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Appendix

Follow-up to the ICPD: Implementing the Reproductive Health Agenda

The success of the International Conference on Population and Development (ICPD) in Cairo in 1994 will ultimately be measured by how effectively the ICPD Programme of Action is implemented.

The Programme of Action marks a profound change in the international consensus on population issues; the new approach starts from the point of view that securing human rights and meeting the needs of individuals also addresses global problems.

One of the key elements of the programme of action is its emphasis on reproductive rights and health. Exercise of reproductive rights includes having access to family planning information and services. Family planning contributes both to reproductive and sexual health and to maternal and child health. Experience over the past two decades has shown that family programmes best respond to users needs when they are integrated with broader health initiatives within the primary health care context.

Experience also shows that women with a full and free choice in the matter of family size tend to have fewer children, and can keep them healthier and better educated.

To assess the ICPD's impact on population policies and programmes around the world, UNFPA invited countries to share their experiences to date in implementing reproductive health interventions. The information below is based on their responses.

Operationalizing reproductive health

Since the ICPD, many countries have organized workshops or seminars for planners and health workers on the reproductive health approach and its implications for their national population programmes. In addition, national medical associations have organized forums or symposiums on how to put the concept of reproductive health into operation in their countries.

Integrating Family Planning into Reproductive Health Programmes

Many Governments have started to reorient and reexamine existing policies. In Guinea for example, the Ministry of Health has begun reviewing its Safe Motherhood/Family Planning programme with the aim of transforming it into a Reproductive Health/Family Planning programme. Indonesia initiated the shift from family planning to reproductive health even before the ICPD, and will accelerate the transition in its current five-year programme (1995-1999). The Government of Paraguay revised its national plan for reproductive health and family planning, elaborated just before the ICPD, to adjust it to the new focus, principles and recommendations of the ICPD Programme of Action.

Countries the world over have responded to the Cairo challenge of adopting a reproductive health approach. Almost two thirds of the countries which responded to the inquiry have taken initial steps to broaden existing family planning and related programmes (maternal and child health, birth spacing, safe motherhood, e.g.) to include other reproductive health information and services. Many countries are heeding the ICPD's call for increased attention to the quality of care in reproductive health and family planning programmes.

Some sub-Saharan African countries are integrating reproductive health services into ongoing activities under the Bamako Initiative. This initiative, launched in 1987 to revive, strengthen and extend basic health care services, has four key features: the rehabilitation and extension of basic health care delivery systems, particularly for maternal and child health; the provision of affordable drugs; appropriate financing for long-term sustainability, and community mobilization.

The degree to which family planning is integrated into reproductive health programmes seems to depend largely on the current state of health care services and facilities. Countries where most essential reproductive health services are already available to most people are directing activities to previously underserved groups in society, or are introducing more specific reproductive health services–such as the prevention and referral of infertility, and prevention and treatment of reproductive tract infections and sexually transmitted diseases. In most least- developed countries, full integration is expected to take more time. In many of these countries, governments have adopted an incremental approach that will gradually introduce reproductive health services within the primary health care system.

The ICPD Programme of Action calls on governments to decentralize the management of public health programmes to promote community participation in reproductive health care. Several governments have already taken steps in this direction.

Despite these encouraging trends, some countries still legally restrict the access of couples and individuals to reproductive health information and services. Some, for instance, reported having laws prohibiting the provision of family planning information and services.

The availability of reproductive health services

In most developing countries the full range of reproductive health services are not available to all eligible women and men. Of the different components of reproductive health information and services, the most widely available are family planning counselling, information and services, as well as facilities for prenatal care, safe delivery and post-natal care. In one quarter of the countries responding to the inquiry, availability of family planning information and services is still considered inadequate. Still unavailable in primary health care facilities in the large majority of developing countries are services for the prevention and treatment of infertility; services for treating the consequences of unsafe abortion; and treatment of reproductive tract infections and cancers of the reproductive system.

Reducing Maternal Mortality

In an effort to reduce high levels of maternal mortality, Uganda is developing a pioneering, cost-effective referral system aimed at improving the health system's response to pregnancy-related emergencies. The new system, Rural Extended Services and Care for Ultimate Emergency Relief (RESCUER), addresses transportation and communication problems that hindered referrals in the past. A radio communication network links traditional birth attendants (TBAs) in villages with health referral points. When emergencies arise, TBAs contact a doctor at the referral point and receive appropriate instructions. If necessary, a vehicle is dispatched to transport the woman for emergency care.

