Reproductive Health, Including Family Planning and Sexual Health, and Reproductive Rights
148. The ICPD Programme of Action endorses the right of all individuals to have their reproductive health needs met over their life-spans through a sexual and reproductive health approach to information and service delivery. Reproductive rights are understood as human rights. The right to voluntary choice in reproductive decisions involves ensuring equality and equity between women and men and the provision of universal and equal access to comprehensive quality sexual and reproductive health services that protect privacy, informed and free consent, and confidentiality.
149. In the years before 1994, some developing countries had witnessed significant changes in their population programmes, having shifted from using family planning programmes for controlling population growth to employing the rights-based approach later adopted by the ICPD. The ICPD provided all countries a major impetus for accelerating this shift away from vertical service provision, targets and quotas, and towards covering all the reproductive health needs of clients and promoting gender equality, equity and the empowerment of women, and adolescent reproductive health.
150. The Programme of Action describes the basic principles for implementing quality sexual and reproductive health services. These include the need to:
- Develop a dynamic policy and implementation process that is participatory and representative of all stakeholders;
- Develop a strategic implementation plan that is based on phased prioritization and on resource availability to ensure effective progress and accountability;
- Conduct a structural and strategic reorientation of health systems and finance in the context of health-sector reform and consider shifting from vertical maternal and child health and family planning (MCH/FP) to rights-based sexual and reproductive health programmes, recognizing that reproductive health is not simply a matter of adding services and information to existing family planning services; and
- Involve and coordinate various sectors to deal with the social, economic and political dimensions of sexual and reproductive health, acknowledging that reproductive health is best addressed through broad, multisectoral approaches and not just by health-sector organizations.
151. This chapter reviews the extent of the change that has taken place in meeting the reproductive rights and sexual and reproductive health goals and objectives of the ICPD. It builds on information gathered through a review of the literature on the subject, interviews, UNFPA field inquiries and Expert Round Table Meetings organized by UNFPA on these issues.4
152. There has been considerable progress in implementing key areas of the ICPD Programme of Action through policy reformulation, programme redesign, increased partnership and collaboration, and increased resource allocation. In particular, there has been increasing progress since 1994 in ensuring reproductive rights and implementing reproductive health as defined by the ICPD Programme of Action. By 1998, many countries had made policy, legislative and/or institutional changes in the area of reproductive health and/or rights since the ICPD. Several countries were testing ways to integrate reproductive health services and were exploring other means to ensure rights-based approaches.
153. Effective and empowered women's movements, other mass movements and NGOs were proving to be important in ensuring progress in policy development and implementation in many parts of the world and in many areas of concern, including generating political will for population and health policies that are rights-based. NGOs, which had been genuine partners in framing the Programme of Action agreements, have become partners in its implementation.
154. Reproductive health is more often being addressed as a component of broad health programmes in countries undertaking health-sector reforms. This broader approach is expected generally to be more cost-effective and to yield greater consumer satisfaction, which, in turn, is likely to lead to more effective use of information and services by consumers.
155. Sector-wide progress in policy formulation has occurred in several countries, while work on improving specific aspects of policies has begun in others. Critical measures undertaken by countries that are more advanced in the implementation of the ICPD agenda have included efforts to provide free and accessible reproductive health services as an overall health component throughout the life cycle (including the voluntary choice of family planning methods). There have also been efforts to broaden issues of reproductive decision-making so that the rights to consensual sexuality, voluntary choice in marriage, family formation and the determination of the number, spacing and timing of children are more widely available.
156. Some policies recognize the equal rights of women and men and the need to enhance women's status so as to allow them to exercise their rights. Most countries give highest priority to those aspects of rights dealing with provision of services, whereas a few specifically address the context in which reproductive decisions are made, i.e., gender and power relations.
157. The success of some countries in formulating reproductive health policies appears to result from the identification by Government of priority needs and the involvement of stakeholders in a multisectoral approach, making the public aware and placing reproductive health at the centre of health-sector reform. In this sense, donors and international agencies have played a facilitating role in Government-NGO collaboration. However, their support for policy and programme development has often been fragmented, which has tended to inhibit the development of national leadership and comprehensive policy and programme development for reproductive health, rights and equality.
158. Various models for policy development have been identified. Some countries embarked on the development of national reproductive health policies; others included reproductive health in policies that address women's health; and some dealt only with specific aspects of reproductive health.
159. Building consensus regarding the reproductive health concept and investing time and resources in the development of policies itself appear to be an auspicious strategy used in some Asian countries. Bangladesh offers a unique example of NGOs engaged in a consortium and of donors working together to support a national goal. The 1997 "Health and Population Sector Strategy", formulated with the involvement of NGOs, professional groups and consultants, affirms the principles of the ICPD and recognizes the need for a client-centred, life-cycle approach in which four areas have priority: safe motherhood, family planning, menstrual regulation and care of post-abortion complications, and the management of RTIs and STDs.5 The state of Rajasthan in India provides an example of a client-oriented and needs-based policy developed in response to the target-free approach in the country.6
160. In Africa, Zambia undertook a multisectoral and decentralized approach involving civil society in formulating a new reproductive health policy which addresses gender issues, including male involvement, as well as the allocation of resources for its implementation. The development of the national reproductive health policy was based on an extensive needs assessment process. Health districts, NGOs, donor agencies, and private and industrial institutions were all involved. In Ghana, the Ministry of Health developed a reproductive health policy as well as reproductive health standards and protocols. The policy was based on the results of a needs assessment process that included consultation with civil-society groups.7 In South Africa, NGOs provided key support to provincial governments in the development of a women's health policy.8
161. The case of Brazil offers an interesting example of what has happened since Cairo. Although a comprehensive women's health policy had been developed in Brazil even before the ICPD, progress accelerated after Cairo with an increased focus on certain aspects, including STDs and HIV/AIDS, safe abortion within the legal provisions, post-abortion care, and adolescents. In 1997, the Congress approved a National Family Planning Law, which covers all temporary contraceptive methods and also recognizes voluntary sterilization as an acceptable procedure for reimbursement by the Unified Health System.9
162. There appear to be no consistent trends in financing reproductive health policies. Funding increased in some countries (Bangladesh, Peru), and plans for the introduction of user fees and cost-recovery mechanisms were being developed in others.10 Even where there was a shift towards increasing private-sector provision of services, some Governments were committed to the provision of a safety net of free services.
