WHO Reproductive Health Strategy to accelerate progress towards the attainment of international development goals and targets

Publication date: 2004

World Health Organization, Geneva Department of Reproductive Health and Research including UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction Reproductive health strategy to accelerate progress towards the attainment of international development goals and targets The strategy presented in this document is the World Health Organization’s first global strategy on reproductive health.1 It was adopted by the 57th World Health Assembly (WHA) in May 2004. 2 (›01 – ›64) 3 ›01 ›02 ›03 INTRODUCTION Reproductive and sexual health2 is fundamental to individuals, couples and families, and the social and economic development of communities and nations. Concerned about the slow progress made in improving repro- ductive and sexual health over the past decade, and knowing that the international development goals would not be achieved without renewed commitment by the international community, the Fifty-fifth World Health Assembly adopted resolution WHA55.19 requesting WHO to develop a strategy for accelerating progress towards attainment of international development goals and targets related to reproductive health. The reso- lution recalled and recognized the programmes and plans of action agreed by governments at the International Conference on Population and Development (Cairo, 1994) and the United Nations Fourth World Conference on Women (Beijing, 1995), and at their respective five-year follow-up review conferences.3 In response to resolution WHA55.19, and following consultations with Member States and partners, WHO has designed a draft strategy that builds on actions taken by Member States pursuant to resolution WHA48.10 on Reproductive health: WHO’s role in the global strategy, which urged Member States to further develop and strengthen their repro- ductive health programmes. The strategy presented in this document is intended for a broad audi- ence of policy-makers within governments, international agencies, pro- fessional associations, nongovernmental organizations and other institu- tions. Part I sets out the major discrepancies between global goals and global realities, and describes the principal barriers to progress, noting in particular the inequities related to gender and poverty and the exposure to risk of adolescents. Part II lays out the strategy, which is guided by prin- ciples based on international human rights. It highlights the core aspects of reproductive and sexual health services and proposes ways for coun- tries and WHO to take innovative approaches. It concludes by reaffirming WHO’s corporate commitment to collaboration with its partners in order to encourage and support Member States in their efforts to attain the United Nations Millennium Development Goals and other internationally agreed goals and targets relating to reproductive and sexual health. 1 See resolution WHA57.12. 2 The definition of reproductive health proposed by WHO and agreed to at the International Conference on Population and Development (Cairo, 1994) includes sexual health (see p.8). 3Twenty-first special session of the United Nations General Assembly for an overall review and appraisal of the implementation of the Programme of Action of the International Conference on Population and Development (New York, 1999) and twenty-third special session of the United Nations General Assembly on Women 2000: gender equality, development and peace for the 21st century (New York, 2000). 4 ›01 ›03 ›04 ›05 ›06 ›07 ›08 ›09 ›10 ›11 ›12 ›13 ›14 ›15 ›16 ›17 ›18 ›19 ›20 ›21 ›22 ›23 ›24 ›25 ›26 >27 ›28 ›29 ›30 ›31 ›32 ›33 ›34 ›35 ›36 >37 ›38 ›39 ›40 ›41 5 ›42 ›43 ›44 ›45 ›46 ›47 ›48 ›49 ›50 ›51 ›52 ›53 ›54 ›55 ›56 ›57 ›58 ›59 ›60 ›61 ›62 ›63 ›64 66 7 I. GLOBAL GOALS, GLOBAL REALITIES ›04 ›05 The Millennium Development Goals, which grew out of the United Nations Millennium Declaration adopted by 189 Member States in 2000, provide the new international framework for measuring progress towards sus- taining development and eliminating poverty. Of the eight Goals, three - improve maternal health, reduce child mortality and combat HIV/AIDS, malaria and other diseases - are directly related to reproductive and sexual health, while four others - eradicate extreme poverty and hunger, achieve universal primary education, promote gender equality and empower women, and ensure environmental sustainability - have a close relation- ship with health, including reproductive health. Among the specific targets are: Additional benchmarks were agreed in 1999 at the twenty-first special session of the United Nations General Assembly for an overall review and appraisal of the implementation of the Programme of Action of the International Conference on Population and Development. For example, by 2015, the proportion of all births assisted by skilled attendants should reach 90% globally and at least 60% in countries with high rates of maternal death.4 to reduce by three quarters, between 1990 an 2015, the maternal mortality ratio; to reduce by two thirds, between 1990 and 2015, the under-five mortality rate; to have halted by 2015, and begun to reverse, the spread of HIV/AIDS. 4 United Nations document A/S-21/5/Add.1, paragraph 64. ›06 The definition of reproductive health adopted at the International Conference on Population and Development in 1994 (see p.8) captures the essential characteristics that make reproductive and sexual health unique compared to other fields of health. Reproductive health extends before and beyond the years of reproduction, and is closely associated with sociocultural factors, gender roles and the respect and protection of human rights, especially - but not only - in regard to sexuality and personal relationships. 