Highlights of 2011

Publication date: 2012

Highlights of 2011 Highlights of 2011 Department of Reproductive Health and Research including UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction Vision RHR’s vision is the attainment by all peoples of the highest possible level of sexual and reproductive health. It strives for a world where all women’s and men’s rights to enjoy sexual and reproductive health are promoted and protected, and all women and men, including adolescents and those who are underserved and marginalized, have access to sexual and reproductive health information and services. Universal access to sexual and reproductive health in the context of the primary health care approach 2 Promoting family planning 4 Improving maternal and perinatal health 6 Preventing unsafe abortion 8 Controlling sexually transmitted and reproductive tract infections 9 Gender, reproductive rights, sexual health and adolescence 12 Research capacity strengthening and programme development 14 Knowledge exchange and transfer 16 Policy and programmatic issues 17 Monitoring and evaluation 18 Health-systems research 19 Implementing Best Practices Initiative 20 Reproductive health essential medicines 21 CROSS-CUTTING AREAS WITHIN INTER-TEAM WORKING GROUPS 22 Knowledge Synthesis and Exchange & Implementation Research 23 Innovations to improve sexual and reproductive health 24 Linkages between sexual and reproductive health and HIV/AIDS interventions 25 Men and sexual and reproductive health 27 Biostatistics and data management 28 Advocacy for sexual and reproductive health and for HRP/RHR 29 Contents Highlights 2011 1 Highlights of 2011 Through its work in research, research capacity strengthening and programme development, WHO’s Department of Reproductive Health and Research (RHR), including the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), contributes to the Millennium Development Goals (MDGs), in particular the targets for achieving universal access to reproductive health by 2015. Achievements by HRP include innovations for saving women’s and children’s lives, in particular in the context of the UN Secretary-General’s Global Strategy for Women’s and Children’s Health, and the ICPD Programme of Action. Countries are supported to improve quality of sexual and reproductive health care through the generation, synthesis, adaptation and adoption of evidence-based information and technical capacity strengthening. Following are selected highlights of activities undertaken in 2011. Highlights 20112 Universal access to sexual and reproductive health in the context of the primary health care approach Vision Universal access to sexual and reproductive health has become a reality for all individuals and needs are met, in particular those of the most vulnerable. Key objectives The work of the Department focusing specifically on “universal access” within a “primary health care” approach aims to promote and support acceleration of progress towards achieving universal access to reproductive health, the second target of Millennium Development Goal 5 (MDG 5B), including through primary health care. Major achievements t� A high-level annual event featuring policy and programmatic innovations that have succeeded in expanding access to reproductive health and family planning was initiated in collaboration with the Aspen Institute. This was the inaugural event for Member States on the Geneva Policy Dialogue Series on Reproductive Health, an annual series to be hosted at the time of the World Health Assembly each year from 2011 to 2014. t� Case-studies on policy, financing, and service delivery innovations to improve reproductive health and health-care outcomes were carried out and published in the form of policy briefs. t� A study exploring effective strategies to reduce maternal mortality was submitted and accepted as a peer-reviewed journal article. The findings from six countries indicate that strategies that have worked in reducing maternal deaths are: – introducing innovative financing measures; – strengthening pre-service education and in-service training for health-care providers; – enhancing obstetric care including infrastructure, equipment and quality of services; – investments in the broader determinants of maternal mortality, particularly family planning, education, and women’s empowerment. Highlights 2011 3 t� Implementation of the WHO Global reproductive health strategy was assessed largely through a survey of countries and a progress report was submitted for review by the Executive Board and the World Health Assembly. t� The country survey on implementation of the WHO Global reproductive health strategy elicited comprehensive information on progress in 58 countries. The results, among others, suggest that increasingly interventions developed by the Department to reduce maternal mortality and improve reproductive health were being put into practice, although this varied across different interventions. For example, in 95% of the countries that responded, magnesium sulfate is registered for use in reducing deaths from eclampsia; and in more than 95% countries, reproductive health essential medicines were on the national essential medicines list. Approximately two thirds included emergency contraception among contraceptive methods provided through public health programmes; while about three quarters reported screening for early detection of cervical cancer. t� At the same time, countries identified barriers to the improvement of reproductive health services. These barriers include: political instability or crisis; poor quality of care; poor coordination of efforts; insufficient human resources and poorly motivated staff; lack of funds and commodities; poverty; low levels of community engagement; and sociocultural factors. – Implication of research findings for policy and programmes: systematic identification of barriers to access to reproductive health care should inform development of policy and strengthening of programmes that address or take into account the relevant barriers. A review of the evidence on health promotion interventions in reproductive health and family planning was carried out to provide input in development of a package of evidence-based, outcome-oriented health promotion actions in the context of primary health care, by the WHO Health Promotion Department. Highlights 20114 Promoting family planning Vision Substantial reduction in the unmet need for contraception and improved access to infertility prevention and care services have been achieved, allowing people to realize their fertility goals. Key objectives In 2011, the Promoting Family Planning area of work was geared towards improving the quality of and access to family planning services, including contraception and infertility services. It focused on disseminating updated evidence-based materials, developing tools and furthering