Universal Reproductive Health: Fulfilling Cairo to Reach the MDGs
The UN Millennium Project has unambiguously established that reproductive health is a central and cost-effective strategy for meeting the MDGs.(3) Reproductive health is a human right, affirmed and reaffirmed as a development priority in international agreements since 1994, including at the ICPD and Beijing ten-year anniversary commemorations. Overwhelming support for the ICPD agenda, and recognition of the strong links between reproductive health and development, were reiterated in 2005 at several high-level meetings on the MDGs with ministers of health, finance and planning, as well as representatives from development banks, civil society and UN agencies.(4)
Most reproductive health problems are preventable through proven interventions. Reproductive health and rights are an integral aspect of poverty reduction, gender equality and women's empowerment, and of efforts to lower maternal and infant mortality and combat HIV/AIDS. Better reproductive health improves families' quality of life. The ability of individuals and couples to choose family size and space births, and a trend towards smaller families overall, can help low-income countries escape the "demographic poverty trap".(5)
Reproductive health programmes can provide convenient access-"one-stop shopping"-to a constellation of services for the poor. Reproductive health services include family planning, prevention and management of sexually transmitted infections, including HIV, and maternal and child health care.(6) They can also cover nutritional education, vitamin supplementation, immunization and malaria prevention. Ideally, as some projects have demonstrated, reproductive health services can also provide information and referrals to other programmes, such as those that address female literacy, gender-based violence, legal rights, access to micro-credit, and training in marketable skills. Linking reproductive health programmes to additional opportunities for women and young people can help them overcome other constraints that compromise reproductive choices and fuel the AIDS epidemic.
37 | GLOBAL CAMPAIGN ON YOUNG PEOPLE AND THE MDGS
In recognition of the role young people play in achieving the Millennium Development Goals (MDGs), UNFPA has taken the lead in launching the Faces of Young People and the MDGs campaign in collaboration with other UN agencies, the World Bank and regional economic commissions. The effort aims to raise awareness and garner policy attention. Its message is simple: Invest in young people.
In 2005, the initiative included a photographic exhibit at the United Nations headquarters in New York that documents the lives of youth from Africa, the Arab States, Asia, Eastern Europe and Latin America and the Caribbean. Each photographic series tells a tale of a young person's life that relates to the MDGs. Other activities include the development of strategic guidance for policymakers, brochures, a website and a planned fundraising concert in 2006 with musical celebrities and young artists focused on young people, AIDS and poverty.
LINKING REPRODUCTIVE HEALTH AND HIV/AIDS PROGRAMMES. Addressing HIV is a component of reproductive health. However, as resources to combat the epidemic have poured in, parallel services have evolved, with their own personnel, administrative structures and funding. The continuing influx of resources presents an opportunity to gain efficiencies, advance the MDG health goals, and make the ICPD vision of universal reproductive health care a reality for the millions of people living in poverty whose quality of life and very survival depend on them.
If these programmes lead to a proliferation of specialized clinics, however, funds earmarked for HIV/AIDS have the potential to pull staff and resources away from other priority health needs of the poor- and from other MDG health goals.(7) This could undercut efforts to strengthen and streamline health systems. It would also be a grave disservice to users. The poor typically receive only piecemeal information and services- even though they may have pressing concerns regarding both HIV and other reproductive health issues. Moreover, sexually transmitted HIV and many other reproductive health problems are rooted in the same attitudes and behaviours.
Linking and integrating HIV prevention and care with general reproductive health services can strengthen both. Both types of services face the same health system challenges-shortages of trained staff, essential supplies and equipment, adequate facilities, and management skills. Both face similar obstacles in building demand for available services and in overcoming the stigmatization that prevents clients from using them, an area in which the reproductive health field has considerable experience. They both require similar supplies and the same types of health provider skills. In some regions, integration is a moral obligation: In sub-Saharan Africa, where the AIDS epidemic is widespread, 63 per cent of women have an unmet need for effective contraception(8) and, consequently, a high proportion of unintended pregnancies. Many women do not know their HIV status and risk passing the virus to their children. Under these circumstances, access to even a minimal integrated package of family planning, HIV, and maternal health services can enable women to protect themselves from both unintended pregnancies and HIV and also prevent HIV transmission to their children.
Integrating a minimum package of reproductive health and HIV/AIDS services can be cost-effective. For example, one study found that integrating services for family planning and sexually transmitted infections into primary health care cost 31 per cent less than if separate services were provided, with savings in staff costs, supplies and administrative overhead.(9) Other pilot studies undertaken by the International Planned Parenthood Federation (IPPF) and UNFPA showed considerable savings and increased demand for services when voluntary HIV testing and counselling was integrated into existing sexual and reproductive health services.(10)
The international community is taking note: A number of agreements and UN resolutions have called for an essential and comprehensive package of reproductive health and HIV/AIDS services to be made available to all service users.(11) This recommendation was echoed by the UN Millennium Project Task Force on Combating AIDS.(12) Providing an essential integrated package is both equitable and ethical. It is also a strategic way to ensure that health systems are strengthened rather than weakened by fragmented approaches and competing priorities.