8 “Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all mat- ters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a sat- isfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. In line with the above definition of reproductive health, reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well- being by preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases.” (Paragraph 7.2) “Bearing in mind the above definition, reproductive rights embrace certain human rights that are already recognized in national laws, inter- national human rights documents and other consensus documents. These rights rest on the recognition of the basic right of all couples and indi- viduals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents. .” (Paragraph 7.3) Programme of Action of the International Conference on Population and Development, New York, United Nations, 1994. 9 ›09 Experience has shown that, even in low-income settings, innovative coun- try-specific approaches can considerably reduce maternal mortality and morbidity, for example. The challenge now is to formulate innovative national strategies for making health services accessible to the people in greatest need, such as adolescents and the poor, in order to attain inter- national goals. At present, many countries suffer from persistently high rates of maternal mortality and morbidity, perinatal mortality, reproduc- tive tract infections and sexually transmitted infections including HIV, unwanted pregnancies, unsafe abortion, and risky sexual behaviour, as the data below show. ›08 Following this conceptualization of, and commitment to, reproductive and sexual health, new partnerships have been forged at national, regional and global levels. New evidence has also been collected in previously neglected areas such as the burden of disease due to reproductive and sexual ill-health and its relation to poverty, and gender-based violence. The number of evidence-based best practices in reproductive and sexual health care has grown substantially, and the scope of clinical and behav- ioural research and of internationally recognized standards, norms and guidelines has broadened. ›07 The adoption of these comprehensive definitions at the International Conference on Population and Development marked the beginning of a new era, and the achievements of the past decade are many and profound. For example, the concept of reproductive and sexual health and rights has, with few exceptions, been widely accepted and has begun to be used by international health and development bodies, national governments, nongovernmental organizations and other parties. New reproductive health policies and programmes have been defined in almost all countries. Their adoption has produced significant changes in some countries in the con- ventional modes of delivering maternal and child health or family plan- ning services. 10 Pregnancy, childbirth and health of newborns Global situation ›10 Each year, some eight million of the estimated 210 million women who become pregnant, suffer life-threatening complications related to preg- nancy, many experiencing long-term morbidities and disabilities. In 2000, an estimated 529 000 women died during pregnancy and childbirth from largely preventable causes. Globally, the maternal mortality ratio has not changed substantially over the past decade. ›11 Regional inequities are extreme, with 99% of these maternal deaths occur- ring in developing countries. The lifetime risk of death from maternal causes in sub-Saharan Africa is 1 in 16 and in South-East Asia 1 in 58, com- pared with 1 in 4000 in industrialized countries. 11 ›12 ›13 ›14 Most maternal deaths arise from complications during childbirth (e.g. severely obstructed labour, especially in early first pregnancies; haemorrhage and hypertensive complications), in the immediate post- partum period (sepsis and haemorrhage), or after unsafe abortion. Factors commonly associated with these deaths are the absence of skilled health personnel5 during childbirth, lack of services able to provide emergency obstetric care and deal with the complications of unsafe abortion, and ineffective referral systems. More than 50% of women living in the world’s poorest regions - the per- centage is higher than 80% in some countries - deliver their babies with- out the help of a skilled birth attendant. In sub-Saharan Africa these pro- portions have not changed over the past decade. Antenatal care is available and widely used in industrialized countries; by contrast, in the late 1990s, almost half of pregnant women in southern Asia and one third in western Asia and sub-Saharan Africa received no antenatal care at all, compared with less than one fifth in eastern Asia and in Latin America and the Caribbean. Of the 10.8 million deaths worldwide of children under five, 3.0 million occur during the first seven days of the neonatal period. Additionally, an esti- mated 2.7 million infants are stillborn. Many of these deaths are related to the poor health of the woman and inadequate care during pregnancy, child- birth and the postpartum period. The neonatal mortality rate (death in the first 28 days) in developing countries has remained unchanged since the early 1980s at about 30 deaths per 1000 live births. Furthermore, a mother’s death can seriously compromise the survival of her children. 