research to address the unmet need for family planning products and services. Social science and biomedical research have provided information for improving the quality of services and improving access to and use of contraceptive technologies. Work in infertility continued, with further recommendations for research and development. Major achievements t� The Medical eligibility criteria for family planning, 4th edition (MEC) was awarded first prize in the Obstetrics and Gynaecology category of the 2011 British Medical Association Book Awards. More translations of the MEC book and MEC Wheel, and electronic and mobile phone versions were also developed and disseminated to meet a high demand from Member States. t� Family planning – a global handbook for providers was updated in 2011. Various new formats for media, such as those for the Kindle and the mobile Android phone developed by the Knowledge for Health project, are being disseminated to increase access to and use of the information in this guideline at the country level. t� RHR supported a master training of trainers in family planning and reproductive health for Iraq’s Ministry of Health, and included members of Jordan’s Ministry of Health. The workshop included updates on contraceptive technology, a session on WHO guidelines and tools, clinical skills demonstrations and sessions on counselling and communication skills. t� In late 2011, RHR issued a technical statement in response to the Heffron et al. study on the safety of using hormonal contraceptives for women at risk of HIV infection. This statement was used by ministries of health to respond to concerns regarding the safety of the use of hormonal contraception with respect to HIV acquisition. t� The fifth edition of the WHO laboratory manual for the examination and processing of human semen (2010) was translated into five languages in 2011; additional translations are underway. This was the most frequently downloaded document from the RHR web site in 2011, illustrating the worldwide demand for WHO’s leadership in this area. Highlights 2011 5 t� Infertility due to unsafe abortion or maternal sepsis was identified as the fifth ranked disability, based on prevalence, in low- and middle-income countries, for ages 0–59 years. This result was obtained following statistical analysis of DHS data and fertility surveys and presented in the first WHO and World Bank Report on Disability (2011). t� In collaboration with partners, a “ToolBox for ART data collection” has been developed. Monitoring and surveillance of assisted reproductive technology (ART) infertility services will facilitate comparison over time and will allow an examination of the impact of national and regional regulations, or the lack of any regulations, on treatment outcomes. Highlights 20116 Improving maternal and perinatal health Vision Universal access for all women and newborns to appropriate prepregnancy, antenatal, childbirth and postpartum care has been achieved. Key objectives The overall objective of the work undertaken by RHR in the area of Maternal and Perinatal Health is to contribute to the United Nations Secretary-General’s Global Strategy for Women’s and Children’s Health by developing, assessing and implementing effective interventions and by addressing barriers to improving access to quality maternal and perinatal health care, particularly in middle- and low-resource settings. Major achievements t� RHR continued to strengthen the global collaborative research and implementation efforts of institutions and individuals working to reduce maternal and newborn deaths, and thus continuing to position HRP at centre stage within the international scientific and public health communities in this area. t� Publication in The Lancet of the results of the “Active management of third stage of labour trial”, which concluded that controlled cord traction can be omitted with little increase in the risk of postpartum haemorrhage in settings where skilled birth attendants are not available. – Implication of research findings for policy and programmes: in settings where skilled birth attendants are not available but injection capability exists, oxytocin intramuscular injection after birth to be incorporated into programme guidance. t� Research on an innovative device (Odon device) to deliver the fetus when complications occur in the second stage of labour has been consolidated and was among the winners of a global call for innovations. t� Two new landmark trials in the field have been initiated and will be coordinated and managed by HRP: a trial to assess short-term catheterization following fistula repair; and a trial to assess whether periconceptional calcium supplementation in high-risk women reduces the incidence of recurrent pre- eclampsia. t� The multicountry survey on maternal and newborn health with focus on the management of severe complications in pregnancy and childbirth reached the projected sample size of 300 000 women in 29 countries. t� Publication of two WHO guidelines and one manual has advanced this area, namely: WHO recommendations for induction of labour; WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia; and Evaluating the quality of care for severe pregnancy complications: the WHO near-miss approach for maternal health. Highlights 2011 7 – Implication of research findings for policy and programmes: For induction of labour, low-dose misoprostol and mechanical methods should be included in clinical protocols. In facilities where full dose of magnesium sulfate is not possible health care workers are recommended to initiate treatment with loading dose before referral. In areas with low calcium intake calcium supplementation should be incorporated in antenatal care protocols. For women at high-risk of developing pre-eclampsia low-dose acetylsalicylic acid should be included in antenatal care protocols. For monitoring of quality of maternal and newborn health care at facilities the WHO maternal and newborn near-miss monitoring tool is recommended. In Peru, this approach is currently implemented as national policy. t� Development of the Women Create Life (WCL) business plan as an innovative financial mechanism for maternal and infant health; and the implementation of a pilot project with the company “Moleskine” to produce a WCL notebook. Highlights 20118 Preventing unsafe abortion Vision Substantial reductions in the incidence of unsafe abortion have been achieved. Key objectives The Department’s programme of work on Preventing Unsafe Abortion strives towards the goal of eliminating unsafe abortion, using a multidisciplinary approach that includes estimating the magnitude of the problem; conducting clinical, operations and social science research; developing appropriate guidelines and tools; and providing technical support to countries using the strategic approach. Major achievements t� Completion of the sixth