Publication Cover
Reproductive Health Matters
An international journal on sexual and reproductive health and rights
Volume 13, 2005 - Issue 25: Implementing ICPD: what's happening in countries
699
Views
23
CrossRef citations to date
0
Altmetric
Original Articles

Strategy to Accelerate Progress towards the Attainment of International Development Goals and Targets Related to Reproductive Health

Pages 11-18 | Published online: 11 Jun 2005

Abstract

Reproductive and sexual ill-health account for 20% of the global burden of ill-health for women, and 14% for men. The strategy presented in this document is the World Health Organization's first global strategy on reproductive health. It was adopted by the 57th World Health Assembly (WHA) in May 2004. Five priority aspects of reproductive and sexual health are targeted: improving antenatal, delivery, postpartum and newborn care; providing high-quality services for family planning, including infertility services; eliminating unsafe abortion; combatting 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 reproductive health, especially those from the International Conference on Population and Development in 1994 and its five-year follow-up. “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.” (Dr Paul Van Look, Director, WHO Department of Reproductive Health and Research).

Résumé

Les pathologies génésiques et sexuelles représentent 20% de la charge mondiale de morbidité chez les femmes, et 14% chez les hommes. La stratégie présentée dans ce document est la première stratégie de l'OMS ayant trait à la santé génésique. Elle a été a adoptée lors de la 57ème Assemblée mondiale de la Santé (AMS) en mai 2004. La stratégie vise cinq aspects prioritaires : améliorer les soins prénatals, les soins lors de l'accouchement et du post-partum et les soins au nouveau-né; dispenser des services de planification familiale de qualité, et notamment des services spécialisés dans les problèmes de stérilité; éliminer les avortements non médicalisés; combattre les infections sexuellement transmissibles, y compris le VIH, les infections de l'appareil reproducteur, le cancer du col et d'autres pathologies gynécologiques; et promouvoir la santé sexuelle. La stratégie a été développée suite à des consultations étendu dans toutes les régions avec les représentants des ministres de santé, associations professionnelles, organisations non gouvernmentales, partenaires des Nations Unis et autres. Elle préconise les actions nécessaires pour accélérer les progrès sur la voie de la réalisation des objectifs du Millénaire pour le développement et ceux qui étaient issus de la Conférence internationale sur la population et le développement (CIPD) en 1994, et de son suivi de cinq ans. « L'adhésion massive de l'AMS à cette stratégie contient le message sans équivoque que les pays sont déterminés à faire ce qui est en leur pouvoir pour atteindre les objectifs du programme d'action de la CIPD adopté en 1994 °. (Dr Paul Van Look, Directeur, Département Santé et recherche génésiques, OMS).

Resumen

El 20% de las enfermedades de las mujeres y el 14% de las de los hombres están relacionadas con la salud sexual y reproductiva. En este documento se presenta la primera estrategia global de la Organización Mundial de la Salud sobre salud reproductiva. Fue adoptada por la 57a Asamblea Mundial de la Salud (AMS) en mayo de 2004. Se concentra en cinco aspectos prioritarios de la salud sexual y reproductiva: mejorar la atención antenatal, del parto, posparto y del recién nacido; prestar servicios de planificación familiar de alta calidad, incluidos los servicios de infertilidad; eliminar el aborto inseguro; combatir las infecciones de transmisión sexual, incluido el VIH, las infecciones del tracto reproductivo, el cáncer cervical y otras morbilidades ginecológicas; y promover la salud sexual. La estrategia fue elaborada tras extensas consultas con representantes de ministerios de salud, asociaciones profesionales, organizaciones no gubernamentales, colegas de las Naciones Unidas y otras partes interesadas clave. Señala las medidas necesarias para acelerar los avances hacia el cumplimiento de los Objetivos de Desarrollo del Milenio (ODM) y otros objetivos y metas internacionales relacionados con la salud reproductiva, especialmente los de la Conferencia Internacional sobre la Población y el Desarrollo, celebrada en 1994, y su seguimiento cinco años después. “La enfática aprobación de esta estrategia por parte de la AMS es un mensaje inequívoco de que los países se comprometen a hacer todo lo posible por lograr los objetivos y las metas del Programa de Acción de la CIPD adoptado en 1994.” (Dr Paul Van Look, Director, Departamento de Salud Reproductiva e Investigación, OMS).

Introduction

World Health Organization

Approved by the World Health AssemblyFootnote* May 2004

1. Reproductive and sexual healthFootnote 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 reproductive 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 resolution 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.Footnote**

2. In response to resolution WHA55.19, and following consultations with Member States and partners, WHO has designed a 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 reproductive health programmes”.

3. The strategy presented in this document is intended for a broad audience of policy-makers within governments, international agencies, professional associations, nongovernmental organizations and other institutions. 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 principles based on international human rights. It highlights the core aspects of reproductive and sexual health services and proposes ways for countries 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.

I. Global Goals, Global Realities

4. 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 sustaining 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 relationship with health, including reproductive health. Among the specific targets are:

to reduce by three quarters, between 1990 and 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.

5. 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.Footnote*

6. The definition of reproductive health adopted at the International Conference on Population and Development in 1994 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.

7. 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 conventional modes of delivering maternal and child health or family planning services.

8. 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 behavioural research and of internationally recognized standards, norms and guidelines has broadened.

9. Experience has shown that, even in low-income settings, innovative country-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 international goals…

(Sections 10–32 omitted)

II. The strategy to accelerate progress

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.

Guiding principle: human rights

34. 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 information 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 sexual 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 countries that bear the largest burden of reproductive and sexual ill-health.