5 ”Skilled birth attendant” or ”skilled health personnel” refers to a health professional such as a midwife, doctor or nurse, who is trained and competent in the skills needed to manage normal childbirth and the immediate postnatal period, and who can identify complications and, as necessary, provide emergency management and/or refer the case to a higher level of health care. In 2000, an estimated 529 000 women died during pregnancy and childbirth from largely preventable causes 14 ›17 ›18 Some 45 million unintended pregnancies are terminated each year, an estimated 19 million of which are unsafe; 40% of all unsafe abor- tions are performed on young women aged 15 to 24. Unsafe abortions kill an estimated 68 000 women every year, representing 13% of all pregnancy-related deaths.6 In addition, they are associated with con- siderable morbidity; for instance, studies indicate that of every five women who have an unsafe abortion, at least one suffers a reproduc- tive tract infection as a result; some of these infections are serious, leading to infertility. Sexually transmitted infections, including HIV, and reproductive tract infections An estimated 340 million new cases of sexually transmitted bacterial infec- tions, most of which are treatable, occur annually. Many are untreated because they are difficult to diagnose and because competent, affordable services are lacking. In addition, millions of cases of mostly-incurable viral infections occur annually, including five million new HIV infections, 600 000 of which are in infants owing to mother-to-child transmission. ›15 ›16 Family planning Contraceptive use has substantially increased in many developing coun- tries and in some is approaching that practised in developed countries. Yet surveys indicate that, in developing countries and countries in transition, more than 120 million couples have an unmet need for safe and effective contraception despite their expressed desire to avoid or to space future pregnancies. Between 9% and 39% of married women (including women in union) have this unmet need for family planning. Data suggest that unmarried sexually active adolescents and adults also face this unmet need. About 80 million women every year have unintended or unwanted pregnancies, some of which occur through contraceptive failure, as no contraceptive method is 100% effective. Unsafe abortion 15 ›19 ›20 ›21 Sexually transmitted human papillomavirus infection is closely associ- ated with cervical cancer, which is diagnosed in more than 490 000 women and causes 240 000 deaths every year. Three quarters of all cervical can- cer cases occur in developing countries where programmes for screening and treatment are seriously deficient or lacking. More than 100 million mostly-curable sexually transmitted infections occur each year in young people aged 15 to 24. These infections facilitate the acquisition and spread of HIV. Almost half all new HIV infections occur in young people. Despite recent positive trends among young people (espe- cially females) in some African countries, overall about twice as many young women as men are infected with HIV in sub-Saharan Africa. In 2001, an estimated 6% to 11% of young women in sub-Saharan Africa were living with HIV/AIDS, compared with 3% to 6% of young men. In other developing regions, the proportion of women with HIV/AIDS is also higher than for men. Additionally, reproductive tract infections, such as bacterial vaginosis and genital candidiasis, which are not sexually trans- mitted, are known to be widespread, although the prevalence and con- sequences of these infections are not well documented. Sexually transmitted infections are also a leading cause of infertility: some 60 to 80 million couples worldwide suffer from infertility and consequent involuntary childlessness, often as a result of tubal blockage caused by an untreated or inadequately treated sexually transmitted infection. ›22 Together, these aspects of reproductive and sexual ill-health (maternal and perinatal mortality and morbidity, cancers, sexually transmitted infections and HIV/AIDS) account for nearly 20% of the global burden of ill-health for women and some 14% for men. These statistics do not capture the full bur- den of ill-health, however. Gender-based violence, and gynaecological con- ditions such as severe menstrual problems, urinary and faecal incontinence due to obstetric fistulae, uterine prolapse, pregnancy loss, and sexual dys- function - all of which have major social, emotional and physical conse- quences - are currently severely underestimated in present global burden of disease estimates. WHO estimates unsafe sex to be the second most important global risk factor to health. 6 An unsafe abortion is defined as a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both (see The prevention and management of unsafe abortion, Report of a technical working group, document WHO/MSM/92.5, 1992). 16 ›23 ›24 Barriers to progress Inequities related to gender Gender disparities in health are often striking. Families may invest less in nutrition, health care, schooling and vocational training for girls than for boys. Sex discrimination and low social status of girls and women frequently result in poor physical and mental health, physical or emotional abuse, and low levels of control over their own lives, particularly their sexual and repro- ductive lives. Violence against women in its many forms has an impact on their repro- ductive and sexual health. In particular, violence from an intimate partner, which occurs throughout the world, includes physical, sexual and emotional abuse. Studies show that between 4% and 20% of women experience vio- lence during pregnancy, with consequences both for them and their babies, such as miscarriage, premature labour and low birth weight. Available data suggest that in some countries nearly one woman in four experiences sex- ual violence from an intimate partner. Rape and sexual assault by acquain- tances and strangers is also common. Trafficking of women and children and forced prostitution are also serious problems, particularly in some regions. The consequences for reproductive and sexual health are exten- sive and include unwanted pregnancy, unsafe abortion, chronic pain syn- dromes, sexually transmitted infections including HIV, and gynaecological disorders. 