C H A P T E R   3
Reproductive Health And Reproductive Rights

Policy Change since the ICPD
Policy change is essential to the ICPD goal of universal access to reproductive health care, and more than 40 countries have taken action in this area since the ICPD. Some have developed comprehensive national reproductive health policies, while others have dealt only with specific aspects. Response to a wide range of interests and a multisectoral approach have been the cornerstones of successful policy-making.

India has replaced a decades-old policy of target-based family planning with a client-centred approach to individuals’ reproductive health needs, providing a range of services including an expanded choice of contraceptive methods. This policy change started before the ICPD and was the result of a sustained effort by women’s health advocates and others calling for change.

In Bangladesh, a government/donor/NGO consortium developed the 1997 Health and Population Sector Strategy, which affirms the principles of the ICPD. Zambia also involved local health districts, NGOs, donor agencies and private institutions in formulating its new national reproductive health policy. Zambia’s extensive needs assessment process addressed gender issues, including male involvement, as well as the allocation of resources for its implementation. In South Africa, NGOs provided key support to provincial governments in the development of a women’s health policy.

Brazil developed a comprehensive women’s health policy a decade before the ICPD, but progress to integrate reproductive health into the Unified Health System accelerated after Cairo. In 1997, the Congress passed a National Family Planning Law that approved all temporary contraceptive methods and recognized voluntary sterilization as a standard procedure.

In China, a UNFPA-supported programme is being introduced in 32 counties spread throughout the country, using a clientcentred approach as recommended by the ICPD. If it is successful, it will be expanded to more parts of the country.22

In addition to broad national policies, countries such as Ghana and Nepal have developed operational policies to guide implementation of reproductive health at the service delivery level. Many countries are lifting regulations and policies that limit access to family planning services, for example, spousal authorization, marital status and age limits. By 1997, however, 14 countries still required spousal authorization for women to receive contraceptive services, and 60 more required spousal authorization for permanent methods.23

Less progress has been made in reorienting polices to address gender issues. Some policies recognize the need to enhance women’s status, but few specifically address gender and the power relations that affect reproductive decisions.

FIGURE 7
Percentage of Sexually Active,
Never- Married Young Women, 15-19,
Using Family Planning, Selected Countries

Health Sector Reform and Decentralization
Reproductive health is often being addressed at the same time as reforms in the whole health sector, and while many countries are decentralizing authority for health services from central ministries to local governments. As part of health-sector reform, most countries are defining priority areas for investment, and making hard choices about allocation of scarce human, financial and institutional resources.

Health-sector reform and decentralization do not guarantee that reproductive health will be included — sometimes the opposite occurs.24 But the process is expected generally to be more cost-effective and result in greater consumer satisfaction, which in turn is likely to lead to more effective use of information and services.

Countries such as India, Bangladesh, Mexico, the Philippines, South Africa and Zambia that have adopted an essential services package approach as part of their health sector reform have generally included reproductive health. For example, Bangladesh’s essential services package includes: maternal health (antenatal, delivery and postnatal care, menstrual regulation and post-abortion complication care); adolescent health; family planning; management and prevention/control of reproductive tract infections, STDs and HIV/AIDS; and child health.

Decentralization has often meant giving more responsibility to local authorities without providing adequate resources.25 Some local governments have started charging even for basic services, which has meant that the poor, especially women and children, often go without health care. It is important that health-sector reform and decentralization should not neglect the ICPD commitment to better reproductive health care.

Integrating and Broadening Reproductive Health Programmes
Most countries are at a critical point as they seek to establish integrated, comprehensive reproductive health programmes. It would be counterproductive to raise the expectations of potential clients without providing the services to meet them, but there are problems regarding both the process and resources to implement it, and there are few models to follow.

Many countries are testing ways of integrating reproductive health services, including Bangladesh, Brazil, Cambodia, Egypt, Ghana, India, Jamaica, Mexico, Peru, the Philippines, Senegal, South Africa, Thailand, Tunisia, Uganda, Viet Nam and Zambia. The integration of family planning and maternal and child health under a common institutional umbrella has been the most common change: Egypt, for example, has centralized reproductive health services under a newly established Ministry of Health and Population. Some countries have linked the components of reproductive health through referrals, particularly among family planning, maternal and child health and STD/HIV/AIDS services.

