HRP Annual Report 2022

Publication date: 2023

HRP ANNUAL REPORT 2022 UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), based in the World Health Organization (WHO) Department of Sexual and Reproductive Health and Research (SRH) HRP ANNUAL REPORT 2022 UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), based in the World Health Organization (WHO) Department of Sexual and Reproductive Health and Research (SRH) HRP annual report 2022 ISBN 978-92-4-007068-4 (electronic version) ISBN 978-92-4-007069-1 (print version) © World Health Organization 2023 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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Design and layout by Lushomo. iii Foreword v 01 About us – HRP at 50 1 02 Why sexual and reproductive health and rights (SRHR)? 3 03 Helping people to realize their desired family size 5 Family planning and contraception 7 Fertility care 10 04 Ensuring the health of pregnant women and girls and their babies 11 05 Safe abortion 16 06 Promoting sexual health and well-being 22 Sexual health and well-being 23 Research on sexually transmitted infections (STIs) 24 Preventing and treating HPV infection and cervical pre-cancers 26 07 Sexual and reproductive health and rights (SRHR) during the global COVID-19 pandemic and other health emergencies 27 SRHR during the COVID-19 pandemic 29 SRHR in humanitarian emergencies 30 08 Healthy adolescence for a healthy future 31 09 Preventing and responding to violence against women and girls 34 Violence against women and girls 35 Female genital mutilation (FGM) 37 10 Achieving gender equality and sexual and reproductive health and rights (SRHR) 39 11 Supporting and strengthening national health systems for achieving universal health coverage (UHC) 42 Health system strengthening for SRHR 43 Measuring and monitoring sexual and reproductive health services 44 Self-care interventions for SRHR 46 Digital health 48 12 Strengthening research capacity for sexual and reproductive health and rights (SRHR) 49 Research capacity strengthening (RCS) 50 Scientific leadership and support 52 Countries where HRP works 53 HRP 2022 donors 54 Credits 55 CONTENTS iii iv HRP ANNUAL REPORT 2022iv HRP ANNUAL REPORT 2022 v Foreword The Special Programme on Human Reproduction, known as HRP, was created in 1972 following a World Health Assembly Resolution. HRP brings together five United Nations agencies (UNDP, UNFPA, UNICEF, WHO, World Bank), policy- makers, scientists, health workers and civil society organizations to focus on generating evidence to better understand and deliver on sexual and reproductive health and rights (SRHR). At the time of its founding – 50 years ago – we could not have predicted the critical importance of the Special Programme to the field of sexual and reproductive health. HRP has weathered storms of dissent and controversy. With the staunch support of several Member States, the five United Nations cosponsors, key civil society organizations, and professional associations, we have not only stayed the course of generating robust evidence for product development and interventions but also supported the translation of this evidence into policy change and practice, contributed to strengthening health systems, and collaborated with partners to impact lives. I am proud to highlight the achievements and advancements made by those dedicated to the mandate of HRP. Our work is at the forefront of diagnostics, product development, clinical and community interventions, implementation research, human rights, norms, values and systems analysis and change. Sexual and reproductive health is often taken for granted. We take notice when something goes wrong; but we also often ignore disorders, discomfort and other pathologies, or are unsure where to seek help or whether help is available. Globally, the lack of access to SRHR services, including contraception and safe abortion, epitomizes many of the characteristics that are the root causes of stigma, discrimination and marginalization. These issues are defined by inequitable distribution of power, inequity and injustice and the intersection with sexual and reproductive dysfunction, morbidity and mortality. Strategies to address these challenges are increasingly evident in our work. Within this framework, HRP has come together with various partners and stakeholders to forge a path towards the realization of its vision of the attainment by all people of the highest possible level of sexual and reproductive health. The leadership and collaboration that defines HRP are on display in the many pivotal research projects and publications this past year, among them: the Abortion care guideline, the Recommendations on maternal care for a positive postnatal experience, updated guidelines on both self-care and family planning, and products that show how to integrate sexual and reproductive health into universal health coverage, including Critical considerations and actions for achieving universal access to sexual and reproductive health in the context of universal health coverage through a primary health care approach, and the Learning by Sharing Portal. While the guidelines, reports and journal publications tend to get the spotlight, behind these products are countless hours and unquantifiable efforts to gather a diverse group of people to influence and overturn long-existing misconceptions about sexual and reproductive health, how research is done and who drives the agenda. Over the course of 2023, please join us in celebrating these five decades of achievements. While we look forward to highlighting the positive impact HRP has had, we’ll also be asking you – our partners and friends – to help us examine what else needs our attention. Pascale Allotey Director, WHO Department of Sexual and Reproductive Health and Research (SRH), including the UNDP- UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP). vi HRP ANNUAL REPORT 2022 1AbOUT Us – HRP AT 50 For over 50 years, the UNDP- UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) has been providing leadership on sexual and reproductive health and rights (SRHR). Founded in 1972, HRP has a unique mandate within the United Nations system to set the research agenda, lead the generation of high-quality scientific evidence, and build research capacity for improving SRHR. Housed at the World Health Organization’s (WHO’s) headquarters in Geneva, Switzerland, HRP sits within the WHO Department of Sexual and Reproductive Health and Research (the SRH Department). Working collaboratively with partners across the world, HRP shapes global thinking on SRHR. We conduct large-scale, high-impact research, inform WHO norms and standards, support research capacity-strengthening in low- and middle-income settings, and facilitate the development and uptake of new information and innovations – including clinical and behavioural interventions, digital technologies, and new medicines and devices. An ethical, human rights-based approach that aims to strengthen gender equality and dismantle structural inequities is integrated throughout our work. HRP shares the WHO vision of the right of every single person across the globe to attain the highest possible standard of sexual and reproductive health. We strive for a world where human rights that enable sexual and reproductive health are safeguarded, and where all people have access to quality and affordable sexual and reproductive health information and services. In 2023 – the same year that WHO celebrates its 75th birthday – HRP is undertaking various activities and events to mark our 50th anniversary. These will delve into a host of subjects at the core of HRP’s work, including sexual health, sexual pleasure, provision of services in humanitarian settings, gender equality, and the future of HRP’s research. HRP is launching a series of films about our areas of work, looking back over our first 50 years and forward to the future. A digital timeline highlights many of the hundreds of achievements HRP researchers have accomplished over the decades – see a sample page of the timeline on the next page of this report. From our inception, with our shared vision of SRHR for all, HRP has profoundly appreciated the dedication and commitment of volunteers, researchers, scientists, academics, health professionals, donors, civil society partners, staff and consultants who have all helped us to make great strides towards achieving that vision. In this year of our 50th anniversary celebrations, we want to take this opportunity to celebrate each and every person, organization and government who has been, continues to be, or is just starting out on this incredible journey with us. And more than this, we also want to look forward to the positive change we can make together in the future. The past 50 years have shown us that with collaboration across sectors, we can make an important difference. Join us in celebrating HRP at 50: teams/sexual-and-reproductive-health-and-research- (srh)/human-reproduction-programme/hrp-at-50 About us – HRP at 50 01 2 HRP ANNUAL REPORT 2022 WHO HRP achievements timeline View the full digital timeline: 3WHy sExUAL ANd REPROdUcTivE HEALTH ANd RigHTs (sRHR)? A series of key initiatives reflects a collective commitment to protecting all people’s human rights to access information and services that will enable them to achieve the highest standards of sexual and reproductive health: • The Sustainable Development Goals (SDGs) • The United Nations Secretary-General’s Global Strategy for Women’s, Children’s and Adolescents’ Health • The WHO Reproductive Health Strategy • The Programme of Action of the 1994 International Conference on Population and Development. While great progress has been made in the 50 years since HRP was established, huge challenges remain. A substantial proportion of women and couples are unable to plan whether and when to have children and how many to have. Preventable deaths continue to happen during pregnancy or during and after childbirth, and rates of stillbirths and neonatal deaths are also unacceptably high. Violence against women and girls – including harmful practices – remains a pervasive human rights violation. Many individuals and couples are still unable to access information and services to ensure their sexual, reproductive, maternal and perinatal health, putting their well-being and lives at risk. Humanitarian crises and disease outbreaks threaten lives, livelihoods, health and access to sexual and reproductive health services for millions. And there are now more adolescents than ever before – about 1.3 billion or 16% of the global population – and they are in need of adolescent-friendly services at a unique stage of human development. Without continuing investments in research, and in improving the capacity of countries to conduct and use research, it is unlikely that national primary health systems will be able to effectively implement globally agreed best practices and standards of care, or to achieve the goal of universal health coverage (UHC). Better data are key to addressing many of the crises that we face. Accurate service statistics made available through robust health management information systems help frontline health workers to provide better services and care, and enable managers to plan for equitable implementation. Rigorously and ethically collected scientific evidence improves the accuracy of estimates of health conditions and informs better strategic planning to address priority needs. Information from research and development, as well as from intervention and implementation research, informs technology and health system innovations, policy, budgeting and programming at scale. For over 50 years, HRP has been conducting research with international and national partners to improve sexual and reproductive health and to safeguard the human rights of all people everywhere. We invite you to join us in our efforts. Why sexual and reproductive health and rights (SRHR)? 02 The right to sexual and reproductive health for the well-being of individuals, families and communities, and for sustainable development, is internationally recognized. 4 HRP ANNUAL REPORT 2022 5HELPiNg PEOPLE TO REALizE THEiR dEsiREd fAmiLy sizE Ensuring access to preferred contraceptive methods for women and couples who want to use them is essential to securing their well-being and autonomy, while supporting the health and development of communities. In 2021, among 1.9 billion women of reproductive age (15–49 years), 46% of them were using modern methods of family planning, 5% were using traditional methods and 9% had an unmet need for contraception. Regions with the lowest proportion of use of modern methods among women who want to avoid pregnancy include sub-Saharan Africa (56%) and Oceania excluding Australia and New Zealand (52%). Reasons for not using modern contraceptives include: fear or experience of side-effects, limited access and choice, cultural or religious opposition, and poor quality of available services. Satisfying the demand for contraception would significantly reduce unintended pregnancies, unplanned births and induced abortions, as well as maternal morbidity and mortality; some forms of contraception can also help prevent transmission of sexually transmitted infections (STIs), including HIV. Infertility affects millions of people globally, with negative health, economic, social and emotional consequences for individuals, couples, families and communities. WHO defines infertility as a disease of the male or female reproductive system characterized by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse. WHO recognizes that high- quality fertility care is one of the core elements of reproductive health, and improving access to prevention, diagnosis and treatment of infertility is essential. However, there are marked disparities in the availability and quality of fertility care globally, and the vast majority of those affected cannot access the essential interventions they need. Despite the scale of infertility and its negative consequences, fertility care is a neglected area of policy, programming and research. HRP is in a unique position to provide global leadership on fertility care, helping people to fulfil their rights to reproductive autonomy, and to benefit from scientific progress, equality and non-discrimination. Helping people to realize their desired family size 03 Access to rights-based, safe, effective, quality, affordable and acceptable contraceptive information and services, together with the prevention and treatment of infertility, supports people to decide if and when to have children, the number of children they would like, and their preferred timing and spacing. 