edition of Unsafe abortion: global and regional estimates. According to these estimates, there was a rise from 19.7 million in 2003 to 21.6 million unsafe abortions in 2008. t� The second edition of Safe abortion technical and policy guidance for health systems was approved by the WHO Guidelines Review Committee. t� Twenty-five research projects (clinical and operations research) were completed or are ongoing. “Induced abortion: incidence and trends worldwide from 1995 to 2008” was published in The Lancet: between 1995 and 2003 the abortion rate per 1000 women of childbearing worldwide dropped from 35 to 29. In 2008 the global abortion rate was 28 per 1000, almost unchanged since 2003. The study found that nearly half of all abortions worldwide are unsafe procedures, and almost all unsafe abortions occur in the developing world. t� Over 20 peer-reviewed publications from staff and partners supported by HRP were published in a range of journals. The study on safety and efficacy of midlevel providers in providing medical abortion was published in The Lancet. A paper on the global rates of abortion, as well as one on the randomized controlled trial on cervical pretreatment prior to surgical abortion were accepted for publication in The Lancet to be published in 2012. t� Demonstration projects to introduce or scale-up safe abortion care were completed in the Republic of Moldova and Ukraine. t� The Kyrgyzstan Ministry of Health, with support from the United Nations Population Fund (UNFPA) and WHO, conducted a strategic assessment on unintended pregnancy, contraception and abortion. Highlights 2011 9 Controlling sexually transmitted and reproductive tract infections Vision Gender-sensitive and non-stigmatizing responses to prevention and control of sexually transmitted (STIs) and reproductive tract infections (RTIs) and their complications have been expanded and their implementation accelerated, and congenital syphilis has been eliminated. Key objectives The goal of the Department of Reproductive Health and Research in the area of Controlling Sexually Transmitted and Reproductive Tract Infections is to prevent and control sexually transmitted and other reproductive tract infections through a systematic programme of work that covers: (a) mapping and generating evidence, testing interventions, and improving technologies; (b) developing evidence-based norms, tools, and guidelines; and (c) providing technical support to countries. Major achievements t� Completion of work on prevalence and incidence of selected sexually transmitted infections: Chlamydia trachomatis, Neisseria gonorrhoeae, syphilis and Trichomonas vaginalis for 2005 (published) and 2008 (to be published in 2012). – Implication of research findings for policy and programmes: Generation of global estimates of sexually transmitted infections should be informed by adequate surveillance for sexually transmitted infections on a Region by Region basis. t� An updated guidance document on Strategies and laboratory methods for strengthening surveillance of sexually transmitted infections was finalized and will be published in 2012. – Implication of research findings for policy and programmes: Surveillance for antimicrobial resistance in Neisseria gonorrhoeae should be standardized across regions and quality assured by running local results against the WHO Neisseria gonorrhoeae reference strain panel. t� Consultations were held to elaborate the Global action plan to control the spread and impact of antimicrobial resistance in Neisseria gonorrhoeae. – Implication of research findings for policy and programmes: Treatment of proven cephalosporin-resistant Neisseria gonorrhoeae should be guided by antimicrobial susceptibility tests in collaboration with an expert in infectious diseases and the laboratory results. Highlights 201110 t� Publication of estimates of syphilis in pregnancy for 2008 indicating that 1.9 million pregnant women had active syphilis with 820 000 associated adverse outcomes of pregnancy. – Implication of research findings for policy and programmes: Accurate identification of causes of stillbirths in a standardized manner is recommended for planning interventions to reduce preventable infant deaths caused by maternal syphilis during pregnancy. t� Publication of WHO guidelines on the Use of cryotherapy for cervical intraepithelial neoplasia. t� Consultations and discussions were held on the effectiveness and safety of a 1% vaginal gel formulation of tenofovir in reducing HIV infection in women and to agree on key priority steps to confirm its safety and effectiveness. t� Technical support was provided to Rwanda, United Republic of Tanzania, and Zambia to strengthen the national programmes for cervical cancer prevention, including the introduction of HPV vaccine. – Implication of research findings for policy and programmes: Determination of, and information on, the prevalent types of human papillomavirus infections should guide the choice of HPV vaccine to implement. t� Production of a tool for countries on Methods for surveillance and monitoring congenital syphilis elimination within existing systems. Highlights 2011 11 Highlights 201112 Gender, reproductive rights, sexual health and adolescence Vision Substantial reductions in gender inequality including the perpetration of violence against women and female genital mutilation have been achieved; laws and policies are supportive of sexual and reproductive health; and universal access to information and appropriate services has been achieved for adolescents. Key objectives The Sexual Health, Gender, Reproductive Rights and Adolescence area of work (GRR) aims to ensure that research, policies and programmes in sexual and reproductive health protect and promote human rights and equality between women and men, including adolescents. GRR supports policy- and programme- relevant research on gender-based violence, female genital mutilation (FGM), adolescent sexual and reproductive health, and actions to promote sexual health and healthy sexuality. It also develops norms, guidelines and tools in these areas, including on research strengthening. Major achievements t� The Working Group on the Classification of Sexual Disorders and Sexual Health for the Revision of ICD-10 was established jointly with the WHO Department of Mental Health and held its first meeting. t� Global and regional estimates of prevalence of intimate partner violence, child sexual abuse and non-partner sexual abuse, and systematic reviews and meta- analysis of different health outcomes including abortion and low-birth weight were completed for the Global Burden of Disease Study. t� Nine systematic reviews for clinical and policy guidelines for health-sector response to violence against women were completed, and draft guidelines were made available for comments during a guidelines development group meeting. t� An interagency statement