163. The other issue involved in funding for reproductive health is the question of decentralization -- an important part of health-sector reform in many countries. When health spending priorities are identified at the local level, safeguarding spending for reproductive health will be dependent either on an understanding of reproductive health having trickled down to the regional or local level -- or its having "trickled up" from a demand from women, which would be dependent on their empowerment to recognize their needs. In Zimbabwe, a country seriously affected by the HIV epidemic, women's NGOs were instrumental in organizing the demand for state-subsidized female condoms that allow women to take control over protection against HIV infection.
164. In most countries, however, resources for reproductive health have been limited. Because the capacity to deliver comprehensive services and to make sweeping social change was limited, most countries have defined priority areas for investment, making hard choices about the allocation of scarce human, financial and institutional resources. Often, strategies have continued to focus on the previously high priority areas of family planning and MCH.
165. In countries where the process of health-sector reform has begun, a special effort is being made to include reproductive health as a priority area in the package of basic health services. In Zambia, where the health-sector reform process has been under way since 1992, a broad-based understanding of reproductive health was facilitated by the involvement of all levels of the public health system in the policy-formulation process.
Constraints in the Development of Policies
166. Despite unmistakable progress in the development of policies worldwide, countries reported that there was still an inadequate level of knowledge and understanding of reproductive rights and health as described in the ICPD Programme of Action, partly because it had not yet been sufficiently disseminated.
167. Even where there was general support for and increased understanding of the ICPD Programme of Action, policies did not yet consistently reflect a human-rights approach nor was there sufficient political commitment. Full support was still lacking for legislation to ensure reproductive rights and reproductive health and gender equity and equality. In many countries, existing laws and regulations impeded the implementation of the ICPD Programme of Action in areas such as sexuality education and adolescent access to reproductive health services.
168. Reproductive health policy has tended to be shaped primarily by health-sector organizations and professionals, to the exclusion of other sectors and disciplines. The result has been inadequate attention to the social, economic and political dimensions of sexual health and reproductive rights and little attention to the psycho-social, gender and emotional aspects of individual health and well-being. Political instability and frequent turnover of civil servants have also undermined the continuity of policy development, implementation and monitoring.
Integrating Sexual and Reproductive Health Programmes
169. Many countries reported the availability of various elements of reproductive health care, and many had taken steps to integrate some components of reproductive health into the primary health-care system. Yet, progress in implementing comprehensive, integrated services has been limited. Some countries were more advanced in moving from policy adjustments to actual implementation of the reproductive health approach, while others were just setting out to undertake changes in service delivery. This contrast should be kept in mind for the following analysis. However, in leading countries in all continents -- Brazil, Bangladesh, Ghana, South Africa, Tunisia and Zambia -- it is possible to identify prevalent strategies and key issues in implementing the reproductive health approach at the national level. In addition, even where health-care systems had not changed to implementing reproductive health approaches, NGOs were often already doing so. The initial steps taken by countries that were advancing in this area included translating reproductive health policies into operational guidelines by designing an approach to reproductive health services reflective of the ICPD commitment, analysing the human and institutional constraints, and preparing for monitoring progress.
Integrating and Broadening Service Delivery
170. Two key strategic aspects of moving towards a reproductive health approach are the integration of existing services and the broadening the constellation of available services. Managerial concerns in implementing these strategies include institutional set-up, training and supervision.
171. Integrating services. Many countries in all regions -- Bangladesh, Brazil, Ghana, Jamaica, Mexico, Peru, South Africa, Tunisia and Zambia, among others -- have been testing ways of integrating reproductive health services. Institutional integration seemed to constitute a major hurdle, even in countries which had made integration a priority issue. In many countries, the vertical organizational structure along with compartmentalized budgets and personnel constituted the main institutional barriers to a more integrated approach. When service-delivery activities were divided, for instance, between family planning and health structures, possibly managed by different ministries, countries experienced parallel systems and wasted resources. Thus, in many cases, the institutional change was only a formal one due to bureaucratic inaction and management segmentation including programming, training and evaluation. In less developed countries that depend to a greater extent on outside donors, the lack of coordination among donors also contributed to such segmentation.
172. The most common institutional change was the integration of family planning and MCH under a common institutional umbrella. Although some reproductive health components had been assembled under one institution, it was recognized that only better coordination was achieved in these cases, not full integration.11
173. At the service-delivery level, countries made progress through initiatives -- often begun before 1994 -- in integrating MCH and family planning services. After the ICPD, the focus was to further integrate these services with STD and HIV/AIDS prevention, screening and treatment. Such integration, however, may have involved only offering services at the same delivery place, while different providers continued to address individual aspects of reproductive health, for instance, screening, counselling and method provision. In some cases, services were offered at the same place and by the same personnel but on different days.
174. Broadening the scope of services. Broadening the scope of services does not necessarily entail the institutional problems of integration, as new services can be placed under the same roof as existing services. Also, a broader approach to service delivery can occur even within vertical structures, which is the case when service providers are trained, for instance, in counselling skills, gender mainstreaming and male involvement. Broadening services involves many of the same considerations regarding training as integrating services. One of the most frequently added services to family planning programmes was the prevention and management of STDs, including HIV/AIDS, followed in some cases by services for the treatment of the complications of unsafe abortion (as in Burkina Faso, India and Mozambique).
175. Referral systems relate both to the integration of services and broadening of the scope of programmes. The establishment of horizontal referral systems has been identified as a useful first step in integration where vertical structures still exist. This was the case for many programmes in African countries that were being linked to STDs and HIV/AIDS programmes.
