ICPD Goals and Targets Worth Revisiting in the Context of Health Sector Reforms

At the International Conference on Population and Development (ICPD) in 1994, countries endorsed a Programme of Action containing a broad range of goals and targets in the broad area of sexual and reproductive health [1]. In 1996, the World Health Organization (WHO) organised an interagency technical process that led to the selection of 15 global indicators for monitoring reproductive health targets [2], to which two additional ones were later added in order to include HIV/AIDS [3].

A five-year review and appraisal of progress in the implementation of the ICPD Programme of Action took place in 1999 (ICPD+5) and culminated in a Special Session of the United Nations General Assembly in July 1999, which identified key actions needed for further implementation of the Programme of Action and specific targets for measuring progress towards ICPD goals [4].

The 17 WHO indicators shown in the left-hand column of Box 1 are worth revisiting regularly to check whether countries are meeting the targets set, and also for assessing the potential and actual impact of health sector reforms on sexual and reproductive services in their countries. The goals and targets related to those indicators, listed in the right-hand column, can be found in the ICPD Programme of Action and the Key Actions for their further implementation.

Box 1. WHO indicators and related ICPD goals and targets [1][2][3][4]

Global indicators	ICPD goals and targets
1. Total fertility rate	– While the programme of Action does not quantify goals for population growth, structure and distribution, it reflects the view that an early stabilisation of world population would make a crucial contribution to realising the overarching objective of sustainable development.
2. Contraceptive prevalence	– Assist couples and individuals to achieve their reproductive goals and give them the full opportunity to exercise the right to have children by choice.
	– Provide universal access to a full range of safe and effective family planning methods, as part of comprehensive sexual and reproductive health care.
	– By 2005, 60% of primary health care and family planning facilities should offer the widest achievable range of safe and effective family planning methods.
3. Maternal mortality ratio	– Countries should strive to effect significant reductions in maternal morbidity and mortality by the year 2015: a reduction in maternal mortality by one half of the 1990 levels by the year 2000 and a further one half by 2015. Disparities in maternal mortality within and between countries, socio-economic and ethnic groups should be narrowed.
4. Antenatal care coverage	– Expand the provision of maternal health services in the context of primary health care. These services should offer prenatal care and counseling, with special emphasis on detecting and managing high-risk pregnancies.
5. Births attended by skilled health personnel	– All births should be attended by trained persons.
	– All countries should continue their efforts so that globally, by 2005 at least 80% of all births should be assisted by skilled attendants, by 2010, 85%, and by 2015, 90%.
6. Availability of basic essential obstetric care	– Expand the provision of maternal health services in the context of primary health care. These services should offer adequate delivery assistance and provision for obstetric emergencies.
7. Availability of comprehensive essential obstetric care	– By 2005, 60% of primary health care and family planning facilities should offer, directly or through referral, essential obstetric care.
8. Perinatal mortality rate	– Within the framework of primary health care, extend integrated reproductive health care and child health services, including safe motherhood, child survival programmes and family planning services, particularly to the most vulnerable and under-served groups.
9. Low birthweight prevalence	– To improve the health and nutritional status of women, especially of pregnant women, and of infants and children.
	– Interventions to reduce low birthweight should include the promotion of maternal nutrition and the promotion of longer intervals between births.
10. Positive syphilis serology prevalence in pregnant women	– Prevent and reduce the incidence of, and provide treatment for, sexually transmitted diseases, including HIV/AIDS.
	– By 2005, 60% of primary health care and family planning facilities should offer prevention and management of reproductive tract infections, including STDs and barrier methods to prevent infection.
11. Prevalence of anaemia in women	– Countries should implement special programmes on the nutritional needs of women of childbearing age, and give particular attention to the prevention and management of nutritional anaemia.
12. Percentage of obstetric and gynaecological admissions owing to abortion	– Women should have access to quality services for the management of complications arising from abortions.
13. Reported prevalence of women with female genital mutilation	– Countries should take steps to eliminate violence against women.
	– Governments should prohibit female genital mutilation wherever it exists and give vigorous support to efforts among non-governmental organisations and religious institutions to eliminate such practices.
14. Prevalence of infertility in women	– Prevent and reduce the incidence of, and provide treatment for, sexually transmitted diseases, including HIV/AIDS, and the complications of sexually transmitted diseases such as infertility, with special attention to girls and women.
	– By 2005, 60% of primary health care and family planning facilities should offer prevention and management of reproductive tract infections, including STDs and barrier methods to prevent infection.
15. Reported incidence of urethritis in men	– Prevent and reduce the incidence of, and provide treatment for, sexually transmitted diseases, including HIV/AIDS.
	– By 2005, 60% of primary health care and family planning facilities should offer prevention and management of reproductive tract infections, including STDs and barrier methods to prevent infection.
16. HIV prevalence in pregnant women	– HIV infection rates in persons 1 5-24 years of age should be reduced by 25% in the most affected countries by 2005 and by 25% globally by 2010.
17. Knowledge of HIV-related prevention practices	– By 2005 at least 90% of young men and women, aged 15-24, should have access to the information, education and services necessary to develop the life skills required to reduce their vulnerability to HIV infection.

In some countries, technical support will be needed to strengthen national capacity to collect and analyze data relating to the goals and targets and to use the results to amend and expand policy and programmes, and develop national guidelines and protocols. National capacity is also required to analyse the content and impact of health sector reforms, in particular:

•	how sexual and reproductive health services are financed, e.g. through taxation, social and other forms of insurance, donor resources user fees and other out-of-pocket expenses;
•	how sexual and reproductive health services are provided, broken down by the range of public and private for-profit and not-for-profit health care providers;
•	how providers are paid, e.g. through salaries, fees for service, diagnostic-related groups or capitation, which shapes access to and quality of care received by beneficiaries [5][6][7]; and
•	which regulatory mechanisms are in place and how they are enforced. This is one of the key leadership functions of government, and plays a pivotal role in ensuring access to essential services, especially for the poor [6].

Two major challenges can be posed. First, the development of national capacity to understand the complexity of relationships among the different actors and stakeholders in the reform process [8] and capacity to gather evidence on the impact of health sector reforms on sexual and reproductive health. Second, the urgent need to understand the influence of context, actors and the processes of implementation of reforms [9], as well as strengthen the linkages between evidence and policy formulation [10]. This is to ensure a continuous feedback loop of evidence to policy [11], which will serve to reverse the negative impacts and sustain and support the positive impacts of health sector reform on sexual and reproductive health.

Acknowledgements

Final support from the Thailand Research Fund to the Research Scholar Program in Health Policy and Systems Research is highly appreciated.