Several countries reported that most aspects of the reproductive health concept were available for middle and higher income groups in urban areas, were unavailable or inadequately available to most of the rural and urban poor. Only a handful of countries reported having all seven components of reproductive health programmes, as described in paragraph 7.6 of the ICPD Programme of Action, available to all women and men through their health system.

Focus on specific groups

The ICPD emphasized the needs of particular groups of society. Various initiatives are being undertaken to address the reproductive health needs of adolescents, the issue of women's participation in decision-making, and the role and responsibilities of men in the area of reproductive health.

Adolescents

To address adolescent sexual and reproductive health issues, the ICPD Programme of Action encourages governments to provide appropriate services and counselling. The questionnaire responses indicate that in many countries adolescents' needs and problems in the field of sexual and reproductive health are being taken much more seriously than before the ICPD. Nearly two thirds of the countries responding reported having undertaken initiatives to address adolescents' reproductive health and rights and to put their needs on the political agenda. These initiatives have been undertaken in some cases by governments, in others in cooperation with NGOs or solely by NGOs.

On the other hand, in more than one third of the responding countries, government or other programmes do not address adolescent reproductive health issues. There are a variety of reasons for this; religious and cultural factors are the most frequently cited.

Addressing Adolescents' Needs

Some countries have found innovative ways to address adolescent sexuality and reproductive health needs. The ICPD Programme of Action notes that health services have largely ignored the reproductive health needs of adolescents. In response, Uganda started a participatory process that led it to form the Programme for Enhancing Adolescent Reproductive Life (PEARL), which aims to enhance the reproductive health of Ugandan adolescents by providing appropriate counselling and services. To ensure sustainability, PEARL calls for young people and community leaders to take a leading role in implementation efforts.

Governments are taking various steps to address adolescents' special needs. Cambodia, for example, has issued guidelines instructing service providers not to discourage adolescents and unmarried clients from coming to service delivery points and to take special care of them. Ghana has established a National Steering Committee on Adolescent Reproductive Health to strengthen coordination and provide a forum for planning and executing activities in this area.

Where governments are reluctant to address adolescents' sexuality and reproductive health needs, non-governmental organizations often fill the gap. Many NGOs and other local or community-based organizations are uniquely positioned to work in this area. In India, for instance, several NGOs have established long-term health and education programmes for rural and urban adolescents. Ghana introduced family life education (FLE) programmes in schools during the early 1970s, and the Planned Parenthood Association of Ghana and the Young Women's Christian Association established FLE Clubs alongside Youth Counselling and Vocational Centres.

In Sudan, required courses on reproductive health and family planning have been added to the curricula of four schools of the Ahfad University for Women. In line with the ICPD Programme of Action (para. 7.48), many NGOs train peer groups in counselling techniques in order to guide adolescents in matters related to responsible sexual and reproductive behaviour.

Governments and NGOs often work hand-in-hand in addressing adolescent reproductive health issues. For example in Mexico, a pre-ICPD national meeting attended by government and NGO representatives issued the Declaration of Monterrey, which recognizes the needs and demands of adolescents. Activities undertaken since then have led to the establishment of 78 adolescent reproductive health care units in facilities around the country; they provide information and advice and promote reproductive health services and family planning. By the end of 1995, the adolescent care programme covered the entire country and each state had at least two units, one in an urban health centre and another in a general hospital.

A similar form of government-NGO cooperation exists in Morocco, where the Ministry of Youth and Sports and the Moroccan Family Planning Association developed an innovative programme to educate youth about reproductive and sexual health. In youth clubs in five regions, adolescents create their own songs, drama, and puppet shows on topics like family planning, sexually transmitted diseases, HIV/AIDS, communication, and family life and sex education; the best are performed at national festivals.

Women's participation

Women's participation in decision-making processes is a crucial aspect of introducing a reproductive health approach in any country. Information received indicates that the level of participation differs considerably from country to country.

Gender concerns are increasingly being taken into account in reproductive health programme designs and implementation. For example, Mexico has established a special unit within the Directorate General of Reproductive Health to advise on the inclusion of gender issues in its programme. Gender training has become a standard component of projects in an increasing number of developing countries. The use of female consultants for project formulation, implementation, monitoring and evaluation is also increasing markedly. In Costa Rica, women consultants and decision-makers actively participate in the formulation and implementation of more than half the current or planned reproductive health projects.