6 HRP ANNUAL REPORT 2022 7HELPiNg PEOPLE TO REALizE THEiR dEsiREd fAmiLy sizE 1 The new 2022 edition of Family planning: a global handbook for providers was launched in November at the International Conference on Family Planning in Thailand, with significant research contributions from HRP. The Family Planning Handbook, as it is known, is the most widely used reference guide on the topic globally – the result of a long-standing collaboration between WHO, the United States Agency for International Development (USAID) and Johns Hopkins University. This 2022 edition incorporates two new chapters that were added to the previous edition’s website in 2021, which discuss how to provide care for adolescents and women at high risk of HIV, and how to provide family planning services during an epidemic. Additionally, the new publication includes updates across a number of chapters to reflect key messages from recently released WHO guidance, including updated recommendations on cervical cancer and pre- cancer prevention, screening and treatment; syndromic management of STIs; family planning in post-abortion care; and the option of self-injection of injectable contraceptives. Importantly, the 2022 edition includes an introductory section dedicated to raising awareness of the importance of gender equality and gender inclusiveness as a rights-based approach to high-quality family planning care. Read about the launch: item/15-11-2022-who-updates-recommendations- to-guide-family-planning-decisions Access the Handbook online: Download the Handbook or the Wall Chart in a range of languages in PDF format: Order a printed copy: order-form Family planning and contraception SPINE FAMILY PLANNING A GLOBAL HANDBOOK FOR PROVIDERS NEW 2022 2022 EDITION FA M ILY P L A N N IN G A G LO B A L H A N D B O O K FO R P R O V ID E R S 2022 W ORLD HEALTH ORGANIZATION JOHN’S HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT C o m p a rin g E ff e ctive n e ss o f F a m ily P la n n in g M e th o d s JOB AID 8 HRP ANNUAL REPORT 2022 2 WHO and HRP developed and launched commitments to FP2030, a global partnership of organizations working on family planning. The organizations signed a memorandum of understanding in November 2022 with the aim of improving access, quality and use of rights-based contraceptive services for everyone who wants them. The commitments are to: • promote rights-based family planning, contraception and fertility care; • promote programme and service innovation and improvements; • provide technical assistance to countries and conduct capacity-building; • facilitate expansion of contraceptive methods; • facilitate meaningful community engagement in the development of guidance; • leverage the IBP (Implementing Best Practices) Network to engage country, regional and global partners; • continue to work with FP2030 through the Adolescent/Youth Technical Assistance Coordination Mechanism; and • work with partners in assessing family planning services in humanitarian settings. Read more about the commitment to strengthen cooperation: 2022-who-and-fp2030-to-strengthen-cooperation- for-sexual-and-reproductive-health-and-rights Access the commitments to FP2030: https://cdn. health/who-srh-fp2030.pdf 3 The two-year Community and Provider-driven Social Accountability Intervention (CaPSAI) project was completed. CaPSAI was a study conducted in Ghana and the United Republic of Tanzania, and supported by HRP, which aimed to demonstrate whether and how social accountability processes influence the quality of family planning information and services provided. It also examined client satisfaction with those services, and aimed to determine whether such interventions lead to improvements in contraceptive uptake and use. There was no significant difference in uptake or continuation of family planning use, when comparing the intervention and control facilities. However a wide range of positive changes in facility-level family planning service provision were reported, including an increase in the number of service users and health personnel, more males accompanying their partners, improved youth-friendly services, training/mentorship for health workers on long- term methods, and more short-term infrastructure improvement projects. A guide was also published to support the implementation of social accountability based on the experiences and results of the CaPSAI study and other available evidence, aimed at implementers – practitioners and civil society organizations. The guide – Community and provider-driven social accountability intervention for family planning and contraceptive service provision: experiences from the field – takes readers through steps to support the design, implementation, monitoring and scale-up of activities, detailing how to establish social accountability programmes that stimulate active engagement from community members as well as health system responsiveness. Access the guide: publications/i/item/9789240031913 9HELPiNg PEOPLE TO REALizE THEiR dEsiREd fAmiLy sizE 4 The WHO Family Planning Accelerator project provided specialized technical support to the national family planning programmes in 14 focus countries, and South–South learning exchange (SSLE) involving 10 countries. The project also strengthened partnerships and global dissemination of new evidence and guidance, depending on the context and needs in each setting. Following this success and the completion of the project, the SRH Department and HRP have obtained funding for Accelerator Plus, a five-year follow-up project to run until 2027, with a focus on scaling up and improving the sustainability of evidence-based interventions like postpartum family planning (PPFP), demand generation, optimizing the roles of health workers providing a range of family planning interventions, self-care, and strengthening adolescent sexual and reproductive health activities. Read an impact story from Afghanistan – the first story in WHO delivering results and making an impact: stories from the ground: https://www.who. int/publications/i/item/9789240064652 Read more in a recent project brief: https://www. planning-accelerator-project 5 Contraception lives in a space where decisions about two socially sensitive topics – fertility and reproduction – take place. Six systematic reviews and an editorial published in the “WHO Values and Preferences” issue of Contraception examined values and preferences relating to contraception across several demographics, including sexually active women, women with specific medical conditions, men, young people and adolescents, women living with HIV, health workers, and people living in humanitarian contexts or special social conditions. The systematic reviews will contribute towards the planned 2023 revision of WHO’s medical eligibility criteria (MEC) and the selected practice recommendations (SPR) for contraceptive use – the two evidence-based guidance documents that are the cornerstones of WHO’s work to develop and implement family planning guidelines for national programmes. Read more: 2022-promoting-contraception-choice-for-every- individual Access the issue: journal/contraception/vol/111/suppl/C 10 HRP ANNUAL REPORT 2022 1 Approximately one in six people – 17.5% – have experienced infertility at some stage in their lives. This is one of the findings of new infertility prevalence estimates for the period 1990–2021, developed by a team including WHO experts, with support from HRP, and published in Human Reproduction Open. Data from 133 studies across the 30-year time span, using five different methods for estimating the prevalence of infertility, were included in the analysis. At a given point in time, the period prevalence of infertility was estimated to be 12.6% of individuals/couples. Infertility prevalence across regions varied, with lifetime prevalence of infertility highest in the WHO Western Pacific Region (23.2%) and lowest in the Eastern Mediterranean Region (10.7%); however, no studies were identified in the South-East Asia Region. The findings did not show any association between countries’ income levels and the prevalence of infertility. Access the article: pmc/articles/PMC9725182/ 2 HRP research revealed wide disparities in the cost of assisted reproductive technology (ART) around the world. A systematic review of the economic costs of fertility care in low- and middle-income countries (LMICs), using data from 17 countries, found that couples pay direct medical costs for ART ranging from US$ 2109 up to US$ 18 592. Costs were generally found to be higher in countries with lower GDP per capita. The costs in countries in the African and South-East Asian Regions were on average around 200% of GDP per capita, while costs were lower in the Americas and in Eastern Mediterranean countries, where there are regulations and government financing mechanisms for ART. These findings support calls for governments in LMICs to implement appropriate regulatory policies and effective public financing mechanisms for ART to ensure universal access to fertility care. The findings will directly inform a WHO fertility care guide, to be published in 2023. Read WHO’s fact sheet on infertility: https://www. Fertility care 11 The major complications that account for nearly 75% of all maternal deaths are severe bleeding, infections, high blood pressure during pregnancy (pre-eclampsia and eclampsia), difficulties during delivery, and unsafe abortion. Maternal deaths are also caused by or associated with diseases such as malaria and HIV. In addition, many more women experience morbidities as a result of complications of pregnancy and childbirth, including various immediate and longer-term debilitating conditions. Just like pregnancy and childbirth, the postnatal period – extending up to six weeks after childbirth – is a critical time for women, newborns, partners, parents, caregivers and families. Up to 30% of maternal deaths occur postpartum, and infants face a high risk of dying in their first month – the global average in 2019 was 17 newborn deaths per 1000 live births. Postnatal care is a fundamental component of the continuum of maternal, newborn and child care, which offers a critical opportunity to improve maternal well-being and support nurturing newborn care. Regrettably, this opportunity is often missed. Recognizing that different approaches are needed to improve maternal and newborn survival, health and well-being, HRP takes a holistic and comprehensive approach across antenatal, intrapartum and postnatal care, while also focusing on leading causes of mortality and morbidity. HRP’s research generates new knowledge and innovative solutions to help ensure equitable access to affordable and good-quality care throughout pregnancy and the perinatal period. HRP continues to generate and synthesize evidence to influence policy change, rapidly translating evidence into clear guidance and fostering partnerships to disseminate best practices, strengthen capacity and address priority challenges faced by health systems. These efforts contribute to reducing maternal and newborn mortality and morbidity, improving the experience of care and ensuring healthy lives and well-being for women and babies. Ensuring the health of pregnant women and girls and their babies 04 Each day in 2020, almost 800 women across the world died from a maternal cause – complications related to pregnancy or childbirth – most of which are preventable or treatable. That is one maternal death every two minutes. The vast majority of these deaths – almost 95% – occurred in low- and lower-middle-income countries in 2020. 