176. Vertical referral systems are also essential with regard to certain aspects of reproductive health, for instance, with regard to maternal care in which referral, including transportation, to emergency obstetric care is an essential intervention to lower maternal mortality and morbidity.
177. A number of countries involved training institutions very early in the process of implementing the reproductive health approach to institutionalize reproductive health training. Also training curricula for both initial and in-service training were adapted to the reproductive health client-centred, needs-based approach, even when full-fledged integration had not taken place. In Romania, the training of staff in family planning to integrate this into primary health care has been a priority as a means of overcoming the service providers' lack of information. In Bangladesh -- where a main need was to improve the competence of health-care providers -- the training programme is reflecting a broader scope of services to be delivered by the same service providers.12
178. Training is also key in integrating cross-cutting issues such as counselling, gender mainstreaming and male involvement. The enhancement of gender skills of staff has been identified as a first and crucial step in mainstreaming gender.13 Progress in this area included the development of techniques for mainstreaming gender in reproductive health training and expanding the availability of such training. For instance, the World Health Organization (WHO), the Women's Health Project, South Africa, and Harvard School of Public Health, USA, developed a core curriculum in gender and reproductive health.
179. Continued supervision that includes problem-solving skills, especially as a follow-up to training activities, has been identified as a key to success.
180. A problem identified in training in the African context -- although the problem may apply elsewhere -- is that, historically, vertical training curricula had been developed for what now constitute the components of reproductive health. In many places, in-service training continued to be provided component by component. In a typical situation, training in family planning, post-abortion care, STDs, HIV/AIDS and safe motherhood was given, each component in separate training sessions. This situation may well reflect the segregation of budgets and lack of coordination within programmes, which are identified as important constraints to integration.
181. Although more integrated training curricula were developed in Latin America and the Caribbean (as in Colombia, Jamaica, Mexico and Peru), issues related to sexuality, critical to sexual and reproductive health, were often absent or diluted in the reproductive health part of the whole concept. Reproductive rights and gender perspectives were also often missing, with a resulting effect on client-provider interactions.
182. The shortage of appropriately trained staff was an obstacle to developing and implementing training programmes. This was the case at the national level, where human resources were needed to redesign training curricula and carry out the training of trainers. The decentralization of programme activities also highlighted the limited human resources available at the local level.14
Quality of Care -- Implementing Reproductive Rights
183. A main objective of the ICPD Programme of Action is to improve the quality of services, defined as the way clients are treated by the service-delivery system. The definition focuses on the process of service delivery, including communication and information sharing; criteria for minimal standards for procedures and examinations; and whether clients receive the service appropriate to their needs. Since the ICPD, much of the debate has centred on the feasibility of improving the standard of quality of care, because it is seen as too costly. However, many studies reveal that improvements in the quality of service provision can be made at a reasonable cost and that without such improvements, initial and continuing utilization of services may suffer.
184. The Population Council developed a situation analysis methodology that assesses the quality of services by observing, among other things, the effectiveness of the use of resources in the clinical setting. Situation analysis studies in some countries of sub-Saharan Africa15 have looked at key aspects of quality of services, such as contraceptive method choice, client load, use of clinical equipment and water, the social context and clients' sexual relationships. This information has begun to shed light on the underutilization of existing resources. These findings also reveal that, with the training of health providers to enhance their interpersonal communication and technical skills, supervisory support, protocols and appropriate rewards, staff can provide better services within the existing narrow scope of services (family planning), and such training may also allow the expansion of services to respond to other reproductive and sexual health needs.
185. One of the critical questions in improving the quality of care is how to define minimum standards in poor resource settings and, at the same time, improve the quality of care continually as more resources become available. Minimum standards should also apply to the private sector, just as special attention should be given to setting minimum standards for unfamiliar or new services and for services provided in emergencies.
186. Among the tools developed for improving the quality of care is Client-Oriented, Provider-Efficient services (COPE), which was designed by AVSC. Now used worldwide in more than 30 countries, COPE facilitates self-assessment and problem-solving by all clinic staff. Family planning providers and supervisors are being trained to solve problems as they arise.16
187. Counselling and interpersonal communication between service providers and clients are key aspects of ensuring informed and voluntary reproductive choices and thus, reproductive rights. If clients are not provided with sufficient information to make fully informed choices, their human rights are not being respected. Quality of care also includes issues of confidentiality, privacy, counselling and interpersonal relations. Since the ICPD, some countries have made progress in involving clients in decisions regarding their reproductive health.
188. To ensure high-quality care in the public and private sectors, some countries reported having improved or developed regulatory frameworks. For example, in India, institutional quality assurance in the health system, including the private sector, will be pursued according to the guidelines disseminated by the central government. In Nepal, the Government recently established the Quality of Care Management Centre within the Family Health Division to provide support to district health-care centres for improving the quality of reproductive health services.
189. Strengthening national information systems, including the development of indicators along with operational and policy-relevant research, is considered a key to allowing more effective planning, implementation and monitoring progress to achieve the reproductive health goals and objectives of the ICPD Programme of Action. The Islamic Republic of Iran and the state of Rajasthan in India offer examples of efficient information system designs that are simple and clear to use at the service-delivery level. In these systems, only the most essential data are collected; appropriate technology is applied; and the findings are of immediate use both at the service-delivery level and at higher levels of the health-care system.
190. However, the essential issue regarding the quality of national information systems is the question of indicators. Identifying indicators should entail a consideration of whether they measure process or output and whether they are qualitative or quantitative. A number of international agencies, including UNFPA, WHO, World Bank and the Evaluation Group supported by the United States Agency for International Development (USAID), have developed groups of global indicators to assist in the further adoption of indicators. These indicators are now being tested in the field.
