UN Population Division, Department of Economic and Social Affairs,
with support from the UN Population Fund (UNFPA)
************************************************************************* This document has been prepared by the Secretariat of the United Nations Inter-Agency Task Force on the Implementation of the ICPD Programme of Action. For further information please contact the United Nations Population Fund, Task Force on ICPD Implementation, 220 East 42nd Street, New York, NY 10017 USA or send E-mail to: firstname.lastname@example.org ************************************************************************** GUIDELINES ON REPRODUCTIVE HEALTH FOR THE UN RESIDENT COORDINATOR SYSTEM I. KEY FACTS ABOUT REPRODUCTIVE HEALTH 1. Definition of reproductive health Reproductive health is a state of complete physical, mental and social well-being, and not merely the absence of reproductive disease or infirmity. Reproductive health deals with the reproductive processes, functions and system at all stages of life. The International Conference on Population and Development Programme of Action states that "reproductive health ... implies that people are able to have a satisfying 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. ... Reproductive health 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." 2. The importance of reproductive health Reproductive health is a crucial part of general health and a central feature of human development. It is a reflection of health during childhood, and crucial during adolescence and adulthood, sets the stage for health beyond the reproductive years for both women and men, and affects the health of the next generation. The health of the newborn is largely a function of the mother's health and nutrition status and of her access to health care. Reproductive health is a universal concern, but is of special importance for women particularly during the reproductive years. Although most reproductive health problems arise during the reproductive years, in old age general health continues to reflect earlier reproductive life events. Men too have reproductive health concerns and needs though their general health is affected by reproductive health to a lesser extent than is the case for women. However, men have particular roles and responsibilities in terms of women's reproductive health because of their decision-making powers in reproductive health matters. At each stage of life individual needs differ. However, there is a cumulative effect across the life course þ events at each phase having important implications for future well-being. Failure to deal with reproductive health problems at any stage in life sets the scene for later health and developmental problems. Because reproductive health is such an important component of general health it is a prerequisite for social, economic and human development. The highest attainable level of health is not only a fundamental human right for all, it is also a social and economic imperative because human energy and creativity are the driving forces of development. Such energy and creativity cannot be generated by sick, tired people, and consequently a healthy and active population becomes a prerequisite of social and economic development. 3. What is new about the concept of reproductive health Reproductive health does not start out from a list of diseases or problems - sexually transmitted diseases, maternal mortality - or from a list of programmes - maternal and child health, safe motherhood, family planning. Reproductive health instead must be understood in the context of relationships: fulfilment and risk; the opportunity to have a desired child þ or alternatively, to avoid unwanted or unsafe pregnancy. Reproductive health contributes enormously to physical and psychosocial comfort and closeness, and to personal and social maturation þ poor reproductive health is frequently associated with disease, abuse, exploitation, unwanted pregnancy, and death. The most significant achievement of the Cairo Conference was to place people firmly at the centre of development efforts, as protagonists in their own reproductive health and lives rather than as objects of external interventions. The aim of interventions is to enhance reproductive health and promote reproductive rights rather than population policies and fertility control. This implies the empowerment of women (including through better access to education); the involvement of women and young people in the development and implementation of programmes and services; reaching out to the poor, the marginalized and the excluded; and assuming greater responsibility for reproductive health on the part of men. 4. How this concept of reproductive health differs from existing family planning and maternal and child health programmes Programmes dealing with various components of reproductive health exist in some form almost everywhere. But they have usually been delivered in a separate way, unconnected to programmes dealing with closely interdependent topics. For example, the objectives, design and evaluation of family planning programmes were largely driven by a demographic imperative, without due consideration to related health issues such as maternal health or STD prevention and management. Evaluation was largely in terms of quantity rather than quality - numbers of contraceptive acceptors as opposed to the ability and opportunity to make informed decisions about reproductive health issues. In general, such programmes exclusively targeted women, taking little account of the social, cultural and intimate realities of their reproductive lives and decision-making powers. They tended to serve only married people, excluding, in particular, young people. Services were rarely designed to serve men even though they have reproductive health concerns of their own, particularly