12 HRP ANNUAL REPORT 2022 13ENsURiNg THE HEALTH Of PREgNANT WOmEN ANd giRLs ANd THEiR bAbiEs 1 A consolidated guideline presenting new and existing recommendations on routine postnatal care for women and newborns was published in March with HRP support, and is applicable in all facility- and community-based settings providing postnatal care. The new document, WHO recommendations on maternal and newborn care for a positive postnatal experience, includes 63 recommendations (approximately half of which are new) covering individual-level and health-system-level interventions to improve the provision and experience of care during the postnatal period. The guideline has been widely and intensively disseminated in collaboration with all WHO regional and country offices, with supporting multilingual assets. Access the full guideline and additional resources: item/9789240045989 Infographics used to support the launch of the guideline: The first weeks following childbirth are an important and special time Person-centred and respectful postnal care Caring for your baby in the first weeks after birth Adjusting to life with a new baby can be challenging 14 HRP ANNUAL REPORT 2022 2 The Maternal and Perinatal Database for Quality, Equity, Dignity (MPD-4-QED) programme was formally handed over to the Nigeria Federal Ministry of Health in Abuja in November. The programme was originally established with the support of HRP in 2019 with the aim of implementing a nationwide electronic data platform across 54 referral-level hospitals to prospectively collect data on maternal and newborn health following childbirth or pregnancy termination. Key findings of both primary and secondary analyses of programme data – on the quality of maternal and perinatal care and related health outcomes – have been published. The primary analysis of data from the programme’s first year, for 76 853 pregnancies, showed that lack of a companion during labour, non-use of a labour monitoring tool, and non-use of a prophylactic uterotonic to prevent postpartum haemorrhage were strongly associated with maternal and perinatal mortality. Lessons learned from the establishment and implementation of the programme were also presented at a meeting of the Maternal and Perinatal Death Surveillance and Response (MPDSR) Technical Working Group convened by WHO. Access the published findings: https://www. 5370(22)00141-9/fulltext Watch the webinar: https://www. webinar-7-strengthening-maternal-and-perinatal- death-surveillance-and-response Read more: 2022-beyond-numbers--database-brings-to-light- quality-of-care-for-women-and-their-babies-at-a- national-scale 3 The “living guidelines” approach is an innovative approach to keeping WHO recommendations up to date, which has been pioneered by HRP and the SRH Department and adopted across WHO. The WHO maternal and perinatal health recommendations were reviewed in light of new evidence, and were updated in several newly published guidelines, following the living guidelines approach. Two such new guidelines provide 12 updated WHO recommendations on antenatal corticosteroid and tocolytic therapies, which supersede the previous 2015 WHO recommendations on these topics. • WHO recommendations on antenatal corticosteroids for improving preterm birth outcomes item/9789240057296 • WHO recommendation on tocolytic therapy for improving preterm birth outcomes https://www. Another three new guidelines provide five updated WHO recommendations on induction of labour, superseding the previous 2011 and 2018 recommendations on this topic. • WHO recommendations on induction of labour, at or beyond term publications/i/item/9789240052796 • WHO recommendations on outpatient settings for induction of labour publications/i/item/9789240055810 • WHO recommendations on mechanical methods for induction of labour publications/i/item/9789240055780 And finally, the recommendation on ultrasound during pregnancy from the 2016 WHO recommendations on antenatal care for a positive pregnancy experience was updated. • Maternal and fetal assessment update: imaging ultrasound before 24 weeks of pregnancy item/9789240046009 (accompanied by a technical brief to support country implementation: publications/i/item/9789240051461). 15ENsURiNg THE HEALTH Of PREgNANT WOmEN ANd giRLs ANd THEiR bAbiEs 4 A low-cost doppler ultrasound device (Umbiflow ®) can be used to detect placental insufficiency – a contributing factor to fetal growth restriction. HRP, in collaboration with partners and researchers in five countries, implemented a prospective cohort study of 7151 pregnant women at low risk for complications to determine the prevalence of raised fetal umbilical artery flow resistance, using a single Umbiflow screening between 28 and 34 weeks of gestation. The findings indicated that this screening approach can detect a large number of fetuses at risk of growth restriction and consequent adverse perinatal outcomes. The results were published in BMJ Open. Access the article: content/12/3/e053622.long 5 Important new evidence emerged from a WHO and HRP multi-country, randomized trial (the WHO ACTION-I Trial) on the safety and efficacy of antenatal corticosteroids in low-resource settings, which changed previous scientific understanding on this subject. The analysis of this large data set showed that, in women at risk of preterm birth prior to 34 weeks of gestation, the use of dexamethasone is cost-effective, and that the neonatal benefits of dexamethasone increase with longer administration- to-birth intervals than previously thought. Access the article: journals/eclinm/article/PIIS2589-5370(22)00473-4/ fulltext Watch the video: watch?v=Qqp1-BN_t4Y& 6 An HRP/WHO series of articles for the journal PLoS Global Public Health includes reviews on strategies to reduce mistreatment of women and improve respectful care during pregnancy, childbirth and postpartum, focusing on power dynamics, physical and verbal abuse, stigma and discrimination, effective communication, and health system factors. In addition, the results of the first study using a WHO tool to explore factors associated with mistreatment during childbirth were published in BMC Pregnancy and Childbirth. To improve women’s experiences of childbirth and their maternal and perinatal outcomes, WHO recommends a companion of choice for all women throughout labour and childbirth. Access the article on stigma and discrimination: article?id=10.1371/journal.pgph.0000582 Access the article on health system factors: article?id=10.1371/journal.pgph.0001134 Access the article on the WHO tool on mistreatment during childbirth: https://pubmed.ncbi.nlm.nih. gov/36550427/ 16 Around 73 million induced abortions take place worldwide each year. Among all global pregnancies, 3 out of 10 end in induced abortion, while 6 out of 10 unintended pregnancies end in induced abortion. The rate of unsafe abortions is higher where access to effective contraception and safe abortion care is limited or unavailable. Life-threatening complications that may result from unsafe abortion include haemorrhage, infection, and injury to the genital tract and internal organs. In addition to the deaths and disabilities caused by unsafe abortion, there are major social and financial costs to women, families, communities and health systems. Almost every abortion-related death and disability could be prevented through comprehensive sexuality education, use of effective contraception, provision of safe and legal induced abortion, and timely care for complications. Enabling policy environments, and improved access to quality comprehensive abortion care, are crucial within a human rights-based approach to HRP’s mandate to achieve sexual and reproductive health for all. Safe abortion 05 Abortion is a common health intervention and is safe when carried out in accordance with WHO guidelines and standards, using methods appropriate to the pregnancy duration, thus minimizing the risk of severe complications. Comprehensive abortion care includes the provision of information, abortion management and post-abortion care. It encompasses care related to miscarriage, induced abortion, incomplete abortion and fetal death. 17SAFE ABORTION 1 HRP was instrumental in producing the WHO Abortion care guideline, updating and replacing all previous WHO recommendations relating to abortion care. The guideline consolidates over 50 new, existing and updated recommendations on the clinical, service delivery, and law and policy aspects of providing abortion care. All of the recommendations are embedded in human rights considerations, and the overarching emphasis is on quality care, based upon evidence that abortion is a safe and non-complex health-care intervention. The guideline is available in both interactive digital and traditional document formats. An evidence brief focusing on the law and policy recommendations was issued along with a resource kit for the guideline containing communication tools, summary chart on clinical care recommendations for medical abortion, pocket guide, answers to frequently asked questions (FAQs), and technical presentation to generate standardized messaging (available upon request). A digital decision-support tool based on the new WHO guidance has also been finalized and is being field-tested in collaboration with WHO regional and country offices and partner organizations. The tool – which will be available as a mobile app – supports health workers in their decision-making when providing abortion care. The new recommendations are already being used in several countries to update national service-delivery guidelines and as a reference where legal and policy change is being considered. The guideline is also being used by human rights treaty monitoring bodies, several of which have made explicit reference to the guideline’s recommendation for the decriminalization of abortion, including the Committee on the Elimination of Racial Discrimination in its concluding observations to the United States of America (paragraph 36), and the Committee Against Torture in its concluding observations to El Salvador (paragraph 31). The report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health focused on racism and the right to health, and included a reference to several of the recommendations in the new guideline. Access all versions of the guideline and related materials: item/9789240039483 Abortion care guideline 18 HRP ANNUAL REPORT 2022 Infographics that accompanied the launch of the guideline: Self-management of medical abortion is one of the safe and effective options of abortion care Abortion is health care Policy makers can support safe and respectful abortion care All health workers who provide abortion services must be supported to provide quality care Quality abortion care Health systems, laws and policies, and information grounded in evidence and human rights support abortion care for all 19SAFE ABORTION 2 HRP and the Guttmacher Institute produced the first ever country-level estimates of the rates of unintended pregnancy and abortion, published in BMJ Global Health. The estimates – modelled for 150 countries for the period 1990–2019 – showed that rates vary widely, even between countries within the same region. For the most recent five-year period in the study, 2015– 2019, estimated unintended pregnancy rates ranged from a low of 11 per 1000 women aged 15–49 years in Montenegro to a high of 145 in Uganda, while in the same period estimated abortion rates ranged from a low of 5 per 1000 women aged 15–49 years in Singapore to a high of 80 in Georgia. The greatest variations between countries were found in Latin America and sub-Saharan Africa. The estimates highlight the need to invest in family planning and quality abortion services but also the need for better country-level data on these topics. These estimates are being used to facilitate country-level dialogue. Read more: 03-2022-first-ever-country-level-estimates-of- unintended-pregnancy-and-abortion Access the article: e007151 3 HRP and WHO launched an evidence-based Family planning and comprehensive abortion care toolkit for the primary health care workforce (FP and CAC Toolkit) – a consultative and collaborative joint effort with WHO’s Health Workforce Department. Volume 1 of the Toolkit presents and describes the three groups of competencies needed by FP and CAC service providers: attitudes, professional competencies and practice competencies. The 57 competencies (organized into 10 domains) will help define learning objectives and design curricula for education and training, set performance standards (for recruitment, appraisal and regulation), develop practice guidelines, and provide a shared language to facilitate effective collaboration in this field. Volume 2 is a programme and curriculum development guide. Volume 3 is under development and will be published in 2023 – the Dissemination, implementation, monitoring and evaluation guide, to support policy-makers, regulators, educators and health service managers to implement the FP and CAC competencies, putting evidence and policy into improved practice. Access the first two volumes of the FP and CAC Toolkit: • Volume 1: Competencies publications/i/item/9789240063884 • Volume 2: Programme and curriculum development guide publications/i/item/9789240063907 Watch the video on FP and CAC competencies for health workers: watch?v=MX-0AuFmh9E 20 HRP ANNUAL REPORT 2022 Nine photos from the International Safe Abortion Day photo story exhibition were displayed at WHO’s main headquarters building to raise awareness of abortion as health care among colleagues and visitors. 4 Given the heightened global interest in the topic of abortion, HRP made use of various media and channels to expand the reach of messaging to the general public on abortion as essential health care, especially around the occasion of International Safe Abortion Day. Before embarking on preparing these live and recorded items, HRP carried out a social media listening exercise to help guide the messaging. • TikTok video on safe abortion: https://www. • Instagram Reels: stories/who/2830833566771959803/ • Read a transcript of the Twitter Space live conversation: item/26-09-2022-ask-the-expert-10-questions- on-safe-abortion-care • Watch the “Science in 5” episode on safe abortion (part of a WHO video and podcast series): science-in-5-safe-abortions • Webinar by WHO and HRP, hosted by the IBP Network: My Story, Your Camera, Our Rights: detail/2022/09/22/default-calendar/webinar-my- story-your-camera-our-rights-communicating-on- abortion-care-and-family-planning-as-health-care Photos from storytelling projects in four WHO regions were exhibited at WHO headquarters and online, sharing positive perspectives on abortion care and contraception. • Photo story exhibition launched on International Safe Abortion Day 2022: room/photo-story/photo-story-detail/ensuring- healthy-outcomes-access-to-quality-abortion-care- for-the-health-and-rights-of-women-and-girls 21SAFE ABORTION 5 HRP provided technical support to over 40 countries across all six WHO regions (see map) to reduce maternal mortality and achieve SDG targets through a health systems approach. This included a fourth year of coordinating the implementation and monitoring of a 10-country initiative for a comprehensive approach to reducing maternal mortality and addressing unsafe abortion through health system strengthening. Through the efforts of five WHO departments at headquarters and 25 dedicated international staff working at the country, region and headquarters levels, the programme reaches most countries across three regions through dissemination, dialogue and focused interventions. Some achievements of this programme include aligning national guidelines and essential medicines lists with WHO recommendations, integrating family planning and comprehensive abortion care competencies into pre-service education and training at academic institutions, addressing gaps in data needed to systematically measure and monitor abortion services and outcomes, and integrating comprehensive abortion care into national basic health services and benefit packages. Another ongoing technical support initiative is the Joint United Nations 2gether 4 SRHR programme – a collaboration between the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF) and WHO to improve sexual and reproductive health outcomes in 10 focus countries in the southern and eastern African Region. The programme works on a range of issues related to abortion care, including supporting countries with national dialogue, assessments, guideline alignment and health worker training, with over 740 health workers trained to date using values clarification and attitude transformation approaches. HRP technical support to countries in 2022 In-depth support Focused activity 22 06 WHO defines sexual health as “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” Promoting sexual health and well-being HRP’s work on sexual health and well-being spans the continuum from disease and dysfunction to well-being. This includes research on the prevention and control of sexually transmitted infections (STIs); prevention of cervical cancer; education, counselling and care related to sexuality, sexual identity and sexual relationships; and sexual function, pleasure, and psychosexual counselling. 