191. At the national level, it has been found to be an advantage if all stakeholders -- i.e., all parties that can make use of the information, such as community representatives, service providers, programme managers and researchers -- come together in designing information systems. They have to identify what information they need, how should it be analysed and how the results should be presented to different users. For example, the Latin American and Caribbean Health Network -- in collaboration with some Governments in the region -- identified six thematic issues to monitor in each country they work in, including sexuality and the reproductive health of adolescents, quality of care, management of unsafe abortion, male involvement and the participation of women in decision-making. Qualitative and quantitative indicators elaborated for each of these issues will be used to assess the reproductive health situation in each country.17
Communication and Education
192. Information and the confidence to take action in personal and institutional relationships are preconditions for sexual and reproductive health. NGOs have been successful in building the knowledge base and confidence of women, men and adolescents to claim their sexual and reproductive rights and promote their sexual and reproductive health, including the effective use of health services.
193. Many diverse and innovative communication methodologies and materials have been developed to empower people to act on their sexual and reproductive rights. These include drama, mass media and peer education. However, the effectiveness of methodologies and materials has not always been evaluated and the content has not always addressed the common human experience, such as sexuality and gender power relations, including violence.
194. Only a few communication programmes, carried out mainly by NGOs, have helped men understand how preventing women's access to sexual and reproductive health care endangers women's health and lives and helped them change their behaviour so as not to put women's health at risk and to protect their own health.
Diversification of Service Provision
195. The diversification of service provision for selected reproductive health services through the participation of the private sector and NGOs has improved access in some countries. For example, in Colombia, PROFAMILIA, an International Planned Parenthood Federation (IPPF) affiliate providing more than 60 per cent of the national family planning services, broadened the provision of reproductive health services after 1994. Through a cost-recovery programme, PROFAMILIA subsidized services in poor and remote communities and for teenagers. Cost recovery helped to ensure voluntary and informed choice as well as to maintain a high quality of care.18
Constraints of Access
196. Notwithstanding improvements, economic conditions and the resulting poor health-care infrastructure in many countries continue to obstruct access to services. Barriers to services include distance, cost, ignorance and the poor attitude of providers. The separation of basic primary health-care services places an exceptional burden on women to meet their diverse needs and those of their children. It also leads to duplication of infrastructural, management, information and other systems.
Increasing Access to Health Services for Adolescents
197. The world today has the largest group of adolescents in history, with 1.1 billion persons aged 10-19. Investing in these young people and providing them with real opportunities in life are vital steps in promoting individual and societal development. However, far too many adolescents lack homes, formal education, work and beneficial recreation, and many live in extreme poverty. Opportunities for girls, as compared with boys, are especially limited.
198. Programme experience indicates that adolescents need support to build self-esteem and to develop life skills and skills to manage intimate relationships and to practice gender equality. Unprotected sexual relations place adolescent girls at risk for both unwanted pregnancy and STDs, including HIV/AIDS, and boys at risk for STDs including HIV/AIDS. Therefore, they need access not only to preventive services, such as information and contraception, but also to youth-friendly health services, including diagnosis, treatment, information and counselling.
199. In the 1998 UNFPA Field Inquiry, it is reported that 55 countries had taken some measures to address the health needs of adolescents, including reproductive health. Among such measures were the inclusion of adolescent reproductive health in youth and national health plans, the development of policies and guidelines for adolescent reproductive health, and the establishment of ministries of sports and youth. In some countries, NGOs were especially active in testing new approaches to programme development for adolescents such as peer education, skills-building and counselling. Actions to foster understanding and support among adults in the family and in the community were being recognized as key investments.
200. In Colombia, PROFAMILIA supported activities in youth centres in 20 of the country's cities, where the youth population have at their disposal medical services, diagnostic support and information, and sexual and reproductive health education. In Kenya, the song "I Need to Know", performed by young Nairobi musicians, was a hit. The song helped adolescents ask for a reproductive health component to be added to school health services. In the Marshall Islands, a youth- to- youth programme trained peer educators and counsellors so that they could provide health education on issues such as teenage pregnancy, STDs and HIV/AIDS, substance abuse and nutrition to youth, their families and the community. The project also catered for the contraceptive needs of adolescents.
201. Young girls are at particular risk of reproductive ill-health. More than 14 million adolescent girls give birth each year. A large proportion of these pregnancies are unwanted. WHO estimates that as many as 4.4 million abortions are sought by adolescent girls each year. Harmful practices, such as FGM and child marriage followed by expectations of early child-bearing, further increase the risk of reproductive ill-health in adolescent girls.
202. Early child-bearing also narrows the life opportunities of girls. In many countries, girls who become pregnant are not allowed to continue to attend school. In others, the education of boys is simply valued higher than that of girls. The result is that girls constitute two thirds of the more than 130 million children not attending school. Some countries have, however, begun to take measures to promote girls' education, including direct incentives, such as waiving fees or providing a small payment or food allocation for girls' attendance, and adapting the school system to facilitate girls' participation. For instance, over the past decade, the Bangladesh Rural Advancement Committee created more than 30,000 schools offering non-formal primary education, in which 70 per cent of the pupils were girls.19
203. Many studies show that sex education promotes responsible attitudes and behaviour. These studies also show that providing adolescents with information and services on reproductive and sexual health enables them to postpone the onset of sexual activity and that, when they do engage in sex, they are more able to protect themselves from pregnancy and STIs, including HIV/AIDS.
204. Ensuring adolescent sexual and reproductive health and rights as well as improved life opportunities equally for girls and boys will require much greater investment. As yet, few Governments have developed comprehensive strategies for investing in adolescent reproductive health.
Increasing Male Responsibility
205. The ICPD Programme of Action recognizes that human sexuality and gender relations significantly affect sexual and reproductive health and that men need to take responsibility for their own sexual behaviour as well as to respect and support the rights and health of their partners. Many countries have undertaken advocacy campaigns to broaden or promote male involvement in sexual and reproductive health. Since the ICPD, there has appeared to be some increase in men's use of condoms and vasectomy and some expansion of male STD services. In a few countries, NGOs, especially, developed innovative approaches to support the involvement of males in pregnancy and child care and to encourage them to develop relationships based on equality and mutual respect. For example, in Mexico, a group of midwives organized a programme to train Community Health Workers to encourage male participation in reproductive health care, teaching men that pregnancy and birth are a family affair and not just "women's business".