with regard to sexually transmitted diseases. Moreover, the involvement of men in reproductive health is important because they have an important role to play as family decision-makers with regard to family size, family planning and use of health services. A reproductive health approach would differ from a narrow family planning approach in several ways. It would aim to build upon what exists and at the same time to modify current narrow, vertical programmes to ones in which every opportunity is taken to offer women and men a full range of reproductive health services in a linked way. The underlying assumption is that people with a need in one particular area - say treatment of a sexually transmitted diseases - also have needs in other areas - family planning or antenatal/postpartum care. Such programmes would recognize that dealing with one aspect of reproductive health can have synergistic effects in dealing with others. For example, management of infertility is difficult and expensive but it can be largely prevented through appropriate care during and after delivery and prevention and management of STDs. Promotion of breast-feeding has an impact on reproductive health in many ways - it helps prevent certain postpartum problems, delays the return to fertility, may help prevent ovarian and breast cancer, and improves neonatal health. Another important difference between existing programmes and those developed to respond to the new concept of reproductive health is the way in which people - particularly women and young people who are the most affected by reproductive health concerns - are involved in programme development, implementation and evaluation. When women become more involved in programmes it becomes clearer that they have health concerns beyond motherhood and also that dealing with reproductive health involves a profound rethinking of the behavioural, social, gender and cultural dimensions of decision-making which affect women's reproductive lives. 5. What reproductive health services include The precise configuration of reproductive health needs and concerns, and the programmes and policies to address them, will vary from country to country and will depend on an assessment of each country's situation and the availability of appropriate interventions. Globally, however, both the epidemiological data and the expressed wishes of diverse constituencies indicate that reproductive health interventions are most likely to include attention to the issues of family planning, STD prevention and management and prevention of maternal and perinatal mortality and morbidity. Reproductive health should also address issues such as harmful practices, unwanted pregnancy, unsafe abortion, reproductive tract infections including sexually transmitted diseases and HIV/AIDS, gender-based violence, infertility, malnutrition and anaemia, and reproductive tract cancers. Appropriate services must be accessible and include information, education, counselling, prevention, detection and management of health problems, care and rehabilitation. Reproductive health strategies should be founded first and foremost on the health of individuals and families. In the operationalization of the strategies all reproductive health services must assume their responsibility to offer accessible and quality care, while ensuring respect for the individual, freedom of choice, informed consent, confidentiality and privacy in all reproductive matters. They should focus special attention on meeting the reproductive health needs of adolescents. 6. Factors affecting reproductive health Reproductive health affects, and is affected by, the broader context of people's lives, including their economic circumstances, education, employment, living conditions and family environment, social and gender relationships, and the traditional and legal structures within which they live. Sexual and reproductive behaviours are governed by complex biological, cultural and psychosocial factors. Therefore, the attainment of reproductive health is not limited to interventions by the health sector alone. Nonetheless, most reproductive health problems cannot be significantly addressed in the absence of health services and medical knowledge and skills. The status of girls and women in society, and how they are treated or mistreated, is a crucial determinant of their reproductive health. Educational opportunities for girls and women powerfully affect their status and the control they have over their own lives and their health and fertility. The empowerment of women is therefore an essential element for health. 7. Who is most affected by reproductive health problems Women bear by far the greatest burden of reproductive health problems. Women are at risk of complications from pregnancy and childbirth; they also face risks in preventing unwanted pregnancy, suffer the complications of unsafe abortion, bear most of the burden of contraception, and are more exposed to contracting, and suffering the complications of reproductive tract infections, particularly sexually transmitted diseases (STDs). Among women of reproductive age, 36% of all healthy years of life lost is due to reproductive health problems such as unregulated fertility, maternal mortality and morbidity and sexually transmitted diseases including HIV/AIDS. By contrast, the equivalent figure for men is 12%. Biological factors alone do not explain women's disparate burden. Their social, economic and political disadvantages have a detrimental impact on their reproductive health. Young people of both sexes, are also particularly vulnerable to reproductive health problems because of a lack of information and access to services. 