23PROmOTiNg sExUAL HEALTH ANd WELL-bEiNg 1 HRP led development of WHO’s first fact sheet on menopause, recognizing this important transition period in the life course, and that women’s sexual health needs are not limited to the reproductive years. Launched on World Menopause Day, the fact sheet was a collaboration with the WHO SRH Department and the Ageing Unit at WHO’s Department of Maternal, Newborn, Child and Adolescent Health and Ageing. Menopause-related health services were also incorporated into the ongoing efforts to develop the sexual and reproductive health and rights (SRHR) module within the UHC Compendium. Access the menopause fact sheet: https://www. Watch the menopause awareness video reel on Instagram: CkS0tpfj9E3/ See the WHO Twitter thread of infographics marking World Menopause Day: https://twitter. com/WHO/status/1582301398225469440 2 HRP completed its four-stage implementation research study on the Brief sexuality-related communication (BSC) guideline in eight primary health care settings in two countries. BSC is a public health intervention recommended by WHO for supporting sexuality counselling in primary health care settings. Preliminary reports were developed and findings were presented at the 23rd IUSTI World Congress in September 2022 in Zimbabwe, and at the Republic of Moldova’s Fifth National Conference on Adolescent Health in November. The study demonstrated willingness to use the BSC intervention among both health workers and clients at primary care level in both countries. BSC was found to improve the ability of providers to talk with their clients about sex, which also benefited the clients, including those from vulnerable and marginalized populations. The BSC intervention has now been included in the National Sexual and Reproductive Health Strategy in the Republic of Moldova, and a comprehensive training package for health workers (in-person and online versions) and training-of-trainers materials are now being field-tested. 3 Interdepartmental collaborative work began on the development of WHO’s first guideline on the health and well-being of trans and gender-diverse (TGD) persons, with the active support of HRP. Refer to Chapter 10, item 2, for more details. Sexual health and well-being 24 HRP ANNUAL REPORT 2022 1 HRP, with the SRH Department, is undertaking an STI research priority-setting exercise to identify global and regional STI research priorities, using a consultative approach to get input from a wide range of global stakeholders. The protocol for this priority-setting process was finalized and approved in 2022. The first online global survey to generate research ideas was subsequently completed and the results were analysed to consolidate the research ideas and develop a second survey, focusing on ranking the research areas (including a monkeypox research priority list based on the results of the first survey), to be carried out in 2023. In addition, a symposium of STI-related research priorities for monkeypox (also now known as mpox) was convened on 5 September at the 23rd IUSTI World Congress in Zimbabwe. Access the flyer about the priority-setting exercise: hq-hiv-hepatitis-and-stis-library/stis/iusti2022_4_ research-agenda.pdf Research on sexually transmitted infections (STIs) 2 The development of new vaccines for STIs is essential for achieving sustainable global STI control. WHO and global partners launched the first online portal on vaccine development for STIs, called STI Watch, and published a roadmap to accelerate STI vaccine development with three key workstreams: (i) make the case for STI vaccine investment; (ii) expedite research and development; and (iii) optimize global benefits and access. New research and innovations will address the evidence gaps that have hindered global progress in STI prevention and control, and thus strengthen the evidence base for new and improved interventions and public health programming. Read more: 09-2022-who-and-partners-launch-a-new-online- resource-to-advance-sti-vaccine-development Access the STI Watch portal, including the STI vaccine roadmap: 25PROmOTiNg sExUAL HEALTH ANd WELL-bEiNg Source: 26 HRP ANNUAL REPORT 2022 1 On the path to eliminating cervical cancer, therapeutic HPV vaccines designed to clear HPV infection or regress cervical pre-cancers could play an important role in reducing cervical cancer deaths. Work in this area has been a long-standing and collaborative focus for HRP. Expert consultations were convened and a report was subsequently published on considerations for assessing the public health value – and defining the preferred characteristics – of these vaccines. After a follow- up expert consultation to draft the preferred product characteristics, these were presented to the WHO Product Development for Vaccines Advisory Committee. The final preferred product characteristics document for therapeutic HPV vaccines will be published in 2023. In addition, a protocol for a qualitative and quantitative end-user assessment for therapeutic HPV vaccines was developed, ethical review was completed, and it will be implemented in 2023. Access the article: https://pubmed.ncbi.nlm.nih. gov/36008233/ 2 A policy brief was published by HRP on the use of and the differences between HPV DNA-based and HPV mRNA-based tests to screen for cervical pre-cancer lesions and prevent cervical cancer. This brief followed up on last year’s updated WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention, with publications focusing on HPV DNA testing and HPV mRNA testing as methods of cervical cancer screening. Access the policy brief on HPV DNA and HPV mRNA testing: item/9789240045248 3 The first meeting of the Guideline Development Group was held to create new “living recommendations and systematic reviews” for screening and treatment to prevent cervical cancer – a new approach to guidelines pioneered by the SRH Department and HRP, involving an ongoing system to critically appraise new evidence and adjust recommendations as appropriate, with rigorous review by a panel of experts as for all WHO guidelines. New screening techniques and strategies with enough accumulated evidence were reviewed and ranked in order of priority, as was new evidence relating to existing techniques – such as ways to improve the technique or the potential to offer the technique to additional populations. Based on this prioritization exercise, research questions are being formulated about these issues, and then systematic reviews will be conducted to gather and analyse the evidence, as a basis for updating and adding WHO recommendations to the guideline. Preventing and treating HPV infection and cervical pre-cancers 27 As health systems and supply chains continue to be affected by severe disruption, people have faced challenges in accessing sexual and reproductive health care – including contraception, fertility care, abortion information and services, and cervical cancer prevention, screening and treatment services. It is critical to uphold women’s rights to a positive pregnancy, intrapartum and postnatal experience, while still observing protocols to avoid infection with COVID-19. According to United Nations estimates, at the end of 2021, approximately 84 million people worldwide were in situations where they had been forcibly displaced and approximately 25% of these people were estimated to be women of reproductive age. While progress has been seen in improving sexual and reproductive health services in some crisis settings, significant gaps remain, which have been further exacerbated by ongoing health emergencies. Women and girls in general are more negatively affected by the socioeconomic repercussions of these crises, including job losses, increased burdens of unpaid work and increased rates of violence against women. The critical importance of scientific evidence to guide planning and action cannot be overstated in order to meet the specific SRHR needs of women and girls, as well as the needs of men and boys, living in health emergencies. Sexual and reproductive health and rights (SRHR) during the global COVID-19 pandemic and other health emergencies 07 Countries around the world are under constant threat from infectious diseases and conflict, and increasingly face threats related to natural disasters and climate change. While COVID-19 remains a global health emergency, other disease outbreaks and health emergencies also require urgent attention. When health systems are disrupted, sexual and reproductive health and rights quickly suffer. 28 HRP ANNUAL REPORT 2022 29 1 HRP led a multi-country prospective cohort study to better understand how infection with SARS-CoV-2 (COVID-19) impacts maternal, pregnancy and postnatal outcomes among women and newborns. The initial protocol was amended to also include research questions about the use of COVID-19 vaccines during pregnancy. The objectives are to (i) determine if SARS-CoV-2 infection during pregnancy increases the risk of adverse outcomes; (ii) assess the proportion of newborns, fetuses and fetal tissue (among all pregnancies) that have detectable SARS-CoV-2 RNA; and (iii) describe the outcomes among women who have received at least one dose of a COVID-19 vaccine during pregnancy. The study was designed to enable the rapid, systematic and harmonized collection of data and biological specimens, and to facilitate data comparison across different settings globally. Technical support to adapt the protocol for study implementation in local contexts has been provided to 44 sites in eight countries and more than 15 200 pregnant women have been recruited to the study to date. Access the study protocol: publications/i/item/WHO-2019-nCoV-pregnancy- and-neonates-2022.1 2 HRP research informed a WHO Questions and Answers (Q&A) document providing information to health workers and the public on the safety and effectiveness of COVID-19 vaccination during pregnancy. The document also interprets the WHO Strategic Advisory Group of Experts (SAGE) recommendations for eight WHO-approved vaccines. Access the Q&A document: https://www.who. int/publications/i/item/WHO-2019-nCoV-FAQ- Pregnancy-Vaccines-2022.1 Watch the animated film “Your Pregnancy and the COVID-19 vaccination” developed with the Partnership for Maternal, Newborn and Child Health (PMNCH) and partners: watch?v=Bo2Ypfp7jv0 SRHR during the COVID-19 pandemic 30 HRP ANNUAL REPORT 2022 1 HRP’s work on health systems and delivery of sexual and reproductive health services in fragile and humanitarian settings has led to the following key achievements in 2022: • Strengthening evidence and prioritizing relevant research: An integrated intervention package on psychosocial, sexual and reproductive health for adolescent girls and young women refugees aged 15–24 was developed. This work was informed and facilitated by two years of research (SEEK trial – Self-efficacy and knowledge to improve sexual and reproductive health and well-being in humanitarian settings) and community engagement, led by international experts in the fields of mental health and sexual and reproductive health, national researchers, national stakeholders, refugees and three in- country research teams. • Strengthening data systems and accountability: A WHO monitoring and evaluation framework for sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) services and outcomes in humanitarian settings was developed. A research paper summarizing the methodology and the phases of development of this framework, and presenting a final list of endorsed indicators, was published in Dialogues in Health. Access the article: science/article/pii/S2772653322000752 SRHR in humanitarian emergencies 31HEALTHy AdOLEscENcE fOR A HEALTHy fUTURE Enormous progress has been made in adolescent sexual and reproductive health (ASRH) over the past two decades, but it has been uneven across different health issues, geographic areas and groups. Many adolescents across the world still face considerable challenges to their sexual and reproductive health and rights (SRHR). These include: sexual coercion and intimate partner violence; lack of education and information; high rates of early and unwanted pregnancy; lack of access to essential health services, especially for contraception and safe abortion; gender inequalities and harmful traditional practices, such as female genital mutilation (FGM), and child/early and forced marriage; and the risk of STIs (including HIV). With ASRH rising on the global health, development and human rights agendas, there has been the opportunity to move forward, but obstacles include global economic and humanitarian crises around the world, and growing opposition to several aspects of sexual and reproductive health care. HRP focuses on using the expertise gained in ASRH over the years to strategically build initiatives in other areas, such as mental health and nutrition, which can also contribute to improved ASRH. When conducting ASRH research, advocacy and capacity-strengthening work, HRP and the SRH Department work with adolescents and young people themselves, and a range of other partners. Healthy adolescence for a healthy future 08 Adolescence is the unique period of life that encompasses the transition from childhood to adulthood. WHO defines adolescents as people aged between 10 and 19 years, while recognizing that age is only one characteristic defining this critical period of rapid human development. An individual’s behaviour and the choices they make during this time can determine their future health and well-being. 