206. It is increasingly recognized that work with boys and youth is essential. Some countries strengthened legislation that supports men's roles in the family, especially concerning child support. There has been little improvement, however, in implementing laws concerning violence against women, and overall progress on male involvement in this area has been limited.
Ensuring reproductive health for refugees
207. Until recently, reproductive health was not considered a priority in the provision of health services in emergency situations. However, the ICPD Programme of Action recognizes the need to ensure reproductive rights and to provide reproductive health care, since reproductive health needs continue to exist. This is especially true for adolescents and women. Women are also at greater risk of sexual violence and rape in emergency situations.
208. Since the ICPD, reproductive health care has been increasingly guaranteed in all emergencies due to the improved capacity and mechanisms of response by the international community. An initiative by United Nations agencies and international NGOs was instrumental in developing a coordinated and collaborative approach to reproductive health. This included the development of a reproductive health manual detailing a basic package of services for emergency situations that includes maternal care; family planning, including emergency contraception; and the prevention and management of STDs and HIV/AIDS. Emergency reproductive health kits have also been developed and stockpiled for immediate distribution when needed.
209. In 1995, an Inter-Agency Working Group was established under the coordination of the United Nations High Commissioner for Refugees (UNHCR), with the representation of 30 NGOs, United Nations agencies, governmental agencies and donor institutions, to organize and facilitate reproductive health in all emergency situations. As a result, the Minimum Initial Service Package (MISP) was developed, consisting of material resources necessary to implement services, including essential drugs, supplies and basic surgical equipment.20
210. Also in 1995, the Reproductive Health for Refugees (RHR) Consortium was funded by organizations representing a mix of field service organizations, public health organizations and policy/advocacy groups. Needs assessment manuals and materials were developed.
211. Although the capacity and mechanisms of the international community to respond to emergency situations have improved, and comprehensive reproductive health services are now being implemented earlier in emergencies, the availability of emergency health personnel skilled in reproductive health information and services remains limited.
212. Whether countries in their overall programme design have pursued the integration of services, improved quality of care or increased access to services, a more comprehensive reproductive health approach can be distinguished by looking at achievements in its key components. Within the concept of integrated and comprehensive reproductive health, three central issues have emerged as global concerns:
- Meeting the need for family planning;
- Ensuring maternal health, and preventing and management of unsafe abortion; and
- Preventing and treating STDs (including HIV/AIDS).
- Some countries, however, are increasingly addressing other reproductive health issues -- namely, the prevention of cervical and breast cancer and infertility.
- Meeting the Need for Quality Family Planning
213. Ensuring the ability of people to choose whether to become parents and, if so, to choose when and how often, is not only a key intervention for improving the health of everyone but is also a human right. For couples and individuals to decide freely and responsibly the number and spacing of their children, a full range of safe and effective methods of family planning, which meet the expressed preferences of people, needs to be accessible and affordable.
214. As of 1998, almost all countries had affirmed the right of couples and individuals to choose the number and timing of children and to have access to information and the means to do so. Only two Member States continued to severely limit access to family planning.21
215. In many countries, policies limiting access to family planning services are being lifted. Also, in many countries, regulations and policies are being reviewed concerning such issues as spousal authorization, marital status and age limits or those that deny services to adolescents, to unmarried, divorced or widowed women, and to women who want to delay or space pregnancies but are not able to negotiate this with their husbands. By 1997, however, 14 countries still required spousal authorization for women to receive contraceptive services, and 60 additional countries required spousal authorization for permanent methods.22
216. Family planning remained the central focus of most programmes. However, a reproductive health approach to family planning was the first step taken in the majority of countries where ICPD implementation had begun. This means that efforts now need to be more focused on meeting the needs of clients. This includes reconsidering the range of contraceptive methods made available; information and counselling services to enable contraceptive choice in the context of assessing the individual's sexuality, partner's relations, gender issues and the social context; and information and counselling on side-effects and their management. NGOs, such as IPPF family planning associations (FPAs) and women's NGOs, are leading in this domain. However, national programmes are also making progress. For example, the "target-free approach" was introduced in India in 1995. It discarded demographic and contraceptive goals, replacing them with a "community needs assessment" approach. China, similarly, was endeavouring to change from pregnancy quotas to a client-centred approach based on reproductive choice in a programme being introduced with UNFPA support in 32 counties throughout the country.
217. Some countries have adopted quality-of-care approaches, which have included appropriate service facilities; appropriate technology; and training of personnel in counselling and communication skills and the availability of a variety of contraceptive methods. Of the clinics studied in five Sub-Saharan African countries, 81 per cent had at least four contraceptive methods in stock.23
218. Despite the encouraging emphasis on improving the determinants for quality of care, this has not automatically led to clients' actually receiving quality care. A review of five situation analysis studies found that at clinics with four or more contraceptive methods in stock, only 34 per cent of new clients interested in spacing births were informed about at least three methods. In addition, in clinics which had informational materials available, these materials were actually used in less than one fifth of client-provider interactions. Moreover, between 23 per cent and 88 per cent of providers with water readily available did not wash their hands before a pelvic examination.24
219. Some countries have made progress in ensuring informed consent in family planning settings. In Bangladesh, Mexico and Peru and in some states of India, for example, providers were better trained in providing information and in obtaining full voluntary consent from clients.