17 ›26 Poverty is almost universally associated with inequitable access to health services, particularly maternal health services. The burden of reproductive and sexual ill-health is greatest in the poorest countries where health ser- vices tend to be scattered or physically inaccessible, poorly staffed, resourced and equipped, and beyond the reach of many poor people. Too often, improvements in public health services disproportionately benefit the better-off, and it is theoretically possible to achieve some of the inter- national health goals without including the lowest income quintile and vul- nerable population groups. Adolescents’ exposure to risk ›25 In most countries, taboos and norms about sexuality (including practices such as child marriage, female genital mutilation and early sexual initia- tion) pose strong barriers to providing the information, reproductive health services and other forms of support that young people need to be healthy. Yet, sexual and reproductive behaviours during adolescence (between the ages of 10 and 19) have immediate and long-term consequences. In some parts of the world, sexual activity begins during adolescence, and is often risky, whether within or outside marriage. Adolescents rarely have the abil- ity or support to resist pressure to have sexual relations, negotiate safer sex, or protect themselves against unintended pregnancy and sexually trans- mitted infections. For very young girls, pregnancy carries a high risk of mater- nal mortality and morbidity. Meeting the needs and protecting the rights of the 1200 million adolescents worldwide are essential to safeguard the health of this and future generations. Inequities related to poverty and access to health services ›27 Since the 1980s, various health-sector reforms have been introduced in many countries, affecting availability of, and access to, health services, including those for reproductive and sexual health. Financing projects, such as prepaid insurance schemes and means-tested subsidies, have frequently failed to result in the desired equitable access for poor people. Thus, spe- cial attention is needed to ensure that disadvantaged groups can access prevention, treatment and life-saving services such as emergency obstet- ric care. 18 ›29 ›30 ›31 ›32 In many countries, inadequate human resources are a major barrier to the expansion of comprehensive reproductive and sexual health services, and to better quality of care. Weaknesses include the severe shortage of per- sonnel, inadequate skills of available personnel, rapid turnover and loss of skilled workers, and the inefficient use and distribution of those who are already in the system. Low or unpaid salaries and poor training, supervi- sion and working conditions are root causes of poor performance and high turnover of health-care professionals. Strategic planning for building and retaining an appropriately skilled health workforce, including for instance skilled birth attendants, is crucial to progress in reproductive and sexual health care. In addition to the barriers that poor and other disadvantaged people face in accessing health services generally, such as distance from services, lack of transport, cost of services and discriminatory treatment of users, repro- ductive health presents special difficulties. These derive from social and cultural factors such as taboos surrounding reproduction and sexuality, women’s lack of decision-making power related to sex and reproduction, low values placed on women’s health, and negative or judgmental attitudes of family members and health-care providers. A holistic examination by communities and local health-care providers of beliefs, attitudes and val- ues offers an important start to overcoming these fundamental obstacles. Over the past two decades, advances have been made in life-saving tech- nologies in reproductive health and effective clinical and programmatic practices. Even with electronic databases and interactive tools, however, many health systems and service providers have little or no access to this new information. Effective demonstration projects in many countries, includ- ing introduction of technology and best practices, often fail to be imple- mented on a larger scale. Failure to use appropriate strategic planning based on adequate qualitative and quantitative data has limited the understand- ing of reasons for poor quality of services and people’s lack of access to, and use of, services. In some countries, laws, policies and regulations may hinder access to ser- vices (e.g. excluding unmarried people from contraceptive services), unnec- essarily limit the roles of health personnel (e.g. preventing midwives from performing life-saving procedures such as removal of the placenta), bar the provision of some services (e.g. over-the-counter provision of emergency contraception), or restrict the importation of some essential drugs and tech- nologies. Removal of such restrictions is likely to contribute significantly to improving people’s access to services. ›28 Recent years have witnessed a decline in overall development aid, while new mechanisms of external financing for health have come into play, such as poverty reduction strategy papers, sector-wide approaches and direct budget support. Also, major new sources of health-sector funding, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, concentrate resources on specific diseases and interventions. It is important to ensure that these new developments contribute to the building of sustainable health-system capacity, including that for reproductive and sexual health services. Other challenges 19 20 21 II. THE STRATEGY TO ACCELERATE PROGRESS ›34 ›35 Guiding