32 HRP ANNUAL REPORT 2022 1 HRP completed a multi-country implementation research study on comprehensive sexuality education (CSE), with support from the SRH Department. The study aimed to test the feasibility, acceptability and effectiveness of efforts to improve the performance of facilitators in delivering CSE to different groups of adolescents in out-of-school settings in four countries. Activities included data collection, management and analysis, plus developing tools to aid the research teams with this work and to ensure consistency between countries. Meetings within and between countries brought together the researchers and supported their collective efforts, including report writing. In 2022, the Government of Norway and UNFPA confirmed their support for extension of the study and expansion to seven other countries. 2 A series of 36 case studies about nimble responses to the sexual and reproductive health needs of adolescents during the COVID-19 crisis distilled valuable country-level experiences and lessons. Some examples from publications include: • The Programme for Adolescent Mothers (PAM) was developed with expertise from within Jamaica to support adolescent girls who are pregnant or young parents to continue their schooling with a package of interventions, including sexuality education and contraceptive services. The Women’s Center of Jamaica Foundation, a Jamaican nongovernmental organization (NGO), led work to pilot, scale up and sustain the programme in Jamaica, before the programme was replicated in other Caribbean countries. Access the case study: full/10.1080/15546128.2022.2093808. • Nigeria’s national Family Life and HIV Education (FLHE) programme has built support and addressed local resistance to sexuality education since 2003, to enable scale-up and sustainability of the programme. Access the case study: doi/10.1515/openhe-2022-0027/html. • A nongovernmental organization in India reoriented an existing district-level programme in Maharashtra State to enable community health workers to respond to the needs of adolescent mothers. Access the case study: HRP, with the SRH Department, posted two briefs about these case studies in WHO’s Health Services Learning Hub: contraception-related-services-during-covid-19 comprehensive-sexuality-education-during- covid-19 The case studies have also been included in an updated version of the WHO tool on Accelerated Action for the Health of Adolescents (AA-HA!), and in major consultations, such as the technical consultation to advance adolescent-responsive health systems, which was co-hosted by the SRH Department and USAID’s Momentum Project in October 2022. Read more about the case studies: https://www. learning/who-case-studies/ 33HEALTHy AdOLEscENcE fOR A HEALTHy fUTURE 3 Eleven countries were supported in three regions through the vibrant WHO Adolescent/Youth Sexual and Reproductive Health and Rights (AYSRHR) Technical Assistance Coordination Mechanism. In three countries, the first phase of technical assistance support was provided successfully and the second phase got under way or was being negotiated in 2022, while the other countries are in or have completed the first phase. Diverse issues have been addressed through this technical assistance programme so far, including: responding to the needs of pregnant adolescents and first- time adolescent mothers; using innovative methods to build capacity among health workers; adolescent health programme priority-setting in difficult contexts; strengthening programming at subnational and district levels; and making the best use of available funds. HRP and the SRH Department drew lessons from this work, and have made steady progress. Tools were developed that can be applied more widely: • a list of five top missed opportunities, with recommendations for ministries of health as they develop their FP2030 commitments (developed in collaboration with FP2030); • an opportunities framework that aims to group recommendations around existing programmes and interventions to help them make the best use of available opportunities (based on work in Afghanistan); • an impact model to help technical assistance providers clarify their tasks and monitor their contributions to defined outcomes. The collective experiences and lessons learned were shared with interested funders during a webinar hosted by the Bill & Melinda Gates Foundation in June 2022, and outputs of these technical assistance efforts have been finalized for sharing among partner organizations and a wider community of stakeholders and practitioners. A funding commitment from the Bill & Melinda Gates Foundation will continue supporting the AYSRHR Technical Assistance Coordination Mechanism’s work for a further five-year period, to follow on from the initial period 2019–2022. 34 09 Violence against women and girls constitutes a major public health concern and is a grave violation of human rights, rooted in gender inequalities. Violence against women and girls takes multiple forms, including intimate partner violence, sexual violence, child/early and forced marriage, femicide and trafficking. WHO estimates indicate that, across their lifetime, one in three women – around 736 million– are subjected to physical or sexual violence by an intimate partner or sexual violence from a non-partner; these numbers have remained largely unchanged over the past decade. Violence against women and girls can lead to a range of adverse physical, mental and psychosocial health outcomes, including negative impacts on sexual and reproductive health and rights (SRHR). Intimate partner violence and non-partner sexual violence can lead to unintended pregnancies, induced abortions, gynaecological problems and STIs, including HIV. Intimate partner violence during pregnancy also increases the likelihood of miscarriage, stillbirth, preterm delivery and low-birth-weight infants. Conflict and post-conflict situations, including displacement, can exacerbate violence against women and girls, and may present the risk of additional forms of violence. The health sector is often the first point of contact for women seeking services for health conditions linked to violence. Countries have a mandate to respond to violence against women through the health sector, in accordance with World Health Assembly Resolutions and a global plan of action. Female genital mutilation (FGM) is a traditional harmful practice that is also rooted in unequal gender norms. FGM affects 200 million women and girls globally. FGM has no health benefits, interferes with the natural functions of girls’ and women’s bodies and can result in negative health consequences, both short- and long- term. The health sector has an important role in ensuring the highest quality of care for girls and women who have already undergone FGM, and in preventing – and ultimately ending – this harmful practice. WHO has a leadership role in building the evidence base for what works, and ensuring that existing guidance and tools for prevention and treatment of FGM are integrated into the health systems in high-prevalence countries. Preventing and responding to violence against women and girls 35PREvENTiNg ANd REsPONdiNg TO viOLENcE AgAiNsT WOmEN ANd giRLs 1 Data are critical for ensuring accountability for the well-being of millions of women and girls at risk of or subjected to violence. HRP’s and WHO’s research, Global, regional, and national prevalence estimates of physical or sexual, or both, intimate partner violence against women in 2018, was published in The Lancet. The findings build upon the estimates for intimate partner violence previously presented in WHO’s Violence against women prevalence estimates, 2018, which also included estimates for non-partner violence. The publication of the Lancet article was accompanied by a press release and an infographic. The estimates and measurement methods were presented at the 16th meeting of the Inter-Agency and Expert Group on Gender Statistics (IAEG-GS) in December 2022, and several presentations at the Sexual Violence Research Initiative (SVRI) Forum in September. Furthermore, a module to measure violence against women was included in the World Health Survey Plus (WHS+), and a new module was developed to capture specific forms of violence experienced by older women, and was tested by the WHS+. Access the article: article/S0140-6736(21)02664-7/fulltext Access the paper detailing the methodology used to generate the estimates of intimate partner violence: articles/10.1186/s12874-022-01634-5 Access a related infographic article highlighting the high global prevalence and regional patterns of intimate partner violence against adolescent girls aged 15–19: S1054-139X(21)00689-3/fulltext 2 Together with UN Women, WHO launched new global technical guidance on Improving the collection and use of administrative data on violence against women in May 2022. This document provides information for the health, justice, police and social services sectors about the essential data that must be reported and managed in a consistent way across sectors, the safety and ethical considerations when recording such data, and how best to use these data to provide effective services for survivors. The new global guidance is available in Arabic, English and French, and HRP and UN Women will be disseminating and rolling out the guidance through webinars and collaborative work at the country level. Access the guidance: publications/i/item/9789240058750 Violence against women and girls 36 HRP ANNUAL REPORT 2022 3 WHO, with HRP, published a new training tool to support the health sector response to violence against women – Addressing violence against women in pre-service health training. This is a companion document to the revised 2021 edition of Caring for women subjected to violence: a WHO curriculum for training health-care providers. The new tool is designed to support pre-service health training programmes, such as those at medical, nursing and midwifery schools, by providing information and resources to help them better prepare their students to care for women subjected to violence. The publication guides users on how to plan, develop and implement activities to help integrate and adapt sessions from the WHO curriculum into pre-service health worker education programmes. It also includes country case studies, illustrating how some countries have integrated the teaching of these skills within their pre-service curricula. Access the pre-service health training tool: www. 4 HRP’s cosponsors – UNDP, UNFPA, UNICEF, WHO and the World Bank – and so many partners have continued to facilitate uptake of the guidelines and tools related to prevention of and response to violence against women, by translating them into policies, health system strengthening efforts and clinical practice, for greater impact in countries, including in humanitarian settings. • The 2020 Clinical management of rape and intimate partner violence survivors guideline for humanitarian settings (which has been recently translated into Polish and Ukrainian) along with the 2021 Caring for women subjected to violence curriculum (mentioned above) were used to train health workers and partners, and to integrate gender-based violence into health emergency plans in 21 current humanitarian emergencies across five WHO regions. A series of five relevant online courses has also been released: https:// • WHO guidelines and tools on violence against women were reportedly being used in at least 73 countries. • The United States President’s Emergency Plan for AIDS Relief (PEPFAR) HIV/AIDS programmes delivered through the United States Agency for International Development (USAID) and the Centers for Disease Control and Prevention (CDC) provided the WHO first-line support training (LIVES: Listen, Inquire, Validate, Enhancing safety and providing Support) to over 1000 people from across their implementing partner agencies, primarily in east and southern Africa (the training is based on the 2021 edition of Caring for women subjected to violence: a WHO curriculum for training health-care providers). • In collaboration with UNFPA, master trainers from 10 countries in the WHO South-East Asia Region were trained to strengthen the capacity of health managers to plan, manage and monitor services for survivors of violence against women and girls, in line with WHO guidelines. • Together with UN Women and UNFPA, WHO facilitated training for personnel from national ministries of health, justice and gender, and the police forces of 12 countries, using the RESPECT Women prevention package to strengthen national capacity for evidence-based prevention programming. Addressing violence against women in pre-service health training Integrating content from the Caring for women subjected to violence curriculum 37PREvENTiNg ANd REsPONdiNg TO viOLENcE AgAiNsT WOmEN ANd giRLs Female genital mutilation (FGM) 1 Health workers are respected members of their communities and thus influential advocates for change. With this in mind, two key training documents relating to FGM prevention and care were launched in early February, in recognition of the International Day of Zero Tolerance for FGM: • HRP and WHO developed the first FGM prevention training package for health workers in countries where FGM is prevalent: Person-centred communication for FGM prevention. Along with a facilitator’s guide, there are training slides and a four-minute animated motivational video for training, which tells the story of a midwife who becomes an opinion leader working to end FGM in her community. The package applies theories relating to changing social norms and behaviour, and uses a highly interactive and participatory approach. The package was field-tested with nurses, midwives and other health workers. • A practical guide was published on integrating FGM content into nursing and midwifery curricula, which walks the user through a series of steps using a worksheet, checklist and tables to tailor FGM content for their curricula, based on their country context and needs. The guide was developed in collaboration with midwives, nurses and educators responsible for curriculum planning at global, regional and country levels. It enables countries to ensure that FGM content is sustainably integrated into pre-service content and is aligned with professional competencies. Access the training package: publications/i/item/9789240041073 Access the practical guide: publications/i/item/9789240042025 Read more about the launch of both documents: supporting-health-care-providers-to-make-positive- change-who-launches-new-training-tools-on- female-genital-mutilation-prevention-and-care 2 A new WHO and HRP web-based resource kit for the health sector on FGM prevention and care hosts a repository of all the latest resources for building a public health approach to end FGM. The resources are organized into six categories: planning; training and education (including the two new resources highlighted in the item above); clinical care; monitoring and evaluation; advocacy; and research. The kit is aimed at health workers, health policy-makers, programme planners and managers, educators, members of professional associations, monitoring and evaluation experts, researchers, civil society and the public. The kit encourages users in countries where FGM is prevalent to implement activities within the health sector by adapting the existing resources to their specific needs, cultural context and language(s). Access the resource kit: fgmresources/ 38 HRP ANNUAL REPORT 2022 3 HRP published an analysis of the economic burden of FGM in 27 high-prevalence countries – the basis for the FGM Cost Calculator (2020). The health economic analysis presents both the health-related costs of FGM and the costs that would be averted by investing in preventing FGM. The launch webinar on 3 February included a panel discussion on the economic impacts of FGM on health systems and the urgent need to invest in prevention, with panellists representing donor countries and the African Union, as well as activists and health workers from FGM-prevalent settings and representatives of youth organizations. Country fact sheets were also developed and added to the FGM Cost Calculator website, showing each country’s specific health economic costs and projections. Several countries are actively using the FGM Cost Calculator as part of their assessments as a basis for health-sector planning and advocacy. Access the article: e004512 Access the FGM Cost Calculator, including the fact sheets: 4 With UNFPA, UNICEF and the Population Council, HRP contributed to a research agenda to strengthen the generation and use of evidence to accelerate the elimination of FGM, based on a synthesis of evidence and a prioritization process. This initiative involved first mapping all the studies that have tested interventions for FGM prevention and care, rating the quality of the available evidence, holding a stakeholder consultation to review evidence gaps, ranking the research priorities, and finally developing a research agenda on FGM-related research priorities to guide researchers, programme planners and donors. The agenda clearly outlines key areas where further research could inform valuable improvements in programming. The research agenda was launched jointly by all partners via a webinar in January, along with WHO/HRP’s ethical considerations in research on FGM. Access the research agenda: https://www.unicef. org/documents/research-agenda-strengthen- evidence-generation-and-utilisation-accelerate- elimination-fgm Access the ethical considerations: https://www. Read more about the launch of both documents: ensuring-quality-and-ethics-of-research-on-fgm- new-who-guidance-out-now 1 INTRODUCTION A RESEARCH AGENDA TO STRENGTHEN EVIDENCE GENERATION AND UTILISATION TO ACCELERATE THE ELIMINATION OF FEMALE GENITAL MUTILATION Effectiveness of Interventions Designed to Prevent or Respond to Female Genital Mutilation A Review of Evidence June 2021 1Ethical considerations in research on female genital mutilation ETHICAL CONSIDERATIONS IN RESEARCH ON FEMALE GENITAL MUTILATION 39 The “right to health does not stand alone but is indivisible from other human rights. Good health not only depends on but is also a prerequisite for pursuing other rights. Human rights cannot be fully enjoyed without health; likewise, health cannot be fully enjoyed without the dignity that is upheld by all other human rights”.1 HRP generates knowledge, standards, tools and approaches that support countries to ensure that sexual and reproductive health interventions not only achieve health outcomes but also address underlying gender inequalities and asymmetries in power, and contribute to the agency of all women, 1 Source: Leading the realization of human rights to health and through health (WHO High-Level Working Group on the Health and Human Rights of Women, Children and Adolescents, 2017). girls and gender-diverse people to achieve bodily autonomy and sexual and reproductive justice. Gender equality and sexual and reproductive rights underpin the entirety of HRP’s programme of research and guidance development, including in cross-cutting focus areas that advance thinking, knowledge and transformative practice, such as furthering knowledge on the relationship between constructions of masculinity and sexual and reproductive health, and addressing bodily autonomy and sexual and reproductive justice for intersex and gender-diverse individuals, including trans people. Achieving gender equality and sexual and reproductive health and rights (SRHR) 10 Human rights and gender equality are fundamental to people’s health and well-being, and to the social and economic development of communities and nations. Discrimination, abuse and violence, however, continue to prevent people everywhere from fulfilling their human right to the highest standard of sexual and reproductive health. 40 HRP ANNUAL REPORT 2022 1 A participatory exercise was launched to establish consensus on research priorities that will improve knowledge and understanding of masculinities (constructions of masculinity) within the global SRHR research community. This priority-setting exercise aims to fill the significant gaps in the evidence base on how to effectively shift harmful gender norms and power asymmetries that restrict bodily autonomy for women, girls and gender- diverse individuals. WHO and HRP launched this exercise together with MenEngage Alliance, Queen’s University Belfast, the University of the Western Cape and Stellenbosch University, as a continuation of ongoing collaborative work addressing masculinities to improve SRHR outcomes. The exercise was conducted using an adapted version of the Child Health and Nutrition Research Initiative (CHNRI) survey methodology, informed by an inclusive, feminist decolonizing approach. The project website was finalized and launched to host the survey as well as provide information on the exercise, including an informational brief in Arabic, English, French and Spanish, and to provide a forum for ongoing engagement. Access the project website: https://masculinities. 2 HRP is playing a leading role in the development of WHO’s first ever guidance document on trans and gender-diverse (TGD) people’s health, to enhance evidence and generate recommendations on various aspects of bodily autonomy and sexual and reproductive health and justice for these populations. A community consultation was conducted in May 2022 to identify priorities. On that basis, HRP – collaborating with the WHO Departments of Global HIV, Hepatitis and STIs Programmes (HHS) and Gender, Equity and Human Rights (GER) – is developing a proposal focusing on gender-affirming care (including hormone therapy), health worker training to provide gender-inclusive care, health-care interventions for survivors of violence against TGD people, gender-inclusive health policies and gender identity recognition laws, and the issues of stigma, discrimination and quality of life. A refined version of the proposal was approved in October 2022. 3 Inadequate attention in research to sex differences and underlying gender inequalities – which influence health risks, outcomes and access to services – has contributed to a situation where inequalities have persisted and many interventions in the area of sexual and reproductive health have been relatively ineffective. HRP, together with the Special Programme for Research and Training in Tropical Diseases (TDR), has built upon existing capacity-strengthening initiatives to address and integrate sex, gender and human rights within sexual and reproductive health research with HRP partners and other research institutions. A systematic review of relevant available capacity-building tools and resources was completed in early 2022, which identified a wide range of resources relevant to the integration of sex, gender and rights within the research process. 4 Several key research reports and guidelines published by HRP and across WHO in 2022 address underlying gender norms and the promotion of rights-based approaches to advance bodily autonomy and sexual and reproductive justice: • The new WHO Abortion care guideline and accompanying evidence brief on a supportive law and policy environment both included significant material on rights, roles and responsibilities. • The updated 2022 edition of Family planning: a global handbook for providers has an introductory section on gender equality and gender inclusiveness. • Counselling on sexual and reproductive rights within respectful and equal gender relationships, and access to rights-based gender-equal and gender-inclusive sexual health education, are included among the sexual health interventions within the UHC Compendium. 41AcHiEviNg gENdER EqUALiTy ANd sExUAL ANd REPROdUcTivE HEALTH ANd RigHTs (sRHR) 5 HRP efforts to centrally position gender equality and human rights on the political and research agenda are more impactful when there is strategic collaboration with other actors. In 2022, HRP renewed and reenergized key collaborations. In particular, HRP has forged a closer and mutually reinforcing strategic partnership with the Office of the United Nations High Commissioner for Human Rights (OHCHR) and with key civil society groups active at international and national levels, with a specific focus on strengthening SRHR accountability and justice. Examples of this include: • The Human Rights Council recognized menstrual health as a human rights and gender equality issue for the first time: news/item/22-06-2022-who-statement-on- menstrual-health-and-rights. • The new WHO Abortion care guideline has been recognized and referenced by United Nations human rights treaty bodies in their recommendations to countries (see Chapter 5, item 1). 6 There has been increased engagement with and improved attention from parliamentarians to gender equality and SRHR as central to universal health coverage (UHC) at the global level and within humanitarian and fragile contexts. Parliamentarians have a particularly important role in ensuring government accountability and the central positioning of SRHR within national public health and gender equality agendas. HRP has worked with parliamentarians to bridge science and policy spaces, within the framework of UHC. HRP and the SRH Department co-convened, with the European Parliamentary Forum for Sexual and Reproductive Health and Rights (EPF) and UNFPA, two parliamentary forums in 2022 with an emphasis on HIV and self-care interventions, and on family planning. HRP also played a catalytic role at the Inter-Parliamentary Union (IPU) Assembly in Kigali, Rwanda, in October, which had the theme “Gender equality and gender-sensitive parliaments as drivers of change for a more resilient and peaceful world”. A side event was organized on “Unlocking gender equality in universal health coverage: how are parliamentarians using sexual and reproductive health and rights as the key?” and significant inputs related to gender equality and SRHR were also provided for the resultant resolution, which stressed gender equality and SRHR as integral to UHC. Similarly, HRP and the SRH Department led an inter-parliamentarian discussion on the role of SRHR in peace-building during the World Health Summit 2022 in Berlin, Germany, in October. 7 SRHR perspectives, including HRP research, guidance and tools, have been integrated within the WHO three-level response to the health emergency triggered by the war in Ukraine in 2022. This support has focused on both Ukraine and refugee-receiving countries and ranged from high-level positioning and advocacy to the technical development and coordination of country-based response actions. Support has been provided to several affected countries, in particular on strengthening systems and services for women subjected to gender-based violence and on fact- finding and documentation of access to sexual and reproductive health services from a human rights accountability perspective. 