Many countries in sub-Saharan Africa have begun to integrate STD/HIV/AIDS services into their clinic-based maternal and child health and family planning services, as the lowest-cost way to reach the highest possible proportion of sexually active women and their partners. However, analysis of Botswana, Ghana, Kenya, Zambia and Zimbabwe shortly after service integration found that virtually no family planning clients underwent any diagnosis or treatment for STD/HIV/AIDS. On the positive side the analysis showed that it would be feasible at least to provide information about symptoms, modes of transmission and protective behaviour.26

Integrating institutional and administrative structures is a particular challenge. In many countries, particularly in Asia, family planning and health have been managed separately for years, at considerable cost, but changes since the ICPD have been nominal, because of bureaucratic inertia and differences in programming, training and evaluation regimes. Countries have made more progress in integration at the service delivery level. Many already had integrated family planning and maternal and child health services and since the ICPD have integrated them further, both with each other and with STD and HIV/AIDS prevention, screening and treatment. For example, services might be offered at the same place by different providers, or by the same personnel but on different days.

Some countries such as Bangladesh provide their essential services package at one location. Others, as in India, refer clients to delivery points where they can find higher levels of service, for example, STD treatment or emergency obstetric care.

Additional training can broaden the scope of services at existing service delivery points without formal integration: countries such as Mozambique and Burkina Faso have added the prevention and management of STDs including HIV/AIDS to family planning services. Many other African countries are linking family planning and STD/HIV/ AIDS programmes by a system of mutual referrals.

NGO Provision of Reproductive Health Services
In some countries, NGOs, most notably the International Planned Parenthood-affiliated family planning associations and women’s organizations, have more flexibility than government services in redesigning programmes and training staff. NGOs can work more easily than government organizations in especially sensitive areas such as adolescent issues and gender-based violence. In countries such as Bangladesh, Colombia, Mexico, Peru and Jamaica, NGOs have taken the lead in expanding reproductive health services and particularly in providing family planning in the context of reproductive health, and in providing services to men and adolescents.

In Zambia, NGOs fully support the health reform process, and the government recognizes NGOs as important partners within the health sector. NGOs are in a position to push the reproductive health agenda forward, to be more innovative and creative, to take risks, and to test models for integrated service delivery that the public sector can duplicate on a larger scale. Donors and technical assistance organizations that feel restricted by public-sector requirements can promote their ideas to NGOs.27

Sri Lanka has a tradition of community-based organizations involved in development and NGOs are linked through an NGO secretariat. The four major NGOs in family planning, including the Family Planning Association of Sri Lanka, are seen as pioneers and continue to work in family planning, reproductive health education, advocacy and service delivery. UNFPA is funding them to serve as umbrella organizations for smaller community-based organizations that provide education and information on family planning. UNFPA is also funding four other NGOs to include linking reproductive health to other development issues and reaching new target groups with information.28

NGO services can be less cost-effective than those of government programmes. The cost per person served is sometimes higher because of overhead, capacity-development costs, diseconomies of scale and small catchment areas. Still, since the ICPD, NGOs have played an increasingly important role in implementing the Programme of Action. In a recent eight-country study on implementing the ICPD Programme of Action, NGOs were consistently cited as being more successful than governments in providing reproductive health services. Respondents in Bangladesh, India, Nepal, Jordan, Ghana, Senegal, Jamaica and Peru noted that the streamlined bureaucracies of NGOs give them the flexibility to expand services.29

NGOs have taken the lead to train providers to offer client-centred services. For example, Jamaica’s family planning association, FAMPLAN, recently participated in a project to integrate family planning and STD services. The project, which included training to help providers break down their biases against STD clients, succeeded in increasing condom use without lengthening the time providers spent with clients.

NGOs have also been credited as being close to communities. In Peru, community-level NGOs working with women have a better conception than government institutions of women’s broad reproductive health needs. These NGOs work closely with health personnel to ensure that women are referred to appropriate organizations for help.