principle: human rights WHO’s strategy for accelerating progress rests on internationally agreed instruments and global consensus declarations on human rights, including the right of all persons to the highest attainable standard of health; the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the informa- tion and means to do so; the right of women to have control over, and decide freely and responsibly on, matters related to their sexuality, including sex- ual and reproductive health - free of coercion, discrimination and violence; the right of men and women to choose a spouse and to enter into marriage only with their free and full consent; the right of access to relevant health information; and the right of everyone to enjoy the benefits of scientific progress and its applications. In order to ensure that these rights are respected, policies, programmes and interventions must promote gender equality, give priority to poor and underserved populations and population groups, especially adolescents, and provide special support to those coun- tries that bear the largest burden of reproductive and sexual ill-health. Core aspects of reproductive and sexual health services The five core aspects of reproductive and sexual health are: improving ante- natal, perinatal, postpartum and newborn care; providing high-quality ser- vices for family planning, including infertility services; eliminating unsafe abortion; combating sexually transmitted infections including HIV, repro- ductive tract infections, cervical cancer and other gynaecological morbidi- ties; and promoting sexual health. Because of the close links between the different aspects of reproductive and sexual health, interventions in one area are likely to have a positive impact on the others. It is critical for coun- tries to strengthen existing services and use them as entry points for new interventions, looking for maximum synergy. ›33 The overarching objective of the strategy is to accelerate progress towards meeting internationally agreed reproductive health targets and, ultimately, to attain the highest achievable standard of reproductive and sexual health for all. ›38 ›39 ›40 The success of family planning services in most countries of the world is evidenced by the great increase in contraceptive use in developing coun- tries over the past two to three decades. These programmes are an essen- tial part of services to reduce maternal and perinatal morbidity and mor- tality because they enable women to postpone, space and limit pregnancies. As these services are directly concerned with the outcomes of sexual rela- tionships, they also have great potential for leading the way in promoting sexual health and efforts to prevent sexually transmitted infections and HIV transmission. Sexually transmitted infections are being diagnosed and treated by phar- macists, drug sellers and traditional healers, often ineffectively. Various attempts have been made to reach women by integrating sexually trans- mitted infections management into existing maternal and child health and/or family planning services, but with limited success. Nonetheless, experi- ence shows that integration of sexually transmitted infection prevention into family planning services, especially through counselling and discus- sion of sexuality and partner relationships, has increased the use of ser- vices and improved quality of care. These approaches can be built on and improved in order to expand coverage and outreach to men, youth and other groups not previously the focus of family planning. In addition, presump- tive treatment in groups at high risk and comprehensive, community-based programmes to control sexually transmitted infections could greatly con- tribute to the reduction of HIV transmission rates. Additional gains from strengthening reproductive health services are numer- ous. They include attention to violence against women, which is now being tackled in various country settings with, for instance, provision of emer- gency contraception, abortion (to the extent allowed by law) if requested, treatment of sexually transmitted infections and post-exposure prophylaxis for HIV infection after rape, screening and treatment of cervical cancer, pre- vention of primary and secondary infertility, and treatment of gynaecolog- ical conditions. Well-designed and effectively delivered reproductive and sexual health services, especially those involving community participation, can also contribute to improved user-provider relations, men’s participa- tion, and women’s empowerment to make reproductive choices. ›37 As a preventable cause of maternal mortality and morbidity, unsafe abortion must be dealt with as part of the Millennium Development Goal on improv- ing maternal health and other international development goals and targets. Several urgent actions are needed, including strengthening family planning services to prevent unintended pregnancies, and, to the extent allowed by law, ensuring that services are available and accessible. Also to the extent allowed by law, provision of safe abortion services requires training health- service providers in modern techniques and equipping them with appropri- ate drugs and supplies, all of which should be available for gynaecological and obstetric care; providing social and other support to women with unin- tended pregnancies; and, to the extent allowed by law, providing abortion ser- vices at primary health care level. For those women who suffer complications of unsafe abortion, prompt and humane treatment through post-abortion care must be available. ›41 All reproductive and sexual health services have a key role to play in pro- viding information and counselling in promoting sexual health. Appropriate information can also contribute to better communication between