42 For this to become a reality, it must be based on strong, people-centred primary health care (PHC). In recognition of this, HRP works to ensure a strong evidence base for integrating, implementing and financing sexual and reproductive health within WHO guidance and tools on implementing UHC in national health systems. WHO colleagues and partners across the world collaborate with HRP to produce evidence and guidance on digital health and self-care interventions, health data and monitoring systems, and the delivery of sexual and reproductive health services in fragile health systems, especially humanitarian settings. These efforts are intended to help decision-makers across sectors make good decisions based on evidence and informed by best practices, with the broader aim of achieving sustainable and well integrated outcomes that recognize local contexts, and ultimately improve health for all. HRP works on innovative digital tools designed to better connect decision-makers with health systems, and health workers with high-quality, evidence-based WHO guidance. At the same time, people-centred self-care interventions for sexual and reproductive health and rights (SRHR) are important to improve people’s autonomy, and the COVID-19 pandemic brought these interventions to the forefront of national health system responses. HRP’s research on self-care innovations as part of broader strategies for health recognizes how self-care can help individuals and communities to access high-quality health services and take care of their own health and the health of their families. Supporting and strengthening national health systems for achieving universal health coverage (UHC) 11 Much of HRP’s research is directly focused on strengthening various elements of national health systems in order to achieve UHC, including access to sexual and reproductive health services for all. UHC – including sexual and reproductive health – means that all people have access to the health services they need, when and where they need them, without suffering financial hardship. 43sUPPORTiNg ANd sTRENgTHENiNg NATiONAL HEALTH sysTEms fOR AcHiEviNg UNivERsAL HEALTH cOvERAgE (UHc) 1 HRP supported a new WHO handbook titled Critical considerations and actions for achieving universal access to sexual and reproductive health in the context of universal health coverage (UHC) through a primary health care (PHC) approach. This handbook is intended to support country-level processes, by providing implementation guidance relevant to the context of PHC and UHC policy and strategy reforms. The handbook is being translated into Arabic, French, Portuguese, Spanish and Russian to maximize uptake. Dissemination is ongoing through WHO regional and country offices, and HRP has been actively engaging with civil society organizations, including the International Planned Parenthood Federation (IPPF), Women Deliver and the UHC2030 Civil Society Engagement Mechanism. HRP has also been working with parliamentarians, including the Inter-Parliamentary Union (IPU) and the European Parliamentary Forum for Sexual and Reproductive Health and Rights (EPF), to customize the handbook for their stakeholders. Access the handbook: publications/i/item/9789240052659 2 The HRP, WHO and UNFPA Sexual and Reproductive Health and Universal Health Coverage “Learning by Sharing” Portal (the SRH–UHC LSP) was launched in July 2022, supported by the IBP Network. The SRH–UHC LSP is a repository of case studies documenting countries’ experiences in implementing and integrating a range of sexual and reproductive health services within UHC programmes and approaches. To date, the LSP features nine implementation stories in both written and “video- telling” format, covering topics such as adolescent health interventions, support for health financing, the value of community health workers, reaching indigenous populations and digital innovations. Information about the Portal has so far been disseminated in the Women Deliver Advocacy Guide on SRHR–UHC integration (September 2022), via the HRP YouTube channel and other HRP communication channels and via the IBP Network’s channels. Since the launch, discussions have been held, including active follow-up with authors of the stories, with a view to monitoring progress and planning further dissemination and uptake of the LSP by national-level stakeholders. In Kazakhstan, for example, WHO and UNFPA country offices collaborated to disseminate Kazakhstan’s implementation story as part of a wider two-day Health Promotion Conference focusing on the health of children and adolescents, aligned with UHC Day on 12 December 2022. Access the SRH–UHC Learning by Sharing Portal: Access HRP’s video about the SRH–UHC Learning by Sharing Portal: watch?v=EsxkKV1jKP4 Health system strengthening for SRHR 44 HRP ANNUAL REPORT 2022 1 A report of global, regional and national maternal mortality estimates, covering the period 2000 to 2020, was completed by HRP. These estimates are crucial for monitoring SDG target 3.1: reduce the global maternal mortality ratio (MMR) to less than 70 maternal deaths per 100 000 live births by 2030. The estimates are the latest in a series of reports by a collaborative estimation group involving WHO, UNICEF, UNFPA, the World Bank Group and the United Nations Department of Economic and Social Affairs (UNDESA) Population Division. These robust and internationally comparable estimates will supersede those in all previous publications in the series that cover any of the same years, because the estimation methods are refined and improved for each round of calculations, based on a larger amount of good quality data from a larger number of countries. The new report includes estimates for the year 2020, and trend information for three periods: 2000–2020 (the full 20 years); 2000–2015 (the entire MDG era); and 2016–2020 (the first five years of the SDG period). Read more: themes/topics/sdg-target-3-1-maternal-mortality 2 HRP published two new guidance documents to support countries in strengthening their maternal mortality data, focusing on maternal deaths that are missing from the official records (incomplete registration) and those that have been misclassified in the official records (e.g. non-maternal deaths that were classified as maternal deaths, and vice versa). The two documents are: Maternal mortality measurement: guidance to improve national reporting and Certification of deaths during pregnancy, childbirth, or the puerperium where confirmed or suspected COVID-19 is a cause of death. Training materials were also subsequently produced on these topics and made available online, including one on the “six-box method”, which aims to make it easier to accurately assess the extent of incomplete and misclassified data, by providing a clear, user-friendly way of counting false positives/negatives and calculating sensitivity and specificity. The guidance documents were actively used for reference during the country consultations that were conducted during the recent round of estimation of maternal mortality for the period 2000–2020, mentioned in the previous item above. Measuring and monitoring sexual and reproductive health services 45sUPPORTiNg ANd sTRENgTHENiNg NATiONAL HEALTH sysTEms fOR AcHiEviNg UNivERsAL HEALTH cOvERAgE (UHc) Access the guidance documents: item/9789240052376 item/9789240049314 Access the “six-box method” training materials: maternal-mortality-measurement--6-box-training- material Read and watch more about all of the above documents: events/detail/2022/09/22/default-calendar/ maternal-mortality-measurement-guidance-to- improve-national-reporting 3 The SRH Department and HRP regularly review and produce scientific responses to proposals received from professional societies, academics and members of the public relating to sexual and reproductive health conditions in the WHO’s International Classification of Diseases (ICD). During 2022, evidence relating to the classification of endometriosis and intersex-related conditions, among others, was reviewed with a view to possible inclusion in future revisions of ICD. 46 HRP ANNUAL REPORT 2022 1 HRP has been mapping and monitoring the development of national-level policies, guidelines and programmes relevant to self-care interventions. since the 2019 publication of the WHO Consolidated guideline on self-care interventions for health: sexual and reproductive health and rights, many countries across WHO regions have amended, developed or are in the process of amending or developing national guidelines or policies on self-care interventions. This includes over 22 countries in Africa – the map on the next page highlights some of these achievements. This equates to a vastly expanded global “policy footprint” for self-care interventions, within two years of WHO’s ground-breaking 2019 publication. This success is thanks to active dissemination efforts with strategic engagement and provision of technical support and capacity-building at country and regional levels, and the use of translations of the global guidance that are available in many national languages, including burmese, Japanese and Portuguese, as well as all six official United Nations languages. Further mapping and monitoring of health inequities in the introduction and uptake of self-care interventions will be key to gaining a better understanding of sRHR outcomes. • The section of the WHO SRHR portal on self-care interventions provides access to a repository of national self-care policies and strategies and a “live” snapshot of the global “policy footprint”. • Country-specific SRHR infographic snapshots, published for all 194 WHO Member States, provide baseline data about areas where there is a need for sustainable introduction or scale- up of self-care interventions for SRHR. The information covers key aspects of an enabling environment, health systems, laws and policies that will facilitate introduction and scale-up of interventions, and which need to be monitored. Viewed and downloaded over 60 000 times to date, these infographics point to the need for more consolidated country-level SRHR data to support national efforts. Access the section of the WHO SRHR portal on self-care interventions: data/sexual-and-reproductive-health-and-rights/ self-care-interventions Self-care interventions for SRHR The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. ©WHO 2022. All rights reserved. 47sUPPORTiNg ANd sTRENgTHENiNg NATiONAL HEALTH sysTEms fOR AcHiEviNg UNivERsAL HEALTH cOvERAgE (UHc) 2 A revised edition of the WHO guideline on self-care interventions for health and well-being was published in July, supported by HRP. The process of updating this guidance involved strengthening the evidence base for self-care interventions, including for sexual and reproductive health. Thirteen new articles were published in peer-reviewed journals including The Lancet, the BMJ and Sexual and Reproductive Health Matters, including reviews and systematic reviews on a range of priority topics to support people-centred, equitable and sustainable access to self-care interventions within supportive health systems. In addition, a supplement to Sexual and Reproductive Health Matters was published on rights-based access to self-care interventions for SRHR, collating articles published during both 2021 and 2022. • Access the revised guideline and related documents, a communications toolkit and a video of the webinar on the results of the Global Values and Preferences Survey: https://www. • Access the web-based version of the guideline: • Access the SRHM supplement: https://www. The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. ©WHO 2022. All rights reserved. BURKINA FASO • National self-care guideline completed • National Technical Working group established • Review conducted of existing policies to support self-care • inclusion of self-care in specific service packages (e.g. humanitarian, emergencies, cOvid-19 responses) ETHIOPIA • National self-care guideline drafted • Policy mapping conducted • inclusion of self- care in specific service packages (e.g. humanitarian, emergencies, NIGERIA • National self-care guideline for sexual, reproductive and maternal health launched • guideline roll-out in 16 states • National behaviour change communication and demand generation strategy for self-care • inclusion of self-care recommendations in national task shifting policy KENYA • National self-care guideline drafted • implementation research to introduce dmPA-sc • Policy dialogues UGANDA • Engagement of moH in partnership with WHO to introduce self-care interventions for sRHR as essential national priority Influencing policy change in the WHO African Region 48 HRP ANNUAL REPORT 2022 1 HRP published the Consolidated telemedicine implementation guide in collaboration with the WHO Digital Health and Innovations (DHI) Department, in November. The guidance highlights key considerations and planning steps (including budgeting), and monitoring and evaluation needs for implementing and sustaining telemedicine. It is intended as a key WHO reference document for countries wishing to initiate or strengthen their telemedicine programmes. The guidance has been included in DHI Department training packages and is among the resources being used to provide orientation and technical assistance to countries wanting to implement telemedicine. For example, it has been used in Guinea Bissau and Indonesia to guide national telemedicine programme planning. Access the guidance: publications/i/item/9789240059184 2 The use of digital health to address barriers to access and provision of sexual and reproductive health services has become more widespread over recent years. The WHO “SMART Guidelines” initiative uses a systematic process for translating WHO guideline content into a structured format that can be reviewed by health programme managers and software developers when designing their digital systems. This approach is known as applying “digital adaptation kits” (DAKs) and it seeks to ensure that the contents of countries’ digital systems are aligned with WHO recommendations. HRP and the SRH Department launched multisite implementation research in Ethiopia and Ghana to align the health contents of their digital systems with the latest WHO recommendations and to assess the effect on service delivery and data flow outcomes when the DAK approach is applied. Using the case of sexual and reproductive health, this implementation research will document a replicable approach to digitizing