on preventing sex-selection was released in 2011 in partnership with OHCHR, UN Women, UNICEF and UNFPA. t� Four regional workshops were held, with the WHO Department of Injuries and Violence Prevention and other partners, on primary prevention of intimate partner and sexual violence against women. Highlights 2011 13 t� A regional workshop on research methods for violence against women was held by the Mahidol University in Thailand. t� An indicator on prevalence of recent intimate partner violence as a marker of gender inequality was included as one of the 30 core indicators for monitoring global progress on HIV/AIDS; and a compendium (forthcoming) of a complementary set of programmatic indicators on gender equality and HIV for country use was developed. t� The global strategy to stop health care providers from performing FGM strongly influenced a Kenyan criminal law against FGM, which was passed in October 2011. t� The first triennial progress report by the Secretariat to the World Health Assembly on Resolution 61.16 on preventing FGM, highlighted progress in some countries. t� An international conference on FGM with a special focus on health research and capacity building for research and interventions was held in October at the University of Nairobi, Kenya. t� The OHCHR (The Office of the High Commissioner for Human Rights) report on preventable maternal mortality and morbidity and human rights, to which RHR contributed, was endorsed by the Human Rights Council and is leading to important follow-up activities in this area. t� Expert technical opinions in connection with international, regional and national human rights, legislative and judiciary processes have been provided on request. Highlights 201114 Research capacity strengthening and programme development Vision Sexual and reproductive health policy and programmes are strengthened through incorporation of relevant research evidence and evidence-based interventions mainly by means of research and technical capacity strengthening, implementation research, and development of intervention delivery approaches. Regional activities Key objectives The Department’s work in the area of research capacity strengthening and programme development aims to strengthen countries’ research capacity to accelerate progress on sexual and reproductive health research relevant to national and regional needs, facilitate participation of local institutions in global research, and support development and implementation of evidence-based policies and programmes. Major achievements t� In 2011, 13 institutions were awarded long-term institutional development (LID) grants. Seven institutions received service guidance centre grants, 7 received competitive intraregional research grants, 10 received resource maintenance and capital grants and 1 institution received a pre-LID grant. t� Research training grants in the form of courses, workshops, and seminars were awarded to three institutions in Africa. In the Region of the Americas, 16 fellows received awards for courses or practical training. t� In collaboration with the Implementation Research Platform (IRP), capacity- building and priority-setting workshops in implementation research were conducted in six countries in Africa. Three out of seven projects coordinated by the Department in the Region of the Americas, the Eastern Mediterranean Region and the African Region were granted funding from the IRP. t� Support for reproductive health programmes was achieved through providing technical assistance for adaptation and/or implementation of guidelines and tools in family planning and sexually transmitted infections and reproductive tract infections (STIs/RTIs). The guidelines were implemented by the respective reproductive health programmes in two countries each in the South-East Asia and Western Pacific regions. t� Following the ending of the Reproductive health strategy for the African Region, 1998–2007, in collaboration with the WHO Regional Office for Africa, the Department initiated the development of an “African Regional Agenda for Reproductive Health”. Highlights 2011 15 t� RHR, together with other WHO departments and other United Nations agencies secured a grant from the French Government to support reproductive, maternal newborn and child health and is coordinating the implementation of the family planning element of the grant in French- speaking countries in Africa. t� RHR, along with seven other partners, has received a new grant from the European Commission to promote health research, education and health- care practice in Africa. The grant will be used to create centres of excellence in Africa and the initial focus will be on the area of HIV/AIDS and sexual and reproductive health. A new feature of this project is that it will use information technology to deliver e-learning courses and enable knowledge-sharing through web-based virtual communities. Entitled “AFRICA BUILD”, the longer- term aim of the project is to create sustainable South-to-South knowledge- sharing groups of African researchers. Highlights 201116 Knowledge exchange and transfer Key objectives The Knowledge Exchange and Transfer area of work of the Department harnesses and synthesizes evidence, knowledge tools and derivatives and supports their dissemination, with The WHO Reproductive Health Library (RHL) being the core tool. It is also linked closely to the Department’s cross-cutting working group on Knowledge Synthesis, Exchange and Implementation Research. Major achievements t� Systematic reviews to support guideline development have been conducted and updated. WHO guidelines on postpartum haemorrhage and labour induction were published in RHL with a critical appraisal of their quality and relevance to low- and middle-income settings. In addition to the reviews supporting guidelines, Cochrane reviews on management of trichomoniasis in pregnancy and types of progestogens in combined oral contraception were updated. A non-Cochrane systematic review on caesarean section classification systems was published. t� RHL continued to be published in six languages despite severe financial constraints. RHL has become the seventh most visited WHO web site with approximately 250 000 hits per month in 2011. Highlights 2011 17 Policy and programmatic issues Key objectives The key objective of the Policy and Programmatic Issues area of work is to strengthen countries’ capacity for strategic planning, development, and implementation of interventions to improve the universal coverage, equitable access and the quality of reproductive health services. Major achievements t� The Ukraine Ministry of Health and its nongovernmental partner Women’s Health and Family Planning completed the first phase of the project “Comprehensive care for unwanted pregnancies”, including infrastructure upgrades and training in comprehensive abortion care conducted in two provinces