part- ners and healthier sexual decision-making, including abstinence and con- dom use. ›36 In most countries, the major entry point will be antenatal, childbirth and postpartum services, which form the backbone of primary health care. Central to reducing maternal morbidity and mortality, and perinatal mor- tality, are the attendance at every birth of skilled health personnel and com- prehensive emergency obstetric care to deal with complications. Provision of these services requires effective referral systems for communication and transport between service points. Maternal health services offer a key opportunity to reach women with family planning. They are also an excel- lent means through which to offer women prevention, counselling, test- ing and treatment for HIV infection and for preventing HIV transmission dur- ing pregnancy and birth and through breastfeeding. Indeed, it is only through these services that these interventions can be adequately provided. These points are further elaborated in the WHO strategy for making pregnancy safer. 22 ›42 WHO proposes the following key action areas for countries, and is committed to supporting Member States in building and strength- ening their capacity to improve reproductive and sexual health. Each country needs to identify problems, set priorities and formu- late strategies for accelerated action through consultative processes involving all stakeholders. Five overarching activities are: strengthening health systems capacity, improving information for priority setting, mobilizing political will, creating supportive legislative and regulatory frameworks, and strengthening moni- toring, evaluation and accountability. ›43 Strengthening health systems capacity A prerequisite for attaining the Millennium Development Goals relating to maternal and infant survival and HIV/AIDS, as well as the broader repro- ductive and sexual health goals, is the existence of a functioning system of essential health care at the primary, secondary and tertiary levels. In some countries, basic health service capacity will have to be strengthened substantially in order to enable provision of a comprehensive range of essen- tial reproductive and sexual health services. Planning at national level for reproductive and sexual health will have to cover sustainable financing mechanisms, human resources, quality in service provision and use of services. ›44 Sustainable financing mechanisms. The central importance of repro- ductive and sexual health needs to be reflected in national health-sector planning and strategic development. Health-sector reforms and related ini- tiatives such as sector-wide approaches to donor funding have been pro- moted as a means of strengthening health systems. The challenge is to ensure that these initiatives and other financing mechanisms foster good quality, comprehensive reproductive and sexual health services, and progress towards universal access. ›45 Necessary actions in this area are: 1 to make reproductive and sexual health central to national planning and strategy development processes, including poverty reduction strat- egy papers and WHO country cooperation strategies; 2 to ensure that reproductive and sexual health is appropriately reflected in national health-sector plans, including those covering the “3 by 5” initiative, proposals to the Global Fund to Fight AIDS, Tuberculosis and Malaria, and other relevant initiatives; 3 to prioritize reproductive and sexual health in essential service pack- ages under health-sector reforms and sector-wide approaches; and 4 where new financing mechanisms such as cost sharing are being intro- duced, to design ways to facilitate access to services by adolescents, poor people and other disadvantaged groups, to monitor the effects of such policies and to adapt them to local conditions. 23 24 ›46 Human resources. Training, recruiting, deploying and retaining skilled health personnel are central elements in improving health and health care generally. Many core reproductive and sexual health interventions can be made by mid-level professionals and paramedical workers. The challenge is to determine the cadres of health workers, skills and forms of training that are most necessary to provide the prioritized reproductive and sexual health services. Enabling conditions will have to be created for health work- ers to realize their full potential and to motivate them to work with all pop- ulation groups, including the poorest. ›47 Necessary actions in this area are: 1 to determine the essential requirements at all levels for numbers and distribution of health workers with the skills needed to perform prioritized reproductive and sexual health interventions; 2 to assess and improve work environments, conditions of employment and supervision; 3 to formulate a strategy to motivate and retain skilled personnel; and 4 to promote policies that enable health-care workers to use their skills to the full. ›48 Quality in service provision. Up-to-date practices implemented in teach- ing hospitals and special projects are frequently not adopted throughout the system, with the result that overall performance remains poor and inequalities in both quality and access persist. Decentralized planning and responsibility associated with health-sector reforms need to give special attention to facilitating system-wide adoption of good practices. Logistical systems for sustained provision of essential commodities must be established. 