8. How countries can identify reproductive health needs and assess priorities A number of countries have expressed the desire to move forward with a new and comprehensive approach to reproductive health. Support to national authorities in carrying out a systematic review of reproductive health needs at country level should focus on the importance of adding innovative and participatory approaches to more familiar epidemiological methodologies in which the process tends to be directed by experts and framed by biomedical approaches and indicators. The identification of reproductive health needs, the determination of priorities and the development of programmatic responses to those needs should be conducted through an inclusive process, soliciting the perspectives of a range of groups concerned with reproductive health including, for example, women's health advocates, youth groups, health care providers at the periphery as well as at the central level, health planners, researchers, and non-governmental organizations. Several instruments have already been developed for situation analysis and needs assessment in different components of reproductive health, for example, family planning and safe motherhood. However, in the context of the new approach to reproductive health it is necessary to ensure that assessment and prioritization reflect people's concerns as agreed at national and local levels and not the priorities of agencies or donors. It is important to avoid duplication and to develop tools that are appropriate for countries themselves. A number of such instruments already exist and are widely used. However, it is important to ensure compatibility and consistency among the various instruments currently available. Similar considerations apply to the selection of priorities for action in reproductive health. Criteria for identification of priority problems should include not only importance - prevalence, severity, public concern, government commitment, impact on family, community and development - but also the feasibility of addressing them - known interventions, cost-effectiveness, availability of financing, human resources and adequate equipment and supplies. 9. Human resources for reproductive health The operationalization of the new concept of reproductive health will mean changes in skills, knowledge, attitudes and management. People will have to work together in new ways. Health care providers will have to collaborate with others, including NGOs, women's health advocates, and young people. Managerial and administrative changes will also be needed because integrated services can impose, at least initially, greater burdens on already over-stretched staff and require attention to planning and logistics in order to ensure availability and continuity of services. Training for reproductive health workers will need to focus on improving both technical and interpersonal skills. Additional training, particularly in counselling skills and in ways of reaching out to under-served groups will be essential elements of such training. The back-up and support of functioning referral systems will be essential elements if the full range of reproductive health concerns is to be adequately addressed. 10. Monitoring and evaluation Monitoring and evaluation of reproductive health takes place at two levels - the country and the global level. Globally, the international community has already defined a number of indicators relevant to reproductive health, including: Maternal mortality % pregnant women who have at least one antenatal visit % of pregnant women who have a trained attendant at delivery % of pregnant women immunized against tetanus contraceptive prevalence rate % of infants weighing less than 2500 g at birth (a newborn indicator that reflects maternal reproductive health) WHO is working on additional indicators for global monitoring in reproductive health, including indicators on incidence and prevalence of sexually transmitted diseases, quality of family planning services, access to and quality of maternal health services, prevalence of female genital mutilation and prevalence and nature of obstetric and gynaecological morbidities. Reproductive health indicators should cover not only quantitative indicators such as those listed above, but also some qualitative indicators, such as women's satisfaction with services, perceptions of quality, maternal discomfort and dissatisfaction, perceived reproductive morbidities, opportunities for choice, and enabling environments. Particular attention will be paid to indicators that identify disparities within countries - between population groups and/or regions, for example. Data collection should be seen as a means towards an end rather than an end in itself. It will, therefore, be necessary to focus increasingly on performance-based measures such as maternal audit, surveillance and other process measures. Such programme indicators should be useful for policy-making and be generated through data collection procedures that are useful for programme management at the level at which the data are collected. All data collection efforts should be sustainable by the national authorities and able to take into account new developments in terms of strategic thinking and implementation. In addition, all indicators should be valid, objectively measurable and reliable. II. KEY ACTIONS FOR THE RESIDENT COORDINATOR SYSTEM TO IMPROVE REPRODUCTIVE HEALTH 1. Advocate for the concept of reproductive and sexual health The Resident Coordinator system can promote recognition of the concept of reproductive health as central to general health and human development. This implies the integration of reproductive health and reproductive rights into all related development priorities and programmes. Resident Coordinators should be aware that reproductive health is a dynamic and continuously evolving concept. Therefore, information sharing and collaboration will be needed to ensure that the approaches developed and implemented are based on the most recent and relevant information available and on the evolving experiences of those working in the field. The Country Strategy Note should be used as a vehicle to promulgate this vision more widely. 