220. Most developing countries with available trend data showed a substantial increase in contraceptive use. The overall yearly increase in contraceptive prevalence for the developing countries was 1.2 percentage points per annum, when weighted by the number of married women of reproductive age.25
221. Although there appears to have been a substantial increase in contraceptive use in many developing countries, various indicators suggest that the level of unmet need remained high, at about 20-25 per cent of couples. For regional groups, the level of unmet need was highest in sub-Saharan Africa (29 per cent) and lowest in Latin American and the Caribbean (18 and 20 per cent).26
222. Two new contraceptive methods became available after 1994: once-a-month injectables and the female condom. Approximately 22 countries in sub-Saharan Africa were beginning to provide the female condom, clearly recognizing that women need a method that they can control. In addition, research shows that IUD CUT380A is now effective for 10 years. Research organizations continued their work on contraceptive safety and post-marketing surveillance.
223. Emergency contraception has become better known and accessible since 1994. It covers specific needs of women who are exposed to unprotected intercourse and can act early to prevent unwanted pregnancy. Emergency contraception has been introduced in a number of countries, and training efforts are also being undertaken.27
224. In 1998, the use of Quinacrine for female medical sterilization, never considered safe by WHO, was finally banned by the U.S. Federal Drug Administration, which also requested the U.S. promoter to cease distribution of the drug in the United States and yield up all its stocks.28
225. Donor support for contraceptives increased 15 per cent between 1994 and 1996.29 By region, donor contraceptive support for the Asia and the Pacific region doubled in 1996 from the year before. The main reason for this was an expanded social marketing operation in the area. Donor support for the Africa region over the period 1995-1996 was 52 per cent higher than the previous biennium. Initiatives are under way at global and national levels among the public, donor and commercial sectors to expand the role of the commercial sector to market lower priced hormonal contraceptives in developing countries to those who can afford them.
226. The diversification of service providers has improved access to family planning services in many parts of the world. For example, social marketing increased by 13 per cent in 1997. More than 16 million couples in 55 countries benefited from social marketing in 1997, versus 14.4 million in 1996. The large increases were mostly the result of the Indian and Indonesian programmes. A total of 937 million condoms were sold by social marketing programmes in 1997, an increase of 20 per cent over the previous year. The sale of more than 900 million condoms indicates the importance of social marketing, especially in view of the AIDS epidemic.30
227. Access to family planning increased dramatically in the Central Asian countries of Kazakhstan, Uzbekistan and Kyrgyzstan. In these three countries, 59 per cent of married couples were practicing contraception, including modern and traditional methods, compared with less than 20 per cent who did so in 1990.31
228. Despite advances in contraceptive technologies and the delivery of family planning services, there remain many people whose access to information and services is severely restricted by logistical, social and behavioural obstacles. These obstacles can be overcome with sensitivity to the changing needs of users and their constraints and with greater attention to logistic systems, management capacity and public information. Providing family planning in the context of comprehensive reproductive health services and encouraging men to accept and support their partners' contraceptive choices will help remove these barriers.
229. Methods for male fertility regulation remain severely inadequate. In this regard, donors and the private sector should increase investments in research and the development of new methods for men as well as female-controlled barrier methods to prevent STD transmission as well as pregnancy.
Promoting Women's Health and Safe Motherhood
230. Greater awareness of the risks of maternal mortality and morbidity exists than 10 years ago due to the momentum generated by the Safe Motherhood Initiative, reinforced by the ICPD and other United Nations conferences. The international health and development community has recognized that maternal mortality is both a development and a human rights issue. WHO and UNICEF estimated that there were 585,000 maternal deaths in 1990. For every women who dies, many more suffer severe injury or ill-health. The ICPD target is to reduce the 1990 levels of maternal mortality by one half by the year 2000. Although accurate measurement is difficult, it is clear that maternal mortality levels remain highest in sub-Saharan Africa and South-East Asia32 and, more generally, that women in developing countries face an unacceptable and far greater risk of death in pregnancy and childbirth (1 in 48) than do women living in developed countries (1 in 1,800).
231. In 1997, a major technical consultation in Colombo, Sri Lanka, organized by the Inter-Agency Group in Safe Motherhood (which includes UNICEF, UNFPA, the World Bank, WHO, IPPF and The Population Council), reviewed strategies and approaches to reducing maternal mortality. The meeting concluded that training traditional birth attendants (TBAs), providing antenatal screening for high-risk pregnant women and providing simple birth kits was not enough. Women must have access to skilled personnel at delivery, including assisted delivery and life-saving treatments backed up by transport in case emergency referral is required; and to post-partum care. To realize this goal, sufficient numbers of skilled attendants -- primarily midwives -- need to be trained and deployed, especially in rural areas. They need to be supported with adequate supplies and equipment, regulations that permit them to carry out necessary procedures, and supportive supervision and monitoring. TBAs, trained or untrained, are not defined as skilled attendants.33
232. At the meeting, it was also recognized that women need to have more autonomy and choices. Increasing education for girls and women and expanding their access to income-earning opportunities and to opportunities for learning life skills can help them improve their status and their access to resources. In this way, they could better avoid poor reproductive health and unsafe motherhood, even before pregnancy occurs.
233. Despite the limited progress overall, some Governments invested resources and developed innovative approaches, some begun before the ICPD. In Tunisia, for example, the Safe Motherhood Programme was initiated in 1990 to improve the quality and coverage of maternal and neonatal health. After the ICPD, the Ministry of Health developed a comprehensive reproductive health strategy with other components, such as reproductive cancers and the prevention and management of STDs. In Indonesia, the coverage of antenatal care and supervised delivery significantly improved after the Government developed a programme to train more than 54,000 community midwives. In Ghana, Nigeria, Uganda and Viet Nam, projects were developed to train midwives in life-saving skills, a training package developed by the American College of Nurse-Midwives. The skills covered in the training were those needed to save the lives of women during obstetric emergencies, including risk assessment, problem-solving and clinical management. In Uganda, the Ministry of Health launched a pilot project in one district to establish a sustainable referral system, which included strengthened referral facilities, communication and transportation. As a result, obstetric referrals and Caesarean sections increased threefold between 1995 and 1996.34
234. Interventions in maternal health are among the most cost-effective in the health sector. A key challenge to their improvement is to alter existing health facilities, logistic systems and training to ensure appropriate and effective care. Another challenge is to overcome social barriers to access.