Core aspects of reproductive and sexual health services

35. The five core aspects of reproductive and sexual health are: improving antenatal, perinatal, 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. 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 countries to strengthen existing services and use them as entry points for new interventions, looking for maximum synergy.

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 mortality, are the attendance at every birth of skilled health personnel and comprehensive 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 excellent means through which to offer women prevention, counselling, testing and treatment for HIV infection and for preventing HIV transmission during 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.

37. As a preventable cause of maternal mortality and morbidity, unsafe abortion must be dealt with as part of the Millennium Development Goal on improving 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 appropriate drugs and supplies, all of which should be available for gynaecological and obstetric care; providing social and other support to women with unintended pregnancies; and, to the extent allowed by law, providing abortion services 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.

38. The success of family planning services in most countries of the world is evidenced by the great increase in contraceptive use in developing countries over the past two to three decades. These programmes are an essential part of services to reduce maternal and perinatal morbidity and mortality because they enable women to postpone, space and limit pregnancies. As these services are directly concerned with the outcomes of sexual relationships, they also have great potential for leading the way in promoting sexual health and efforts to prevent sexually transmitted infections and HIV transmission.

39. Sexually transmitted infections are being diagnosed and treated by pharmacists, drug sellers and traditional healers, often ineffectively. Various attempts have been made to reach women by integrating sexually transmitted infections management into existing maternal and child health and/or family planning services, but with limited success. Nonetheless, experience shows that integration of sexually transmitted infection prevention into family planning services, especially through counselling and discussion of sexuality and partner relationships, has increased the use of services 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, presumptive treatment in groups at high risk and comprehensive, community-based programmes to control sexually transmitted infections could greatly contribute to the reduction of HIV transmission rates.

40. Additional gains from strengthening reproductive health services are numerous. They include attention to violence against women, which is now being tackled in various country settings with, for instance, provision of emergency 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, prevention of primary and secondary infertility, and treatment of gynaecological 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 participation, and women's empowerment to make reproductive choices.

41. All reproductive and sexual health services have a key role to play in providing information and counselling in promoting sexual health. Appropriate information can also contribute to better communication between partners and healthier sexual decision-making, including abstinence and condom use.

Actions

42. WHO proposes the following key action areas for countries, and is committed to supporting Member States in building and strengthening their capacity to improve reproductive and sexual health. Each country needs to identify problems, set priorities and formulate 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 monitoring, evaluation and accountability.

Strengthening health systems capacity

43. A prerequisite for attaining the Millennium Development Goals relating to maternal and infant survival and HIV/AIDS, as well as the broader reproductive 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 essential 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 reproductive and sexual health needs to be reflected in national health-sector planning and strategic development. Health-sector reforms and related initiatives such as sector-wide approaches to donor funding have been promoted 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 strategy 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 packages under health-sector reforms and sector-wide approaches; and

(4)

where new financing mechanisms such as cost sharing are being introduced, 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.

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 workers to realize their full potential and to motivate them to work with all population 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 teaching 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.

49. Necessary actions in this area are:

(1)

to conduct strategic planning, involving health professionals and managers, to assess current quality of care and to determine the best way to improve quality within existing resource constraints;

(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.

Improving information for priority setting

52. Analysis of epidemiological and social science data is needed to understand 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 competing 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.

53. 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.

54. 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 consultative process, with attention being paid to equitable access especially for poor and other underserved groups.

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 levels. Political commitment and advocacy must be sufficiently strong to sustain good policies and programmes, particularly for underserved groups.

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 ministries, 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 adolescent 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 infections including HIV, unwanted pregnancies, unsafe abortion, early marriage or childbearing, and sexual coercion and violence, both within and outside marriage.

Creating supportive legislative and regulatory frameworks

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.

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.

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 accountability mechanisms for the provision of services and for collaboration and complementary action among the private, nongovernmental and public sectors.

Strengthening monitoring, evaluation and accountability

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.

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 reduction 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 meetings) to increase accountability at facility and district levels.

WHO's commitment to attaining global reproductive health goals

62. In all the action areas outlined above, WHO will continue and intensify its technical assistance to countries by:

supporting action-oriented research and research-capacity strengthening

streamlining and carefully focusing evidence-based norms and standards

advocating globally for reproductive and sexual health.

63. All these activities will systematically pay attention to and promote equity, including gender equity, and the human rights dimensions of reproductive and sexual health.

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 newborn 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 prevention of mother-to-child transmission of HIV. WHO will also ensure attention to reproductive and sexual health by strengthening collaboration with other key public health programmes including immunization, nutrition and prevention and treatment of malaria and tuberculosis, especially in pregnant women; and

(4)

ensure accountability through reporting on progress towards reproductive and sexual health as part of achieving the Millennium Development Goals.

Note

This text is reproduced in full from the Strategy document of the same title. excluding sections 10 to 32, which contain data on the global situation as regards sexual and reproductive health and describe barriers to progress. The full document is available at: ⟨www.who.int/⟩ and is reproduced here with kind permission of the World Health Organization Department of Reproductive Health and Research.

Notes

* See resolution WHA57.12.

† The definition of reproductive health proposed by WHO and agreed to at the International Conference on Population and Development (Cairo, 1994) includes sexual health.

** 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 (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).

* United Nations document A/S-21/5/Add.1, paragraph 64.

Reprints and Corporate Permissions

Please note: Selecting permissions does not provide access to the full text of the article, please see our help page How do I view content?

To request a reprint or corporate permissions for this article, please click on the relevant link below:

Academic Permissions

Please note: Selecting permissions does not provide access to the full text of the article, please see our help page How do I view content?

Obtain permissions instantly via Rightslink by clicking on the button below:

If you are unable to obtain permissions via Rightslink, please complete and submit this Permissions form. For more information, please visit our Permissions help page.