2. Promote multi-sectoral action Reproductive health is a health issue but encompasses more than biomedical aspects and goes beyond the health sector. The determinants of reproductive ill-health lie in poverty, gender and other forms of inequity, social injustice, marginalization and development failures. All sectors affect and are affected by reproductive health. The Resident Coordinator system can advocate that all agencies and all sectors have roles and responsibilities in promoting reproductive health. One of the key actions needed to improve reproductive health is the empowerment of women especially through education. The UN Resident Coordinator system can mobilize increased energies and resources for women's education both in-school and out-of-school (youth groups, workplaces, adult literacy and income generation groups etc.). 3. Stimulate adherence to essential principles The Resident Coordinator system can disseminate the underlying principles which must serve as a guide to action in reproductive health. These are the guiding principles of human rights, equality and gender equity, and placing people at the centre of development efforts. Operational principles for the implementation of reproductive health policies and programmes include participatory processes, involvement of multiple perspectives and multi-sectoral action. The Resident Coordinator system is well-placed to ensure the involvement of different sectors and the participation of all those concerned with reproductive health. Where there are major regional, ethnic, religious or cultural variations within countries, these must be taken into account in the development of reproductive health strategies. Where certain groups have difficulties in making their voices heard, the Resident Coordinator system can play a role in providing a forum for the exchange of ideas and experiences. 4. Foster national ownership A global reproductive health strategy must be translated into approaches that are country-driven. Implementation of reproductive health programmes is the sovereign right of each country, in a way that is consistent with national laws and development priorities, with full respect for religious, cultural and ethical values and in harmony with universally recognized human rights. The Resident Coordinator system can ensure that the development of strategies, policies and programmes is a nationally owned process and that decisions taken reflect national priorities and are not dictated by external agencies. 5. Ensure consistency and complementarity Translating the concept of reproductive health into actions means ensuring a shared understanding of the concept and consistency and complementarity in the application of approaches. It is critically important to avoid conflicting messages from UN agencies to national counterparts. The Resident Coordinator system can help to ensure consistency and bring together different parties in order to avoid duplication and make best use of resources. One practical way of doing this would be the creation in countries of a database of information from all in-country agencies on project design, implementation, monitoring, evaluation, lessons learned and future programme plans. This could be drawn upon by all agencies and would help avoid duplication while ensuring greater information-sharing and networking among agencies. 6. Coordinate agency, regional, bilateral and NGO activities Each agency has specific mandates and comparative advantages which need to be incorporated into the concept of reproductive health. Some agencies, including WHO, UNAIDS, UNFPA, UNICEF, and UNHCR are likely to have a deeper involvement than others in reproductive health issues. While subscribing to the overall broad concept of reproductive health, agencies select priorities in a focused way on the basis on capacities and resources. Resident Coordinators should be well aware of agency mandates, capacities and resources and be able to assess where there are gaps and duplications and recommend strategies to overcome them. Resident Coordinators can promote harmony between the activities of international agencies, bilateral donors and NGOs working to support government and regional strategies in reproductive health. The Resident Coordinator system should gather and disseminate information about the resources available at country, regional and global levels, in terms of funding, knowledge and expertise. 7. Assist in the identification of reproductive health needs The Resident Coordinator system can help countries in the identification of national reproductive health needs and the selection of priorities, in the evaluation of current programmatic responses to the needs identified and in assessing potential for improvement and avoidance of overlap. The Resident Coordinators should promote the need for appropriate guidance and training for all agency, regional and national representatives in the reproductive health approach. 8. Support national planning The resident coordinator system should support national planning through making the most effective use of specific agency plans and programmes, making the best use of the comparative advantages of each agency, and through seeking to achieve an appropriate balance in the response of country and agency activities and promoting an incremental improvement in programmes bearing the overall reproductive health vision in mind. Of particular importance in the national planning process is the development of decision-making tools and the improvement of managerial capacities. The overall objective is to increase national capacity for planning and implementation of reproductive health policies and programmes within national constraints, objectives and approaches. 