Prevention and Management of Unsafe Abortion
235. WHO estimates that some 20 million unsafe abortions take place in developing countries each year and that as many as 70,000 women die, accounting for 13 per cent of maternal deaths.35 Most countries are strengthening efforts to prevent unwanted pregnancies, and some are working more systematically to reduce the health impact of unsafe abortion, which remains a major public health concern. A study by the Alan Guttmacher Institute of abortion laws of 152 nations and territories with a population of 1 million or more found that, since 1985, 19 countries (among them, 3 since 1994) enacted new or modified existing abortion laws to expand women's access and choice.
236. The prevention of unwanted pregnancies is the primary objective of any family planning programme or family planning component of reproductive health programmes. The correlation of such efforts to decreasing abortion rates is illustrated in the three Central Asian Republics of Kazakhstan, Uzbekistan and Kyrgyzstan. Data from the Ministries of Health show that the use of modern contraception increased in these countries from 30 per cent to 50 per cent since the beginning of this decade.36 At the same time, reported abortion rates declined by as much as 50 per cent.
237. High rates of abortion are also characteristic of a number of eastern European countries. Here, too, efforts are under way to reverse this by increasing contraceptive use. An interesting example is Romania, where family planning was illegal under the previous regime. Consequently, maternal mortality levels caused by unsafe abortions were very high. A dramatic fall in the maternal mortality ratio was evident after December 1989, when an abortion law was enacted. However, to further decrease maternal mortality levels caused by abortion complications, the promotion of modern family planning methods within the scope of the law, were made priorities.37
238. A number of countries -- including, in Africa, Ghana, Ethiopia, Kenya, Malawi, Nigeria, South Africa, Uganda, the United Republic of Tanzania, Zambia and Zimbabwe, and, in Latin America, Brazil, Chile, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Paraguay and Peru -- have focused on reducing the health impact of unsafe abortion through post-abortion care. As of 1997, more than 114 hospitals and health centres in Mexico were using manual vacuum aspiration (MVA) for the treatment of incomplete abortion. In Ghana, a study was undertaken on the training of midwives working at primary and secondary levels to offer post-abortion care, including the treatment of incomplete abortion. The study demonstrated the feasibility and acceptability of authorizing mid-level providers to offer post-abortion care and had far-reaching repercussions in areas such as improved referral with area hospitals, better community education about unsafe abortion and improved standing of these midwives within their communities.38
HIV/AIDS and STDs
239. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that 33.4 million people currently live with HIV/AIDS, of whom 5.8 million were newly infected in 1998, the majority due to unprotected sexual intercourse. An estimated 13.9 million AIDS deaths have occurred since the beginning of the epidemic, 2.5 million of them in 1998.39 It is further estimated that half of all new infections are to young people between the ages of 15 and 24. The HIV/AIDS epidemic draws its largest toll in Sub-Saharan Africa, where 20.8 million or close to 70 per cent of HIV-infected people live. In 29 countries of this region, life expectancy at birth is already 7 years less than it would have been in the absence of AIDS. Moreover, a total of 7.8 million, equaling 95 per cent, of children who are orphans because of the disease live in Sub-Saharan Africa. Nevertheless, several countries still do not recognize HIV as a major threat to public health.40
240. UNAIDS, which became operational after the ICPD, is co-sponsored by UNICEF, the United Nations Development Programme (UNDP), UNFPA, UNESCO, WHO and the World Bank. The mission of UNAIDS is to lead, strengthen and support an expanded response aimed at preventing the transmission of HIV, providing care and support, reducing the vulnerability of individuals and communities to HIV/AIDS, in full partnership with its United Nations co-sponsors. Since January 1996, UNAIDS theme groups consisting of representatives of the co-sponsoring organizations and, in some places, of other interested parties, have been established in most countries to increase the efficiency and effectiveness of the response of United Nations system and to coordinate HIV/AIDS activities among the co-sponsoring agencies and with national AIDS programmes. NGOs are also members of the theme group or technical working group in a number of countries, including Brazil, Chile, Democratic Republic of the Congo, Jordan, Rwanda and Swaziland.
241. There is widespread agreement that RTIs and STDs, including HIV/AIDS prevention and treatment, should be an integral component of reproductive health programmes. Since the ICPD, much effort has gone into developing operational strategies and apparatus. Studies have demonstrated the feasibility of integration. Specifically, reproductive health programmes can reduce levels of STDs, including HIV/AIDS, by:
- Providing information and counselling that addresses critical issues such as human relationships, including sexuality, gender roles and power imbalances between women and men, and mother-to-child transmission of HIV;
- Distributing female and male condoms; and
- Diagnosing and treating STDs, developing strategies for contact tracing and referring people infected with HIV for further services.
242. Some case-studies indicate that the training and support for service providers is insufficient, especially in such activities as information and communication, and counselling. For instance, four case-studies conducted in East and Southern Africa underline the need for providers to have sufficient training, available equipment and implementation aids. These studies also identify as important factors for the success of integration the providers' willingness to discuss sexuality and STDs with clients and their ability to correctly identify risk cases for screening.
243. The education of young people is clearly critical to promoting behavioural change in human relationships, values and norms regarding gender roles and gender power imbalances. In 64 countries, support had been provided for the integration of HIV/AIDS-prevention modules into in-school and out-of-school education programmes. According to a 1997 UNAIDS review of the impact of preventive education on the sexual behaviour of young people, quality sex education helps adolescents delay sexual intercourse and increase safe sexual practices.41 The value of focused efforts can be seen in Uganda, where a direct and comprehensive approach was taken to address the problem among young people, in particular, and where HIV/AIDS prevalence rates are now stabilizing among youth.
244. The technology for HIV/AIDS prevention and control is still inadequate. A vaccine is not yet available, but an important accomplishment has been the development of the female condom, the only female-controlled barrier method that can protect against HIV transmission. Countries have already introduced this new method as a result of the organized demand of women's groups and in recognition of the importance of supporting women's control in this area. Indications are that the public-sector price will fall in response to increasing demand. With regard to microbicides, 40 new leads have been identified and 15 are now in the clinical trial stage.