and one clinic in Kiev. t� The Moldova Ministry of Health and partners completed the first phase of scaling-up the pilot model of outpatient abortion care (including post- abortion contraception), extending services to 3 of the country’s 12 perinatal consultation centres and 1 district-level hospital. t� A new ExpandNet/RHR guidance document entitled Beginning with the end in mind: planning pilot projects and other programmatic research for successful scaling up was field-tested through technical assistance to a project introducing Medabon (a combination of mifepristone and misoprostol for medical abortion) in Thailand and to a new mobile Health project in Karnataka, India. t� A Knowledge for Health (K4H) e-toolkit was developed as an additional resource to disseminate the ExpandNet/RHR guidance tools for scaling-up, targeting programme managers and others who want to ensure that scaling-up health innovations has wider impact. t� ExpandNet is a core partner with Pathfinder International, together with MSH, IntraHealth and PATH, in the new USAID “Evidence 2 Action” family planning and reproductive health project which will focus initially in 10 “Global Health Initiative” priority countries in Asia and Africa. Highlights 201118 Monitoring and evaluation Key objectives The Department’s monitoring and evaluation work aims to support monitoring progress in the achievement of global goals and targets related to sexual and reproductive health and in the implementation of the WHO Global Reproductive Health Strategy, through leading, carrying out and contributing to analytical work, as well as developing relevant standards and tools and strengthening capacity in their use. Major achievements t� Analysis and publication of a systematic review reporting the first-ever estimates of global, regional and national levels and trends of stillbirths between 1995 and 2009. The review showed that there were an estimated 2.6 million (uncertainty range 2.1–3.8 million) stillbirths in 2009 worldwide and the stillbirth rate has declined by 14%, from 22.1 stillbirths per 1000 births in 1995 to 18.9 stillbirths per 1000 births in 2009. – Policy and programmatic implications: Antenatal care programmes should include essential elements to prevent stillbirths including screening and treatment for syphilis. t� A system for continuous updating of the maternal mortality estimation input database and schedules for biannual updates of maternal mortality levels and trends were put in place. t� A classification system for causes of maternal mortality that standardizes the attribution of cause of deaths as part of the International Classification of Diseases and Related Health Problems (ICD)– ICD-MM was developed. – Implication of research findings for policy and programmes: Accurate identification of causes of maternal deaths in a standard manner is recommended for planning interventions to reduce maternal deaths. t� Opening of chapters of the ICD-11 relating to sexual and reproductive health to stakeholders, for alpha testing and review. Highlights 2011 19 Health-systems research Key objectives The key objective of the health-systems research area of work is to build the evidence base on how the changes in sectoral policy and programme operations are improving the universal coverage of, equitable access to and quality of reproductive health services. Major achievements t� The final wrap-up assessment was carried out of a four-year joint project with the United Nations Population Fund (UNFPA)/WHO that produced four country case-studies and a published synthesis report that explored how the evolution of trends in aid effectiveness have changed the way that WHO and UNFPA work at country level to support sexual and reproductive health. t� A three-year study was completed that investigated the impact of the Population Services International/Myanmar Sun Quality Health franchise, producing three published papers and influencing the management of the franchise. t� Baseline results from a prospective-controlled cohort study to identify the economic impact of maternal death on rural Chinese households. Highlights of the baseline survey are scheduled for publication. t� Publication of a retrospective longitudinal controlled study design in the Philippines that compared maternal-health-programme performance and outcomes in one province, where a set of health-system reforms had a fast track implementation, with other provinces in the same region, where reforms were introduced in less systematic and intensive manner. The findings indicate the positive synergistic effects of increased investments (technical and financial) across multiple health system functions to improve maternal health. t� Fieldwork began on a joint project with the Global Fund to Fight AIDS, Tuberculosis and Malaria that investigates the magnitude and impact of sexual and reproductive health expenditures from the Global Fund’s HIV/ AIDS grants. The ongoing project uses a case-study methodology built around expenditure-tracking methods in Ethiopia. The final results will be published in 2012. t� Impact evaluations of civil society advocacy for reproductive health were conducted in Bangladesh, the Philippines and Uganda using innovative, realist evaluation case-study methodology. A synthesis report was released and a paper is scheduled for publication in 2012. Highlights 201120 Implementing Best Practices Initiative Key objectives Since 1999, the Department, in collaboration with the United States Agency for International Development (USAID) and the United Nations Population Fund (UNFPA), has supported a partnership of 35 international agencies known as the Implementing Best Practice Initiative (IBP). This partnership works at the global, regional and country level to expand and sustain an effective network of collaborating international and national organizations willing to harmonize approaches, reduce duplication and support the implementation and scaling-up of best practices to improve sexual and reproductive health. Major achievements t� The IBP Knowledge Gateway hosted global discussion forums reaching close to 3000 people in most countries of the world. Forum topics included emergency contraception, managing health supply chains, developing an African Agenda for Reproductive Health, and issues leading up to the International Conference on Family Planning held in Senegal and a Women Deliver forum on the Millennium Development Goals. t� The IBP secretariat, in collaboration with the WHO department working on disability, facilitated a session at the regional meeting organized in collaboration with the Regional Office for South-East Asia in Hua Hin, Thailand. After the meeting, the Myanmar country team organized a national workshop to introduce the World report on disability. t� As a follow-up to the introduction of the Guide for fostering change to scale up effective