOs and government health services providing integrated programmes in a climate-stressed rural district in Uganda. Methods: Qualitative research examined whether and how integrated programmes could lead to improvements in IPV, SRHR and wider gender equity in eight villages in Rukiga, Uganda. Forty-four focus group discussions in integrated and non-integrated ("parallel") sites gathered lived experiences comparing pre- and post-intervention between April 2021-December 2023. Results: Over time, although participants still described food insecurity, poverty and IPV (prevalent at baseline) many also reported positive shifts in IPV-triggers including gender-dynamics and male attitudes towards family planning (FP). Overall, participants in integrated sites reported increased male acceptance of family planning-reducing a potential IPV trigger - and greater community support for women's economic participation. Integrated delivery that engaged all adults in livelihoods as well as reproductive health activities helped disrupt gendered information (and practice) silos and promote greater reported community cohesion supporting women's legitimate participation in economic activities alongside better male support for women's reproductive rights. Discussion: Findings suggest that integrated programmes pairing climate-resilient livelihood strategies with rights-based family planning and reproductive health services can enhance reproductive choice for women and help address root-causes of IPV, reproductive coercion and abuse by partners. Protecting women's reproductive rights and wider social wellbeing in the context of severe climate stress means health services and systems must move beyond siloed SRHR programming and service delivery, to embrace partnerships with organisations tackling linked livelihoods and wider wellbeing issues. To be effective, health services and systems must explicitly embed gender-responsive and justice-oriented approaches that ensure the safety of women while addressing persistent inequalities, resource scarcity, and power dynamics.