245. UNAIDS, UNFPA, UNICEF and WHO, in 1998, embarked on a new initiative to reduce HIV transmission from mother to child in low-income countries. The initiative aims at offering voluntary and confidential HIV counselling and testing to pregnant women, and at providing those who learn they are infected with antiretroviral drugs, better birth care, safe infant-feeding methods and postnatal counselling and family planning. The initiative seeks, initially in approximately 11 pilot countries, to translate into action the findings of research into the efficacy of short-term drug regimens, as in one study in Thailand, which found that a one-month course of an antiretroviral drug had effectively halved the risk of HIV infection in non-breast-fed infants born to HIV-positive women.
246. To fully realize the goals and objectives of the ICPD Programme of Action in reproductive health and rights, a number of key areas require increased attention. Future actions must be based on the principles, goals and objectives adopted by the ICPD, which emphasize the universality of human rights, including the sexual and reproductive rights of women, men and adolescents, and the need for partnerships of all kinds to enable Governments to meet the ICPD Programme of Action objectives.
Developing Reproductive Health Policies
247. Governments should ensure that national health plans, including health-sector reform processes, fully take into account the sexual and reproductive health needs of their population.
248. Government and donors should both facilitate and finance participatory policy development processes to include representatives of all stakeholders. To ensure effective progress and accountability, policies must include a strategic implementation plan that takes into account human resources, institutional capacity and resource availability.
249. Governments should enact and implement legislation and policies required to meet the commitments made in Cairo, using all necessary and appropriate means, such as removing restrictive laws. They should continue to promote reorientation of the health system to ensure that policies, strategic plans, and all aspects of implementation are rights-based, cover the life cycle and serve everyone.
250. Governments should invest in training parliamentarians, legislators and the media in the importance of the Programme of Action.
251. Governments should engage not only the health sector but all relevant sectors in policy development and implementation.
252. Governments should develop reproductive health programmes based on an assessment of sexual and reproductive health needs which fully involves all stakeholders.
253. Governments should ensure that NGOs and the private sector are enabled to make their fullest possible contribution to national reproductive health programmes.
254. Governments and the international community should ensure that the continuing reproductive health needs of individuals, especially women and adolescents, in emergency situations are met.
Implementing Quality Sexual and Reproductive Health Programmes
255. To move vertical services and management systems towards integrated comprehensive care, Governments, supported by donors and NGOs, will need to undertake several actions, as follows:
- Bring about the structural integration of reproductive health services or, at least, functional integration, including effective referral systems, training and supervision;
- Increase investments in standards of service provision, maximizing the use of existing resources to provide quality services and conducting continuing evaluation;
- Increase investments in training not only to provide technical skills but also to prepare providers to communicate clearly with empathy and with respect for human rights, gender equality (including a recognition of violence against women) and dignity, and to provide dignified care; and,
- Improve regulatory frameworks and their application to ensure high-quality care.
256. All reproductive health service providers should have integrated reproductive health training, which would increasingly enable them to provide additional reproductive health services at the primary health level.
Strengthening Communication and Education
257. Governments, as well as NGOs, should increase their efforts to evaluate the effectiveness of communication techniques and materials and share them widely. The content must address all appropriate aspects of sexual and reproductive health, including sexuality, power relations between men and women, and violence.
258. The mass media should be encouraged to convey images and messages that are respectful of both women and men, foster positive adolescent health and promote gender equality.
Increasing Access to Health Services for Adolescents
259. Governments should develop and implement a national plan for investing in young people. The plan should include education, vocational training, income-generating opportunities, and sexual and reproductive health information services. Special attention should be given to gender equality and equity and to youth who are disadvantaged due to poverty, residence or disability.
260. Governments should ensure that sexual and reproductive health programmes encompass more than "sex education" and the provision of contraceptives. They should include basic health care and STD screening and treatment, effective referral services, and counselling that addresses sexuality, builds self-esteem and promotes gender equality; skill training to develop broad-based life skills, including assertiveness and decision-making training to resist peer pressure or abusive situations and to manage sexual feelings and overtures, both wanted and unwanted.
Increasing Male Responsibility
261. Governments, together with NGOs and international organizations, should enhance their support for the promotion of male responsibility in reproductive and sexual health, including respect for human rights, support for a partner's access to reproductive health care, and increased responsibility in child care. Information on and access to contraceptive methods that provide protection against STDs, including HIV/AIDS, need to be extended as a way of helping men to take responsibility for their own reproductive and sexual behaviour.
Meeting the Need for Quality Family Planning Services
262. Governments should increase their efforts to ensure access to a full range of safe contraceptive methods, including new options such as the female condom and emergency contraception.
Promoting Women's Health and Safe Motherhood
263. Governments and donors should invest in training skilled providers and in ensuring effective access to well-staffed and equipped first-referral-level hospitals, including transport, and much stronger interventions to help the community -- particularly males -- understand and accept their roles and responsibilities in preventing maternal mortality.
Preventing and Managing Unsafe Abortion
264. Governments should train and equip health personnel to provide post-abortion care and provide reliable information, compassionate counselling and post-abortion family planning.
265. International agencies should develop a system for monitoring the implementation of paragraph 8.25 of the ICPD Programme of Action.
Dealing with HIV/AIDS and STDs
266. Countries should increase access to female condoms. Investments are urgently required for research and development of microbicides, simpler diagnostic tests and single-dose treatments. Service and communication campaigns must include sexuality and gender power issues.
267. Governments and the international community should ensure that prevention and management of STDs, including HIV/AIDS, become an integral part of reproductive health programmes, particularly at the primary health-care level.
268. Governments and the international community should make HIV/AIDS prevention and control a priority at the highest political level and immediately focus their major efforts in the most severely affected countries in Southern Africa.