NGOs do not provide services on the same scale as public-sector agencies in most countries; in fact, their size is probably a virtue in allowing NGOs the flexibility to change services. In Senegal, large NGOs provide a small proportion of family planning and reproductive health services, but respondents said that they set standards for quality, and contribute technical expertise to the programme. Smaller NGOs are also a significant factor in communities, particularly in working on AIDS and FGM. Community women’s organizations carry out education in reproductive health, a task for which public-sector health workers often lack time.

For now, however, NGOs do not have the resources needed to offer all components of reproductive health. Increasing resources channelled to NGOs would be a good investment in most countries. However, if NGOs were expected to grow to serve the same number of clients and the same geographic locations as public-sector agencies, they might lose their ability to provide flexible and innovative programming.

Increasing Access to Quality Services
The quality of reproductive health care is critical in determining whether the service meets clients’ expectations, and thus whether they use it. The components of quality of care are well established. Clients need a choice of contraceptive methods, accurate and complete information, technically competent care, good interaction with providers, continuity of care, and a constellation of related services.30 These elements apply equally to other components of reproductive health care.

If they are given a choice, clients will use facilities and providers that offer the best care as they perceive it. Studies around the world 31 suggest that clients want:

• Respect, friendliness, courtesy, confidentiality and privacy.

• Understanding on the part of providers of each clients’ situation and needs.

• Complete and accurate information. Clients want all the facts, particularly about side-effects of contraceptives.

• Technical competence. Clients judge the cleanliness of clinics, the thoroughness of examinations and the types of medication they are given, and ultimately whether their needs are met or their problems resolved.

• Access and continuity of care and supplies. Clients want convenient, prompt and reliable services and supplies. Access also means that services are reliable, affordable and without barriers.

• Fairness. Clients want providers to offer information and services to everyone regardless of class or ethnicity.

• Results. Clients are frustrated when they are told to wait or come back on a different day, or when their complaints are dismissed as unimportant.

Studies in Jamaica, Kenya and Malawi have shown that clients generally have a less positive view than providers about issues such as waiting time, time spent in consultation and the information given to clients.32 Research in Morocco revealed communication problems because of hierarchical modes of communication and a lack of female providers. Women said they wanted more information on contraceptive methods and to be offered more than just family planning.33 In Albania, some service delivery sites miss the opportunity to provide women with family planning. In one study, a woman said, "The staff in our area don’t serve women; they say, ‘We are only here for children’s vaccinations. ’ So we don’t know where to get this service [family planning]."34

Quality matters to clients. In Bolivia, women in one study said they would travel further to clinics that provide better quality. One woman said, "I prefer to go there [to the family planning clinic] even though it is far away. They talk to me; they explain things. Even though I have to pay, it’s okay."35 In Tanzania, another study found the same thing: quality of care affected clients’ choice of service site.36 In Bangladesh, one woman noted, "I sat down in a chair inside [the provider’s] office, and she asked me . . . my name [and] many things about myself — how many children I had, how old my youngest child was, and so on…. She told me that if I had any serious problems in the meantime, I should come and see her again. . . . [She] behaved nicely with me. There were no difficulties."37

Research and evaluation can indicate what is needed to make improvements. The Population Council’s Situation Analysis studies in sub-Saharan Africa have shown how underutilization of resources diminishes quality and choice of clients.38 Elsewhere quality suffers from shortages of water, electricity, equipment or supplies, particularly in rural areas. In Pakistan, for example, only around 10 per cent of the population have access to family planning services.39 In Burkina Faso and Côte d’Ivoire, family planning is not available in many health facilities.