The health sector is notoriously vulnerable to economic and social crisis. Since most health workers are female, women's participation in health care, including reproductive health care, often suffers most in economic hard times. In Brazil, women have always been involved in planning and implementing reproductive health programmes, but in recent years overall difficulties in the health and government sector appear to have reduced this involvement somewhat.

Women and Decision Making

Having women in decision-making positions advances efforts to meet women's reproductive health needs. El Salvador, for instance, reports that women's health and well-being are taken more seriously since some women in the National Assembly started to speak out on related issues. Togo changed the structure of the Family Health Division in its Ministry of Health last year; women now occupy 8 of 17 decision-making positions.

Women are most visibly involved in planning and implementing reproductive health programmes through the rapidly growing number of NGOs dealing with reproductive health care. These NGOs are often headed by women, and most or all of their staff are women. As a result of the ICPD, governments are more inclined to collaborate with national and local NGOs and other grass-roots or community-based organizations.

The role of men

The ICPD Programme of Action urges governments to increase the participation of men in all aspects of reproductive health, and to encourage men to share responsibility in matters related to family planning, parenting, gender equality and the empowerment of women. Most countries responding to the inquiry indicate an increased awareness of the need to involve men in reproductive health programmes. Many reported having started programmes specifically directed at male involvement, some of them quite innovative.

Involving Men

In Côte d'Ivoire, male nurses are being trained to reduce the barriers keeping men from using health care facilities. The reproductive health programme is also producing information materials addressing male family heads. Similar programmes are being implemented in India and other countries. In the Philippines, male peer counsellors are being trained to convince married men to practise or support family planning; this approach was adopted after research found that many husbands prevent their wives from practising family planning. A number of other countries are taking a similar approach. The Philippines has also established the first reproductive health centre catering to the specific needs of men. In Sierra Leone, an NGO runs a similar male-only clinic.

In several countries plays have been developed to generate discussions among men on their responsibility in the use of family planning. A number of countries have officially approved vasectomy as a method of family planning. In Nepal, condom boxes have been placed in most health facilities, providing free and unhindered access. Indonesia intends to expand its counselling programme and develop new training materials to emphasize male participation in family planning.

The role of civil society

The ICPD Programme of Action calls for a broad and effective partnership between governments and the non-governmental sector in delivering reproductive health information and services. Governments are encouraged to promote much greater community participation in reproductive health care by decentralizing the management of public health programmes and collaborating with local non-governmental organizations and private health-care providers.

NGO involvement in the reproductive health field differs greatly from country to country. In some countries, NGOs were heavily involved before the ICPD; NGO involvement in others is still only marginal, but in general seems to be growing. The Family Planning Association of Iran, which had been inactive for several years, was reactivated after the ICPD.

In many developing countries, NGOs continue to provide a large volume of reproductive health services, information and education, thereby increasing both demand for and access to these services. However, some countries reported that worsening economic conditions had weakened NGOs' ability to provide services. In some countries, NGOs have not had the resources to reach large segments of society, particularly in rural areas. Some NGOs have had to shift their focus from low-income groups to middle-income groups.

More and more NGOs are participating in national committees or councils set up by several governments to coordinate national implementation of the ICPD Programme of Action. NGOs are also increasingly collaborating and networking among themselves to expand their influence in project formulation and execution. In Ethiopia, for example, 11 NGOs have established a Consortium of Non-Governmental Organizations in Family Planning.

Traditionally, NGOs have played an important role in providing information and services to segments of society not well-served by official programmes, such as the poor, adolescents, commercial sex workers, unmarried couples, and men. They have also addressed sensitive or controversial issues such as abortion, violence against women, and traditional practices that harm women. NGOs often pioneer innovative approaches to issues related to women's health, reproduction and family planning. The Togolese Family Welfare Association operates a model clinic to demonstrate the integrated approach to reproductive health and family planning services; it plans to establish four more such clinics.

The ICPD's emphasis on a comprehensive approach to reproductive health has also influenced the work of NGOs. Traditional family planning NGOs are increasingly including other reproductive health services in their clinics, and are training their staffs in the implications of this new concept of reproductive health.