practices, significant progress was made in implementing an action plan developed by the Zimbabwe team, which offers youth-friendly services to nursing students and is currently being scaled-up to other schools. Preliminary results show a dramatic decrease in unwanted pregnancies and abortions. t� IBP partners hosted six interactive “knowledge-to-action” sessions addressing major areas for action to improve demand for, access to and quality of family planning services as well as an auxiliary session to introduce participants to IBP at the International Family Planning Conference, Dakar, Senegal. t� A new strategic five-year plan for IBP was developed with input and consensus from all 35 partners. t� A peer-reviewed article was published on an evaluation of virtual discussion forums held on the IBP Knowledge Gateway, and its evolution over six years. The paper also included next steps for improving the evaluation of future virtual discussions. Highlights 2011 21 Reproductive health essential medicines Key objectives The Department’s Reproductive Health Essential Medicines (RHEM) project has contributed to laying the groundwork for more effective public-sector procurement of good-quality reproductive health medicines, including contraceptives and commodities. In 2011, it continued to play a pivotal role in the development of normative guidance and capacity building needed to support the production and procurement of quality RHEM products. However, activities have been constrained due to the paucity of funding available, which may threaten further the ability to implement the plans for 2012–2013. Major achievements t� Technical papers were prepared on: – analysis of issues that must be considered when establishing the general, safety, efficacy and performance criteria for the female condom; – guidance for the manufacturers to enable submission of product dossiers and manufacturing site master files as part of the prequalification process; – scientific and technical requirements for review of the female condom, to create a generic specification to support a bulk procurement and guidance document on how to undertake a clinical evaluation of the female condom. Implication of research findings for policy and programmes: Female condom procurement processes should use the specified criteria for bulk procurement. t� The WHO/United Nations Population Fund (UNFPA)/Family Health International (FHI 360) Female Condom Technical Review Committee was convened. t� A draft specification for cryotherapy equipment and a paper detailing the safe management of gases were prepared. t� A specification and advisory note to support the procurement of cycle beads, a visual aid for the Standard Days Method were prepared. t� In collaboration with partners, preparation and ethical and technical review of a framework to undertake the clinical evaluation, in South Africa and China, of three female condoms was supported. t� An international conference on professionalizing logisticians was convened, in collaboration with major bulk procurement agencies, with over 120 participants. Highlights 201122 Cross-cutting areas within inter-team working groups Highlights 2011 23 Knowledge Synthesis and Exchange & Implementation Research Key objectives The key objectives of the work of the Department’s working group on Knowledge Synthesis and Exchange & Implementation Research (KSE & IR) are to coordinate the Department’s work linking relevant activities within the thematic areas (such as maternal and perinatal health) to implementation efforts with emphasis on the “Knowledge-to-Action” framework adopted by the Department and on improving the knowledge and science of various methodological aspects of knowledge transfer, exchange and implementation research. In 2011, important KSE & IR activities were initiated by the Department. By focusing on research and capacity strengthening in both conducting research and its methodology at the country level and within WHO, the Department established its leadership in this field. The breadth and depth of the Department’s KSE & IR portfolio can be seen in individual thematic areas and the Research Capacity Strengthening reports. Major achievements t� The Programme is managing implementation research projects that were shortlisted following a competitive process launched within the Implementation Research Platform. A common feature of these projects is the focus on reducing maternal and perinatal mortality and improving the quality of care. t� Several other implementation research projects are being managed by the thematic areas including an antenatal care trial focusing on improving supply- chain management and implementing counselling to reduce violence against women in a cluster randomized trial. t� Thirteen systematic reviews are being supported that assess results from implementation research studies in selected areas. t� Implementation research priorities have been identified in 12 countries through workshops with ministries of health, researchers and programme managers. Highlights 201124 Innovations to improve sexual and reproductive health Key objectives For 40 years, RHR has been a champion of innovation in the field of sexual and reproductive health, contributing to enormous gains in health among populations globally. The work of the Department supporting innovations aims to: t� foster the development and validation of innovations that focus on improving sexual and reproductive health in populations with the greatest need; t� develop and support mechanisms that improve the awareness, availability, and use of innovations that focus on improving sexual and reproductive health; support research that aims to understand and overcome barriers that prevent innovations from achieving widespread adoption. Major achievements t� RHR was awarded a Wellcome Trust grant to develop, assess the impact of, and scale a mobile technologies for health (“mHealth”) package for rural health workers in India, in support of the Ministry of Health National Rural Health Mission. t� RHR was awarded the “Saving Lives at Birth” Grand Challenge award for the new low-cost Odon device to aid safe delivery during prolonged labour; RHR also co-developed the mCheck project, focusing on empowering clients to recognize danger signs during the seven days postpartum, which was a Grand Challenge project finalist. t� RHR was awarded a three-year United Nations Foundation grant to lead research focused on scaling-up 25 “mHealth” projects awarded catalytic grants from the United Nations Secretary-General’s Innovations Working Group. Highlights 2011 25 Linkages between sexual and reproductive health and HIV/AIDS interventions Vision Universal access to sexual and reproductive health services and to HIV prevention, treatment and care has been fostered through strengthening linkages between sexual and reproductive health and HIV policies, programmes