The Situation Analysis studies in five sub-Saharan African countries revealed several missed opportunities for quality care 40 :

• New clients seeking to space pregnancies were not offered all the spacing methods available at the clinic, restricting clients’ ability to choose the most appropriate or desirable method;

• Providers generally do not make use of information materials which could improve clients’ understanding and assist them in making more fully informed decisions;

• Most providers see three or fewer family planning clients per day, suggesting that they could increase the length of client visits, improve the quality of information given, and expand the reproductive health service offered;

• Providers commonly make use of equipment such as blood pressure machines and ultrasound when available; however, they often do not wash their hands during pelvic exams, even when clean water and gloves are in the exam room, putting clients at risk of infection;

• Providers frequently do not inquire about the number and frequency of partners or whether the partner is included in the decision to seek contraception, and are thus unable to assess or recommend appropriate methods;

• The ability of a given method to protect against sexually transmitted infections, and in particular the dual-protection benefit of condoms, is rarely discussed.

Improving quality of care requires a focus on the process of service delivery, including communication and information sharing; establishing minimal standards for procedures and examinations; and ensuring that clients receive the service appropriate to their needs. Some countries, such as Sri Lanka, have made considerable progress, beginning before the ICPD, to provide high-quality, client-centred integrated services.

Studies show that improvements in quality can be made at a reasonable cost; without them, people will not come to or continue using the service.41 Using various tools,42 family planning providers and supervisors worldwide are being trained to improve quality of care, thereby creating commitment to solve problems as they arise.

Among the team-based approaches to making improvements, one of the most widely used tools is COPE (Client-Oriented and Provider Efficient), developed by the NGO AVSC International. COPE uses a set of simple self-assessment tools developed for workers in family planning clinics and for their supervisors. Staff members analyse client flow through the clinic, conduct interviews with clients, and complete a questionnaire on every aspect of service delivery. COPE has been used in over 35 countries. An evaluation of COPE at 11 clinics in Africa found that teams had solved 64 of 109 problems identified through the COPE process.43

Training in quality of care creates commitment to solve problems as they arise. Principles include treating the client well, providing the client’s preferred method, individualizing care, aiming for dynamic interaction, avoiding information overload and using and providing memory aids.44 Some countries, such as India, Nepal, Egypt, Indonesia and Jordan, are instituting quality assurance procedures related to reproductive health services. Egypt’s Gold Star programme is one of the largest quality assurance programmes in the world. It is designed not only to improve the quality of services, but also to create the expectation of better services. About half of all Ministry of Health and Population units reached Gold Star status by the end of 1998. 45

In many countries, public-sector providers also work part-time as private providers. Many clients prefer private-sector providers because their clinics are more convenient and less crowded, and because they believe that private-sector providers are more competent; but this perception may be more myth than reality. Mechanisms to improve quality in the private sector have included continuing medical education on reproductive health topics, setting up quality assurance mechanisms, and strengthening linkages between public- and private-sector providers.

Communication and Education Well-designed communication strengthens good programmes, but information without services only produces dissatisfaction. Raising awareness about reproductive health is not the same as increasing the use of the services. In many countries, information campaigns are developed without the involvement of local providers, communities and representatives from the target groups. Messages are usually designed for adult women and ignore key target groups like men, adolescents, newlyweds and opinion leaders.

In many countries, a lack of trained staff has slowed the expansion of reproductive health services.

Communication strategies are not always well linked with services: a campaign may raise awareness of contraception but may not say where to find it; or motivate potential clients before the services are available. Information, education and communication (IEC) strategies about reproductive health must go well beyond sensitization to provide information about how to avoid reproductive tract infections, unwanted pregnancies and obstetrical complications, for example. Hot lines and radio call-in shows are good for providing accurate and confidential information. Combining several media also reinforces messages.46

Information and education strategies about reproductive health and population and development issues must advance beyond awareness raising. Policy makers and programme beneficiaries alike need information that will help them to make decisions and act on them. They need information about, for example, the risks of STDs, the danger signs of a difficult pregnancy, and available methods of contraception. They also need information on who can provide assistance, where services are to be found and what kinds of treatment they can expect and have a right to demand.

This information must reach everyone who needs it. The mass media are useful for giving practical information,47 but traditional and local communication channels are also needed. So are non-governmental organizations and community groups. Countries wishing to improve IEC do not have to start from scratch: in many countries there is a wealth of material, especially for family planning, maternal and child health, STDs/AIDS and sexuality, that could be adapted to reproductive health. For example, the Philippines strategy and guide-book for family planning IEC is excellent and could be easily modified to fit reproductive health.