STRENGTHENING HEALTH SYSTEMS. Experts agree that achieving the three MDGs related to health will depend on whether investments can shore up health systems and extend their reach to underserved groups, especially in rural areas and urban slums.(13) Both the ICPD and the UN Millennium Project call for an approach that focuses on prevention and primary health care-the first point of contact for people living in poor communities.
Most countries have undertaken reforms intended to improve the quality, efficiency and equity of their health care systems. But the result, many experts conclude, is less equity in access and more expensive health care for the poor.(14) In various countries, macroeconomic factors, such as debt servicing and spending caps on health care, have transferred many health costs to families. Subsidies and user fee exemptions are not always well targeted and sometimes benefit higher-income groups rather than the poorest people who need them most.(15)
The cost of health care continues to be a significant barrier to service access and use. For example, country studies have found that user fees introduced by health sector reforms cause steep drops in the use of maternal health services.(16) The intended beneficiaries of fee exemptions are not necessarily aware of them, nor are the exemptions consistently applied. Some health systems are so underfunded that underthe- table payments for services are common, and clients are obliged to purchase their own basic medical supplies. The UN Millennium Project has called for the elimination of user fees for basic health services as a "quick win"(17) that can diminish health inequities related to poverty and gender discrimination.
Despite the challenges, sector-wide health reforms provide excellent opportunities for setting priorities and addressing bottlenecks in the delivery of quality services. Investing more in hospitals and less on prevention has left basic health care out of reach and out of touch with the urgent needs of the poorest of the poor. In sub-Saharan Africa and Asia, 75 per cent of the poor live in rural areas.(18) Well-functioning preventive services could help ward off millions of cases of HIV, infant and maternal deaths, and fatalities from malaria and other maladies unheard of in industrialized countries.
The shortage of skilled professionals is a paramount concern. In African countries, a ratio of one doctor for every 10,000 people is not uncommon. This compares to 1 doctor per 500 people in the United States.(19) Reforming laws and policies to devolve authority to midwives and nurses wherever medically safe and feasible is one solution, as successful efforts to lower maternal mortality have proven.(20) The UN Millennium Project has called for immediate training of community health workers so that they can make essential information and services available at local levels.(21)
Stemming the "brain drain" of qualified medical personnel seeking better salaries and working conditions abroad is another priority. This will need to be a collaborative undertaking by governments of the North and South, with attention paid to the rights and working conditions of health workers.(22) Researchers estimate that in 1999 as many midwives emigrated from Ghana as were trained in that country that same year.(23) Similar losses are occurring throughout the developing world. Only about half of developing countries have midwifery training centres, though this is a health sector priority for meeting the MDGs.(24) Sub-Saharan Africa will need an estimated one million more health workers in order to reach the health-related MDGs.(25) Filling this gap can be achieved by providing better incentives, training and recruitment, including of those who left the health field to work in other occupations in their own countries.(26) Skilled managers are also urgently needed.(27)
TRANSFORMING AND ENGENDERING HEALTH SYSTEMS. Quality of care remains one of the key challenges to improving health systems and achieving the MDGs. Quality of care goes beyond meeting medical and scientific standards, offering safe and continuous supplies of essential medicines and other commodities, and practising proper procedures. It also encompasses the personal interactions that take place when a person visits a health centre. It thus requires transformations in the attitudes and communication skills of health providers and managers with particular attention to ensuring non-discriminatory, gender and culturallysensitive care. All of these dimensions of care suffer when health services are underfunded or overwhelmed. Health providers can be valuable assets to their communities, but often lack the backup support to provide the best possible care for their clients. Weak management, ineffectual policies and lack of essential medical supplies and equipment add to the challenges.
Poor people often report feeling mistreated or disrespected by health providers.(28) As a result, many women, men and adolescents turn instead to trusted members of the community. These traditional birth attendants and healers, however, lack the medical training to resolve serious health problems. Integrating gender and culturally sensitive curricula in healthprovider training institutions, especially in reproductive health, HIV/AIDS and adolescent health, is a medium-term investment with long-term returns. It is central to sustained improvements in quality of care and can maximize the efficiency and efficacy of health sector investments.
As the UN Millennium Project Task Force on Maternal and Child Health emphasizes, health systems are an integral part of the social fabric. Their success relies on the trust of the communities they serve. This trust, in turn, can be built on a platform of rights-based, participatory, gender-responsive and youth-friendly approaches that encourage ongoing dialogue between clients and health managers. Human rights, and the duties implied by them, can serve as guideposts for health system performance, and can help governments and managers address the factors hampering progress towards the MDG health goals. For instance, the primacy of a woman's right to life carries with it a legal obligation for health systems to provide skilled attendance during delivery and prompt emergency obstetric care 24 hours a day.(29) The fundamental rights to control one's own fertility and to protect oneself from HIV must be guiding principles for any policy and health provider. Discrimination based on gender, ethnicity, age or other biases may have severe and irreversible consequences for clients.