25 ›49 Necessary actions in this area are: 1 to conduct strategic planning, involving health professionals and man- agers, to assess current quality of care and to determine the best way to improve quality within existing resourceconstraints; 2 to design and test strategies to expand interventions of proven effectiveness; 3 to formulate, adopt and monitor standards for clinical practice in private and public sectors; 4 to recruit partners among nongovernmental organizations and within the private and commercial sectors to maximize availability and use of reproductive health services; and 5 to promote the sharing of lessons learnt within and between countries. ›50 Use of services. Where health services exist, there are many reasons - social, economic and cultural - why people nevertheless do not use them, particularly in relation to reproductive and sexual health. Identifying and overcoming obstacles requires working with women, young people, and other community groups to understand better their needs, analyse problems and find acceptable solutions. ›51 Necessary actions in this area are: 1 to carry out social and operations research to identify barriers to use of services and devise and test measures to overcome them; and 2 to use participatory approaches to work with communities, public and private sector institutions, and nongovernmental organizations to overcome such barriers and promote appropriate use of available services. 26 ›53 ›54 Improving information for priority setting The process of setting priorities on the basis of good data, however, must involve multiple stakeholders from government, bilateral and multilateral agencies, professional associations, women’s groups and other sectors of civil society. Bringing together these different stakeholders with their varied perspectives will help to build a broad consensus, foster collaboration and increase the likelihood that interventions will be successful. Stakeholders must carefully balance cost-effectiveness with equity and consider the need to invest more in order to reach the poor and other underserved groups. Necessary actions in this area are: 1 to strengthen the capabilities for collecting and analysing data about health status, its underlying determinants and the functioning of health services at local, district and national levels; and 2 to set priorities based on data, using a multiple stakeholder consulta- tive process, with attention being paid to equitable access especially for poor and other underserved groups. ›52 Analysis of epidemiological and social science data is needed to under- stand the type, severity and distribution of reproductive and sexual risk exposure and ill-health in the population, to interpret the dynamics that drive poor reproductive and sexual health, and to illuminate the links between such ill-health and poverty, gender and social vulnerability. Improved data collection and analysis, including information about costs and cost-effectiveness, are essential bases for selecting among compet- ing priorities for action and for aiming health-system interventions at targets that are most likely to make a difference within the limits of available resources. 27 ›56 Necessary actions in this area are: 1 to build strong support for investment in reproductive and sexual health using evidence of benefits to public health and human rights; 2 to mobilize crucial constituencies (e.g. health professionals, legal experts, human rights groups, women’s associations, governmental min- istries, political leaders and parties, religious and community leaders) to support a national reproductive and sexual health agenda and make concerted use of the mass media; and 3 to build a strong, evidence-based case for strategic investment in ado- lescent sexual and reproductive health and rights, and place them high on the national agenda; to disseminate information on the nature, causes and consequences of adolescents’ reproductive health needs and problems, such as their vulnerability to sexually transmitted infec- tions including HIV, unwanted pregnancies, unsafe abortion, early mar- riage orchildbearing, and sexual coercion and violence, both within and outside marriage. Mobilizing political will ›55 Creating a dynamic environment of strong international, national and local support for rights-based reproductive and sexual health initiatives will help to overcome inertia, galvanize investment and establish high standards and mechanisms for performance accountability. This requires the involvement of not only ministries of health, but also ministries of finance, education and possibly other sectors, and their counterparts at district and local lev- els. Political commitment and advocacy must be sufficiently strong to sus- tain good policies and programmes, particularly for underserved groups. 28 Creating supportive legislative and regulatory frameworks ›58 Regulations are needed to ensure that commodities (medicines, equipment and supplies) are made available on a consistent and equitable basis and that they meet international quality standards. In addition, an effective regulatory environment is needed to ensure public and private sector accountability for providing high-quality care for all the population. ›57 Removal of unnecessary restrictions from policies and regulations, in order to create a supportive framework for reproductive and sexual health, is likely to contribute significantly to improved access to services. 29 ›59 Necessary actions in this area are: 1 to review, and if necessary modify, laws and policies in order to ensure that they facilitate universal and equitable access to reproductive and sexual health education, information and services; 2 to ensure that regulations and standards are in place so that necessary commodities, which meet international quality standards, are available on a consistent and equitable basis; and 3 to set performance standards and devise monitoring and account- ability mechanisms for the provision of services and for collaboration and complementary action among the private, nongovernmental and public sectors. 