Developing Human Resources
In many countries, particularly in sub-Saharan Africa, but also in Nepal, India and Pakistan, and in parts of many others, especially rural areas, lack of staff (particularly female providers) has slowed the expansion of reproductive health services. In India and other countries, staff turnover is high and many positions remain vacant for long periods. In many countries, staff, particularly physicians, do not want to be posted in rural health facilities.

Situation Analysis findings show that staff can be trained to provide not only better quality family planning services, but other services to meet clients’ reproductive and sexual health needs as well. Providers like the reproductive health approach, but question how many tasks an individual worker can be trained to carry out, particularly lower-level workers in health posts. In India, for example, an auxiliary nurse-midwife is already expected to do 40 tasks. How much more can she do?

Countries recognize that training is crucial to the success of the reproductive health approach. Peru, Mexico, Colombia and Jamaica have developed curricula for integrated training. In Bangladesh, a programme is being developed to train providers in all aspects of reproductive health. Romania has placed a priority on staff being trained in family planning in order to integrate it into primary health care. In general, however, training has not kept pace with the expansion of services.

In most countries, training curricula for both initial and in-service training are slowly being adapted to the client-centred, needs-based reproductive health approach, though sexuality, reproductive rights and the effects of gender relations on client-provider interactions are often missing or diluted. In all countries, it will take time to retrain all service providers, in addition to training new ones.

In training, as elsewhere, human resources are in short supply. There is a shortage of experts to redesign pre-service and in-service curricula and train the trainers. Decentralization of programme activities has shown how few staff are available to do training at the local level.

Training in reproductive health should begin in medical, nursing and midwifery courses. Pre-service training is generally less disruptive to the service delivery system, less expensive and more sustainable than in-service training,48 but it calls for revising the curricula of medical schools and training institutions. Continued supervision and follow-up to training need to be strengthened in most countries.

To make the most of their training, providers need equipment and supplies, rewards, evaluation, opportunities to practice new skills, and better recruitment and job assignments.49

Monitoring and Evaluation
In order to maintain the gains (and highlight shortcomings) in policies and programmes that have emanated from the ICPD, the Programme of Action called for careful monitoring of implementation of the reproductive health and rights agenda. Ideally, programmes should have information systems that are simple and clear to use at the service delivery level; only the most essential data are collected; appropriate technology is applied; and findings are of immediate use at the service delivery level, but also at higher levels of the health-care system. Progress has been made in this area in many countries. For example, Iran as well as the state of Rajasthan in India offer examples of efficient national information system designs.

International organizations, including UNFPA, have taken the lead in developing reproductive health indicators to help countries revise their management information systems to monitor progress in implementing reproductive health and rights programmes. Most progress has been made in countries in which all stakeholders that can make use of the information (e.g., community representatives, service providers, programme managers, and researchers) have participated in designing the information systems.

For example, the Latin American and Caribbean Health Network — in collaboration with some governments in the region — has identified a set of thematic issues to monitor in each country they work in, including: 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 have been identified for each of these issues that will be used to assess the reproductive health situation in each country.

NGOs, particularly women’s groups, are also monitoring the implementation of the ICPD Programme of Action in order to hold governments accountable for the progress made. For example, the Latin American and Caribbean Women’s Health Network is working in Brazil, Chile, Colombia, Nicaragua and Peru to monitor implementation. They are monitoring six issues: improving girls status; male responsibility; participation of the women’s health movement in decision-making processes; quality of reproductive health services; adolescents’ access to sexual education and reproductive health services; and unsafe abortion.

Their monitoring has thus far revealed: great difficulties in including civil society and specifically women in the implementation process (in three of the five countries); an absence of data disaggregated by sex, age and geographical region; incomplete incorporation in all of the five countries of sexual and reproductive rights in laws and health services; continued poor quality of reproductive health services; no implementation of national sexual education programmes (in two of the five countries); and low impact of service and policy changes since Cairo on maternal mortality rates, with unsafe abortion still a principal cause of maternal death.50

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