and services. Key objectives The objective of this area of work in the Department is to strengthen linkages between sexual and reproductive health (SRH) services and HIV interventions in order to transform the broader health and development agenda and accelerate progress towards the Millennium Development Goals on gender equality, child health, and maternal health (MDGs 3–6). Major achievements t� Operations research was implemented in Zambia to evaluate the feasibility, acceptability, quality and effectiveness of innovative models for strengthening the continuum from antenatal, pregnancy, delivery and postpartum care. t� The first comprehensive baseline study of STI components in all HIV proposals approved by the Global Fund to Fight AIDS, Tuberculosis and Malaria from Rounds 1–9 was completed and published discussing how investments into STI prevention, treatment and care can be leveraged to advance sexual and reproductive health and rights. Highlights 201126 t� Three subregional consultations to share the experiences of the implementation of the Rapid assessment tool for sexual and reproductive health and HIV linkages were held in: (1) Europe–central Asian republics, (2) Latin America and the Caribbean, and (3) the South Asia and Western Pacific regions. This tool has now been implemented in over 45 countries and country briefs have been developed for 15 of them (Belize, Benin, Botswana, Burkina Faso, Cote d’Ivoire, Kyrgyzstan, Lebanon, Malawi, Morocco, Pakistan, Russian Federation, Swaziland, Tunisia, Uganda and United Republic of Tanzania) highlighting experiences and best practices to inform national, regional and global agendas. t� A resource pack on SRH/HIV linkages was updated and widely disseminated. This pack is an output of the interagency working group on SRH/HIV linkages and has helped to build a common understanding of key issues and definitions, and provide an overview of the current status of linkages among key partners. t� A subregional consultation was held on the engagement of men in PMTCT that defined male engagement in PMTCT, including indicators and methods of measurement as well as a conceptual framework that embeds male engagement in the four key elements of PMTCT. t� A global action plan was finalized to minimize the impact of antimicrobial resistance in Neisseria gonorrhoeae through articulating the public health, policy and economic case for urgent, heightened and sustained action to control N. gonorrhoea infection and to mitigate the emergence and impact of antimicrobial resistance; and to coordinate communication, partnership and advocacy efforts at national, regional and international levels to support the global response. Highlights 2011 27 Men and sexual and reproductive health Key objectives The working group on men and sexual and reproductive health was established to address men’s behaviour and roles in decision-making and sexual and reproductive health outcomes. The working group has provided a formal process to discuss strategy and programming related to men’s sexual and reproductive health needs and the roles and responsibilities of men in bringing about positive changes in the sexual and reproductive health of women, families and communities. The Department’s work related to men and sexual and reproductive health takes place within the technical teams and is therefore prioritized and implemented within the context of each team’s workplan. The multidisciplinary working group is open to all Department staff. Major achievements t� RHR played a significant role in the development of the sections related to sexually transmitted infections in the WHO guideline Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people: recommendations for a public health approach 2011. t� The first international consultation on the engagement of men in the prevention of mother-to-child transmission of HIV was convened by WHO, UNAIDS and the Government of Rwanda. The background paper, meeting report and resulting conceptual framework will help to focus key policy and programmatic strategies. t� The RHR-coordinated Implementing Best Practices Initiative sponsored a knowledge-to-action session on “Engaging men in family planning” at the 2011 International Conference on Family Planning in Dakar, Senegal. This topic had been identified as one of the five action areas that emerged from the 2009 International Conference on Family Planning. Highlights 201128 Biostatistics and data management Key objectives The Biostatistics and Data Management work of RHR provides support for the statistical data processing and coordination of the HRP’s research projects, supports the research capacity strengthening of institutions in biostatistics and data management, and provides informatics support for the Department. Major achievements t� Support in statistics data management, research coordination and monitoring was provided for more than 30 clinical trials and epidemiological studies. On-site research training of staff was conducted in collaborating centres participating in HRP projects in the Democratic Republic of the Congo, Ethiopia, Guinea, Hungary, Kenya, Niger, Nigeria, Sierra Leone, South Africa, Uganda, Zambia and Zimbabwe. t� The Department continues to implement new technologies to support the conduction of good-clinical-practice-compliant research in resource-poor settings. Highlights 2011 29 Advocacy for sexual and reproductive health and for HRP/RHR Key objectives Through its work in advocacy and communication, the Department aims to promote uptake of its evidence-based outputs, to build awareness of key issues in sexual and reproductive health, and to raise funds and to ensure the continued commitment and engagement of Member States, WHO and other agencies. Major achievements t� 42 new technical publications in English were produced and distributed. Fourteen publications were translated into official languages. t� A new e-bulletin – RH Update – was launched informing subscribers of Department research publications, events and new documents. t� There were 2.9 million visits to the HRP, Reproductive Health and RHL web sites, and 696 000 documents were downloaded. t� Three donors returned to RHR in 2011, two new donors joined, and many donors increased their contributions. WHO/RHR/HRP/12.13 © World Health Organization 2012 All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed by the WHO Document Production Services, Geneva, Switzerland For more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20, CH-1211 Geneva 27, Switzerland Fax: +41 22 791 4171 E-mail: reproductivehealth@who.int www.who.int/reproductivehealth For more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20, CH-1211 Geneva 27 Switzerland Fax: +41 22 791 4171 E-mail: reproductivehealth@who.int www.who.int/reproductivehealth << /ASCII85EncodePages false /AllowTransparency false /AutoPositionEPSFiles true /AutoRotatePages /All /Binding /Left /CalGrayProfile (Gray Gamma 2.2) /CalRGBProfile (sRGB IEC61966-2.1) /CalCMYKProfile (U.S. Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Warning /CompatibilityLevel 1.3 /CompressObjects /Tags /CompressPages true /ConvertImagesToIndexed true /PassThroughJPEGImages true /CreateJDFFile false /CreateJobTicket false /DefaultRenderingIntent /Default /DetectBlends true /DetectCurves 0.1000 /ColorConversionStrategy /sRGB /DoThumbnails false /EmbedAllFonts false /EmbedOpenType false /ParseICCProfilesInComments true /EmbedJobOptions true /DSCReportingLevel 0 /EmitDSCWarnings false /EndPage -1 /ImageMemory 1048576 /LockDistillerParams false /MaxSubsetPct 100 /Optimize true /OPM 1 /ParseDSCComments true /ParseDSCCommentsForDocInfo false /PreserveCopyPage true /PreserveDICMYKValues true /PreserveEPSInfo false /PreserveFlatness true /PreserveHalftoneInfo false /PreserveOPIComments false /PreserveOverprintSettings true /StartPage 1 /SubsetFonts true /TransferFunctionInfo /Apply /UCRandBGInfo /Remove /UsePrologue false /ColorSettingsFile () /AlwaysEmbed [ true ] /NeverEmbed [ true ] /AntiAliasColorImages false /CropColorImages true /ColorImageMinResolution 100 /ColorImageMinResolutionPolicy /OK /DownsampleColorImages true /ColorImageDownsampleType /Bicubic /ColorImageResolution 100 /ColorImageDepth -1 /ColorImageMinDownsampleDepth 1 /ColorImageDownsampleThreshold 1.50000 /EncodeColorImages true /ColorImageFilter /DCTEncode /AutoFilterColorImages true /ColorImageAutoFilterStrategy /JPEG /ColorACSImageDict << /QFactor 0.76 /HSamples [2 1 1 2] /VSamples [2 1 1 2] >> /ColorImageDict << /QFactor 1.30 /HSamples [2 1 1 2] /VSamples [2 1 1 2] >> /JPEG2000ColorACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 10 >> /JPEG2000ColorImageDict << /TileWidth 256 /TileHeight 256 /Quality 10 >> /AntiAliasGrayImages false /CropGrayImages true /GrayImageMinResolution 150 /GrayImageMinResolutionPolicy /OK /DownsampleGrayImages true /GrayImageDownsampleType /Bicubic /GrayImageResolution 100 /GrayImageDepth -1 /GrayImageMinDownsampleDepth 2 /GrayImageDownsampleThreshold 1.50000 /EncodeGrayImages true /GrayImageFilter /DCTEncode /AutoFilterGrayImages true /GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict << /QFactor 0.76 /HSamples [2 1 1 2] /VSamples [2 1 1 2] >> /GrayImageDict << /QFactor 1.30 /HSamples [2 1 1 2] /VSamples [2 1 1 2] >> /JPEG2000GrayACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 10 >> /JPEG2000GrayImageDict << /TileWidth 256 /TileHeight 256 /Quality 10 >> /AntiAliasMonoImages false /CropMonoImages true /MonoImageMinResolution 300 /MonoImageMinResolutionPolicy /OK /DownsampleMonoImages true /MonoImageDownsampleType /Bicubic /MonoImageResolution 250 /MonoImageDepth -1 /MonoImageDownsampleThreshold 1.20000 /EncodeMonoImages true /MonoImageFilter /CCITTFaxEncode /MonoImageDict << /K -1 >> /AllowPSXObjects true /CheckCompliance [ /None ] /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false /PDFXNoTrimBoxError true /PDFXTrimBoxToMediaBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXSetBleedBoxToMediaBox true /PDFXBleedBoxToTrimBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXOutputIntentProfile (None) /PDFXOutputConditionIdentifier () /PDFXOutputCondition () /PDFXRegistryName () /PDFXTrapped /False /Description << /CHS <FEFF4f7f75288fd94e9b8bbe5b9a521b5efa7684002000410064006f006200650020005000440046002065876863900275284e8e5c4f5e55663e793a3001901a8fc775355b5090ae4ef653d190014ee553ca901a8fc756e072797f5153d15e03300260a853ef4ee54f7f75280020004100630072006f0062006100740020548c002000410064006f00620065002000520065006100640065007200200035002e003000204ee553ca66f49ad87248672c676562535f00521b5efa768400200050004400460020658768633002> /CHT <FEFF4f7f752890194e9b8a2d7f6e5efa7acb7684002000410064006f006200650020005000440046002065874ef69069752865bc87a25e55986f793a3001901a904e96fb5b5090f54ef650b390014ee553ca57287db2969b7db28def4e0a767c5e03300260a853ef4ee54f7f75280020004100630072006f0062006100740020548c002000410064006f00620065002000520065006100640065007200200035002e003000204ee553ca66f49ad87248672c4f86958b555f5df25efa7acb76840020005000440046002065874ef63002> /DAN <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> /DEU <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> /ESP <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> /FRA <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> /ITA <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> /JPN <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> /KOR <FEFFc7740020c124c815c7440020c0acc6a9d558c5ec0020d654ba740020d45cc2dc002c0020c804c7900020ba54c77c002c0020c778d130b137c5d00020ac00c7a50020c801d569d55c002000410064006f0062006500200050004400460020bb38c11cb97c0020c791c131d569b2c8b2e4002e0020c774b807ac8c0020c791c131b41c00200050004400460020bb38c11cb2940020004100630072006f0062006100740020bc0f002000410064006f00620065002000520065006100640065007200200035002e00300020c774c0c1c5d0c11c0020c5f40020c2180020c788c2b5b2c8b2e4002e> /NLD (Gebruik deze instellingen om Adobe PDF-documenten te maken die zijn geoptimaliseerd voor weergave op een beeldscherm, e-mail en internet. De gemaakte PDF-documenten kunnen worden geopend met Acrobat en Adobe Reader 5.0 en hoger.) /NOR <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> /PTB <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> /SUO <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> /SVE <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> /ENU (Use these settings to create Adobe PDF documents best suited for on-screen display, e-mail, and the Internet. Created PDF documents can be opened with Acrobat and Adobe Reader 5.0 and later.) /ENG (Low settings) >> /Namespace [ (Adobe) (Common) (1.0) ] /OtherNamespaces [ << /AsReaderSpreads false /CropImagesToFrames true /ErrorControl /WarnAndContinue /FlattenerIgnoreSpreadOverrides false /IncludeGuidesGrids false /IncludeNonPrinting false /IncludeSlug false /Namespace [ (Adobe) (InDesign) (4.0) ] /OmitPlacedBitmaps false /OmitPlacedEPS false /OmitPlacedPDF false /SimulateOverprint /Legacy >> << /AddBleedMarks false /AddColorBars false /AddCropMarks false /AddPageInfo false /AddRegMarks false /ConvertColors /ConvertToRGB /DestinationProfileName (sRGB IEC61966-2.1) /DestinationProfileSelector /UseName /Downsample16BitImages true /FlattenerPreset << /PresetSelector /MediumResolution >> /FormElements false /GenerateStructure false /IncludeBookmarks false /IncludeHyperlinks false /IncludeInteractive false /IncludeLayers false /IncludeProfiles true /MultimediaHandling /UseObjectSettings /Namespace [ (Adobe) (CreativeSuite) (2.0) ] /PDFXOutputIntentProfileSelector /NA /PreserveEditing false /UntaggedCMYKHandling /UseDocumentProfile /UntaggedRGBHandling /UseDocumentProfile /UseDocumentBleed false >> ] >> setdistillerparams << /HWResolution [300 300] /PageSize [612.000 792.000] >> setpagedevice

View the publication