30 ›61 Necessary actions in this area are: 1 to establish and strengthen monitoring and evaluation mechanisms based on a clear plan of what is to be achieved, how and by when, with a clear set of indicators and strong baseline data; 2 to monitor health-sector reforms, sector-wide approaches, and the implementation of other financing mechanisms such as poverty redu tion strategy papers, cost-sharing and direct budget support in order to ensure that they benefit the poor and other socially or economically marginalized groups, and contribute to strengthening reproductive and sexual health services at all levels; and 3 to develop mechanisms (such as local committees or community meet- ings) to increase accountability at facility and district levels. ›60 Monitoring and evaluation are essential for learning what does and does not work, and why. They may also reveal changing needs and unexpected impacts, both positive and negative. Strengthening monitoring, evaluation and accountability 31 ›62 ›63 WHO’s commitment to attaining global reproductive health goals All these activities will systematically pay attention to and promote equity, including gender equity, and the human rights dimensions of reproductive and sexual health. In all the action areas outlined above, WHO will continue and intensify its technical assistance to countries by: ›64 At the global level, WHO will: 1 redouble its efforts to implement the Making Pregnancy Safer initiative, as a priority component of the reproductive and sexual health strategy, particularly for countries where maternal mortality is highest; 2 continue to strengthen its partnerships with other organizations in the United Nations system (in particular UNICEF, UNFPA and UNAIDS), the World Bank, associations of health professionals, nongovernmental organizations and other partners in order to ensure collaboration and coordinated actions by a broad range of partners. The new partnership for safe motherhood and new born health, to be hosted by WHO, will play a critical role in this; 3 promote and strengthen reproductive and sexual health services as the basis of the prevention and treatment of HIV/AIDS, particularly through family planning; antenatal, childbirth and postpartum care; control of sexually transmitted infections; the promotion of safer sex; and the pre- vention of mother-to-child transmission of HIV. WHO will also ensure attention to reproductive and sexual health by strengthening collabo- ration with other key public health programmes including immuniza- tion, nutrition and prevention and treatment of malaria and tuberculo- sis, especially in pregnant women; and 4 ensure accountability through reporting on progress towards repro- ductive and sexual health as part of achieving the Millennium Development Goals. • supporting action-oriented research and research-capacity strengthening • streamlining and carefully focusing evidence-based norms and standards • advocating globally for reproductive and sexual health. Photo credits © WHO: Cover photo: Rasoka Thor; inside front cover: Nathalie Scohier; p. 4-5: Natalie Behring-Chisholm; p. 6: Masaru Goto; p. 8: Mukunda Bogati; p. 10-11: Elin Hoyland; p. 12-13: Masaru Goto; p. 15-16: Masaru Goto; p. 16-17: Zbigniew Kosc; p. 19: Tarapada Banerjee; p. 20: Htin Lin; p. 23: Nathalie Scohier; p. 24-25: Richard Guidatti; p. 26-27: Liba Taylor; p. 28-29: Abir Abdullah; p. 30: Thierry Geenen; inside back cover: Carmen Cristina Urdaneta. WHO/RHR/04.8 The strategy presented in this document is the World Health Organization’s first global strategy on repro- ductive health. It was adopted by the 57th World Health Assembly (WHA) in May 2004. Reproductive and sex- ual ill-health accounts for 20% of the global burden of ill-health for women, and 14% for men. Five priority aspects of reproductive and sexual health are targeted in the strategy: improving antenatal, delivery, postpartum and newborn care; providing high-quality services for family planning, including infertility services; eliminating unsafe abortion; combating sexually transmitted infections, including HIV, reproductive tract infections, cervical cancer and other gynaecological morbidities; and promoting sexual health. The strategy was developed as a result of extensive consultations in all regions with representatives from ministries of health, professional associations, non-governmental organizations, United Nations partners and other key stakeholders. It lays out actions needed for accelerating progress towards the attainment of the Millennium Development Goals (MDGs) and other international goals and targets relating to repro- ductive health, especially those from the International Conference on Population and Development (ICPD) in 1994, and its five-year follow-up (ICPD+5). Three of the eight MDGs are directly related to reproductive and sexual health, namely, improving maternal health, reducing child mortality and combating HIV/AIDS, malaria and other diseases. “The strong endorsement of this strategy by the WHA represents an unequivocal message that countries are committed to do all they can to achieve the goals and targets of the ICPD Programme of Action adopted in 1994,” says Dr Paul Van Look, Director of WHO's Department of Reproductive Health and Research. “The Strategy gives our Member States and the Organization itself a clear roadmap on how we can work together in the coming years to achieve the ICPD goals.” © World Health Organization 2004 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland, tel: +41 22 791 2476; fax: +41 22 791 4857, email: bookorders@who.int. Requests for permission to reproduce or translate WHO publications - whether for sale or for noncommercial distribution - should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int).

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