primary health care services and reinforcing WHO guideline recommendations through routine point-of-care digital systems. HRP and the SRH Department also collaborated with the WHO Regional Office for Africa to disseminate and provide technical assistance in implementing the DAKs within the digital systems used by countries in the region. Specifically, the SRH Department organized a series of national workshops and supported the incorporation of DAK content within the national digital systems in Malawi, Zambia and Zimbabwe as part of a collaboration to bolster digitizing efforts through the joint United Nations 2gether 4 SRHR programme. Read more about WHO SMART Guidelines and DAKs: reproductive-health-and-research-(srh)/areas-of- work/digital-innovations/smart-guidelines-and- digital-adaptation-kits Digital health 49 Rigorous scientific methods are essential to develop valid and credible evidence that informs guidelines and standards, as a basis for the provision of safe, effective, equitable and acceptable sexual and reproductive health services. As the only body within the United Nations system with a global mandate to work on strengthening research capacity in SRHR, HRP promotes and funds relevant research, training, institutional development and networking to increase the research capacity in low- and middle-income countries. This is spearheaded by the HRP Alliance. Since 2015, it has been bringing together HRP research partners for research capacity strengthening (RCS) from across the globe, collaborating with WHO regional and country offices, WHO Collaborating Centres (WHOCCs), and other WHO special research programmes – namely the Special Programme for Research and Training in Tropical Diseases (TDR) and the Alliance for Health Policy and Systems Research (AHPSR). During global emergencies, HRP is equipped to provide scientific leadership for research planning and capacity-building efforts and to leverage funding and resources, and advance novel research methodologies. Strengthening research capacity for sexual and reproductive health and rights (SRHR) 12 In many countries across the world, there is a need to improve scientific quality by strengthening SRHR research capacity and infrastructure, and to counteract inequities in SRHR research leadership and management. 50 HRP ANNUAL REPORT 2022 1 HRP Alliance hubs and research capacity strengthening (RCS) partners have been research leaders in critical roles in the initiation, design and conduct of COVID-19 and SRHR research. For further information, see item 1 in the next subsection of this chapter. 2 The HRP Alliance continues to provide cross-cutting support to HRP research and other projects done in collaboration with research partners or WHOCCs. In 2022, HRP has engaged with WHOCCs in the United Kingdom and Sweden for several collaborative research projects with integrated RCS activities. These include: • A study on self-managed medical abortion, using respondent-driven sampling, involves HRP and the WHOCC at the Karolinska Institute in Sweden, and also Centro de Estudios de Estado y Sociedad (CEDES) and Centro Rosarino de Estudios Perinatales (CREP, a WHOCC), both in Argentina. The first phase was completed and the results were presented in Buenos Aires in November. • A study involving individual participant data (IPD) meta-analysis, network meta-analysis and economic evaluation is under way, for the i-CIP (International Calcium in Pregnancy) IPD Collaborative Network. The study is being led by the WHOCC at the University of Birmingham in the United Kingdom, with technical support from HRP, and RCS has been embedded in the proposal. • A multi-country study was initiated to assess the accuracy of lactate testing as a means to improve identification of maternal sepsis. The LACTate in mATernal sEpsis (LACTATE) study is led by the WHOCC at the University of Liverpool in the United Kingdom and the Malawi–Liverpool–Wellcome Trust (MLW) in Blantyre, Malawi, and implemented in three countries (Malawi, Pakistan, Uganda) with technical support from HRP. RCS activities included support to junior researchers, including the principal investigator in Pakistan who is completing his PhD at Aga Khan University in Pakistan. Research capacity strengthening (RCS) 51sTRENgTHENiNg REsEARcH cAPAciTy fOR sExUAL ANd REPROdUcTivE HEALTH ANd RigHTs (sRHR) 3 Since the current RCS strategy was launched in 2017, seven regional HRP Alliance SRHR RCS hubs (in Brazil, Burkina Faso, Ghana, Kenya, Pakistan, Thailand and Viet Nam) have been leading RCS efforts in their regions or subregions. In 2022, all hubs offering online training programmes extended registration to any individual affiliated with HRP research partner institutions, regardless of region. During the year, 23 short courses were attended by a total of 718 junior and mid-level researchers/ HRP Alliance Fellows (PhD students supported by the HRP Alliance) representing 291 institutions, thus supporting their institutions with capacity-building of these staff members. The courses covered topics such as values clarification and attitudes training for research on sensitive topics, qualitative and quantitative research methods, integration of sex and gender into health research, and gender- based violence. In addition, the hubs supported 45 doctoral students (11 of whom were recruited in 2022) and 58 master’s students (16 of whom were recruited in 2022). All the hubs keep in touch with master’s and doctoral degree graduates to follow up about their post-graduation employment and research opportunities (including current research, grant applications and publications), and their use of skills learned through the academic programmes they attended. After degree training, as of 2022, a total of 32 HRP Alliance Fellows had moved into SRHR research-related employment. 4 A year-long HRP Alliance mentorship programme for researchers identifying as women was completed, following the pilot programme completed in 2021. The programme was open to mentors of any gender, and it paired 19 mentees with 18 mentors; eight of the selected mentors were male. As well as mentor and mentee networking meetings throughout the year, four skills-based workshops covered topics ranging from communication and networking to branding and career progression, and were open to all current and past mentees and interested mentors as well as HRP Alliance Fellows. A formal mixed-methods evaluation of the 2021 pilot programme was undertaken, with the data collection and analysis being conducted by junior researchers at two HRP Alliance hubs. A paper detailing the development and design of the mentorship programme was accepted for publication in Global Health Action. 52 HRP ANNUAL REPORT 2022 1 In collaboration with the WHO Health Emergencies Programme, HRP has successfully raised funds and regularly provides senior scientific input, leadership and support relating to all aspects of ongoing and past epidemics/pandemics, including Ebola, Zika, COVID-19 and monkeypox. This has included input to guidelines, research projects, living systematic reviews and knowledge-gathering initiatives. In particular: • HRP has been leading a multi-country prospective cohort study on COVID-19 and pregnancy, and COVID-19 vaccines during pregnancy, implemented in eight countries so far. Recruitment continues and the study will close at the end of 2023 (see Chapter 7, Sexual and reproductive health during the COVID-19 pandemic, item 1). • A protocol was developed and published in BMJ Open for a health systems analysis and evaluation of the barriers to availability, utilization and readiness of sexual and reproductive health services in COVID-19-affected areas. This study was implemented in nine countries, including six with HRP Alliance hubs with HRP providing senior scientific leadership, links to RCS efforts and quantitative assessment management. Baseline data collection was completed in all nine countries. HRP Alliance representatives presented findings from this study at the International Conference on Family Planning (ICFP) in Thailand in November. Access the protocol: content/12/6/e057810.long • A protocol was also developed and published in BMJ Open for qualitative research on women’s reproductive and psychosocial health related to pregnancy, pregnancy prevention and induced abortion in the context of COVID-19. This work involved staff from five HRP Alliance hubs (Brazil, Burkina Faso, Ghana, Pakistan and Thailand). Opportunities for RCS were embedded in the protocol. Access the protocol: https://bmjopen. 2 The Research Project Review Panel (RP2) is part of HRP governance and includes an external, independent body of scientific experts that provides in-depth scientific review of all HRP research protocols, prior to ethical review by the WHO Ethics Review Committee. Ongoing research projects are subject to investigator-initiated mandatory review of any amendments. Panel members represent diverse expertise and regions, and among the 32 RP2 panel members, 19 are women. In total, 44 new submissions for review were submitted to and managed by the RP2 Secretariat in 2022. Scientific leadership and support 53 Africa Benin Botswana Burkina Faso Cameroon Central African Republic Chad Côte d’Ivoire Democratic Republic of the Congo Eswatini Ethiopia Ghana Guinea Kenya Lesotho Liberia Madagascar Malawi Mali Mauritania Mozambique Namibia Niger Nigeria Rwanda Senegal Sierra Leone South Africa South Sudan Togo Uganda United Republic of Tanzania Zambia Zimbabwe The Americas Argentina Brazil Canada Chile Colombia Costa Rica Dominican Republic Ecuador El Salvador Guatemala Honduras Mexico Paraguay Peru Trinidad and Tobago Uruguay Eastern Mediterranean Afghanistan Egypt Iran (Islamic Republic of) Iraq Jordan Lebanon Morocco Occupied Palestinian territory, including east Jerusalem Pakistan Somalia State of Libya Sudan Syrian Arab Republic Tunisia Yemen Europe Germany Italy Moldova Russian Federation Türkiye Ukraine United Kingdom of Great Britain and Northern Ireland South-East Asia Bangladesh Bhutan India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste Western Pacific Australia China Lao People’s Democratic Republic Malaysia Mongolia Papua New Guinea Philippines Viet Nam Countries where HRP works 54 HRP ANNUAL REPORT 2022 HRP 2022 donors United Nations agencies United Nations Entity for Gender Equality and the Empowerment of Women (UN Women) United Nations Population Fund (UNFPA) World Health Organization (WHO) Governments China Flanders, Belgium Netherlands Norway Russian Federation Sweden Switzerland Thailand United Kingdom of Great Britain and Northern Ireland Non-State actors Bill & Melinda Gates Foundation David and Lucile Packard Foundation Elrha Guttmacher Institute Johns Hopkins University Karolinska Institute Male Contraceptive Initiative Merck Sharp & Dohme Corp. The Global Fund to Fight AIDS, Tuberculosis and Malaria Unitaid University of Birmingham 55 Credits Cover: © UNICEF/U.S. CDC/Unique Page v: © UNICEF/Frank Dejongh Page 1: © UNICEF/Tanhoa Page 3: © UNICEF/Dejongh Page 4: © WHO/PAHO Page 5: © WHO/Hickmatu Leigh Page 6: © WHO/Yoshi Shimizu Page 7: © ILO Asia and Pacific Page 10: © The Global Financing Facility/Dominic Chavez Page 11: © WHO/Igor Vrabie Page 12: © UNICEF/Raab Page 16 : © Yagazie Emezi after Getty Images/Images of Empowerment Page 21: © WHO/Lindsay Mackenzie page 22: © International Women’s Health Coalition Page 23: © MyStockPhotos Page 24: © Showkat Nanda/MSF Page 26: © UNICEF/U.S. CDC/Unique Page 27: © UNICEF/Ramoneda Page 28: © UNICEF/Chikondi Page 29: © WHO/Blink Media - Hilina Abebe Page 30: © MSF/Severine Sajous Page 31: © Unsplash/Hobi Industri Page 34: © UNICEF/Nestbitt Page 35: © UN Women/Ismael Jiménez Page 37: © UNICEF/Asselin Page 39: © Unsplash/Alexander Grey Page 42: © UNICEF/Abdul Page 43: © UNICEF/Pouget Page 44: © UNICEF/Naftalin Page 46: © UNICEF/Diarassouba Page 48: © WHO/Blink Media — Juliana Tan Page 49: © UNICEF/Mostafa Page 50: © HRP/Mark Leong Page 52: © Getty Images/Images of Empowerment/Yagazie Emezi This report was written by Jane Patten/Green Ink Publishing Services Ltd. World Health Organization department of sexual and Reproductive Health and Research Avenue Appia 20 1211 geneva 27 switzerland Email: Website: _Hlk130983611 _Hlk125988593 _Hlk125555496 _Hlk130223821 _Hlk119734524 _Hlk119160586 Foreword About us – HRP at 50 Why sexual and reproductive health and rights (SRHR)? Helping people to realize their desired family size Family planning and contraception Fertility care Ensuring the health of pregnant women and girls and their babies Safe abortion Promoting sexual health and well-being Sexual health and well-being Research on sexually transmitted infections (STIs) Preventing and treating HPV infection and cervical pre-cancers Sexual and reproductive health and rights (SRHR) during the global COVID-19 pandemic and other health emergencies SRHR during the COVID-19 pandemic SRHR in humanitarian emergencies Healthy adolescence for a healthy future Preventing and responding to violence against women and girls Violence against women and girls Female genital mutilation (FGM) Achieving gender equality and sexual and reproductive health and rights (SRHR) Supporting and strengthening national health systems for achieving universal health coverage (UHC) Health system strengthening for SRHR Measuring and monitoring sexual and reproductive health services Self-care interventions for SRHR Digital health Strengthening research capacity for sexual and reproductive health and rights (SRHR) Research capacity strengthening (RCS) Scientific leadership and support Countries where HRP works HRP 2022 donors

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The Supplies Information Database (SID) is an online reference library with more than 2000 records on the status of reproductive health supplies. The library includes studies, assessments and other publications dating back to 1986, many of which are no longer available even in their country of origin. Explore the database here.

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