9. Promote integrated approaches The Resident Coordinator system can ensure integration of all aspects of reproductive health, especially those delivered in the past through vertical programmes such as family planning. The Resident Coordinator can encourage the incorporation into reproductive health programmes of such concerns as the eradication of harmful practices affecting women's health, as well as various forms of violence. The Resident Coordinator system can integrate follow-up to the various international conferences on related issues such as population, reproductive health and development, including the World Summit for Children, the United Nations Conference on Environment and Development, the World Social Summit, the United Nations Conference on Human Rights and the forthcoming Fourth World Conference on Women. 10. Support monitoring and evaluation The Resident Coordinator system has an important role to play in monitoring and evaluation. Global monitoring should be limited and not impose additional burdens on national reporting systems. The Resident Coordinator should support national capacity-building for monitoring progress in country programmes in a way which is helpful to programme management and useful at the point of delivery of the intervention. ================================================================= SELECTED BIBLIOGRAPHY Berer M. Population and family planning policies: women-centred perspectives. Reproductive Health Matters, 1993, 1:4-12. Cook R. International law and women's health. In: Gomez E. ed. Gender, Women and Health in the Americas. Washington DC, PAHO, 1993:272-77 Dixon-Mueller R. Population Policy and Women's Rights: Transforming Reproductive Choice. Westport, CN, Praeger, 1993. Dixon-Mueller R. The sexuality connection in reproductive health. Studies in Family Planning. 1993, 24:269-82. Faundes A, Hardy E, Pinotti JA. Commentary on women's reproductive health: means or end? International Journal of Gynecology and Obstetrics. 1989, (supp)3:115-8. Freedman LP, Isaacs SL. Human rights and reproductive choice. Studies in Family Planning, 1993, 24:18-30. Germain, A. and Kyte, R. The Cairo Consensus, International Women's Health Coalition, New York, 1995 Graham WJ, Reproductive health in developing countries: measurement, determinants, and consequences: overview. In: International Population Conference. Liege, Belgium: IUSSP. 1993, 571-7. Graham WJ, Campbell OM. Maternal health and the measurement trap. Social Science and Medicine, 1992, 35(8):967-77. IWHC and WHO. Creating common ground. Geneva, WHO, 1991. Jacobson, J. The silent emergency: Women's reproductive health, Worldwatch Institute, 1991. Jain A, Bruce J. Implications of reproductive health for objectives and efficacy of family planning programs. New York, The Population Council. (Programs Division Working Papers No. 8). 1993 Koblinsky M, Timyan J, Gay J. eds. The Health of Women: a Global Perspective. Boulder, Westview Press, 1993:33-62. Lane, S. From population policy to a reproductive health agenda. Social Science and Medicine 39 (9), 1994 Mazur LA, ed. Beyond the Numbers: A reader on Population, Consumption, and the Environment. Washington DC, Island Press. 1994:150-7. Rockefeller Foundation. Improving the quality and reach of reproductive health service delivery: a strategy paper. New York, The Rockefeller Foundation, 1994. Sen G, Germain A, Chen L, eds. Population Policies Reconsidered: Health, Development, and Human Rights. Cambridge, Harvard University Press, 1994:1-17 Tinker A et al. Women's health and nutrition: Making a difference. Washington, DC, World Bank (Discussion Paper No. 256), 1994. UNFPA. Reproductive Health and Family Planning: Directions for UNFPA Assistance. Report on Expert Consultation. New York, 1995. World Bank. World Development Report 1993. New York, Oxford University Press, 1993. World Bank. Population in Developing Countries: Implications for the World Bank. Washington DC, World Bank, 1994. World Bank. Improving Reproductive Health: The Role of the World Bank. Washington DC, World Bank, 1995 World Health Organization. Care of mother and Baby at the health centre: a practical guide. WHO/FHE/MSM/94.2. Geneva, WHO, 1994. World Health Organization. Health, Population and Development, WHO/FHE/94.1. Geneva, WHO, 1994. World Health Organization. Mother-Baby Package: Implementing Safe Motherhood in Countries. WHO/FHE/MSM/94.11. Geneva, WHO, 1994. World Health Organization. Achieving Reproductive Health For All. The Role of WHO. WHO/FHE/95.6. Geneva, WHO, 1995. World Health Organization. Women's Health: Improve our health - improve the world. WHO/FHE/95.8. Geneva, WHO, 1995. =============================================================== AGENCY PROFILES World Health Organization (WHO) WHO was an active contributor throughout the ICPD process and fully subscribes and is committed to the implementation of the Programme of Action, and to reinforcing the central role of health and human development in the global agenda for sustainable development. In following up ICPD WHO is committed to further build upon the existing collaboration within the UN system to support countries in their efforts to take on the challenges of Cairo. WHO will foster its relationship with UNICEF, UNFPA, UNDP and the World Bank in particular, at both global and country levels. WHO will continue to affirm that to bring about the necessary changes and improve health and quality of life, health policies must reach beyond the health sector while remaining rooted in the health-for-all principles of primary health care. A primary health care approach includes promotive and preventive aspects as well as care and rehabilitation and comprises actions at the community level supported by referral to a higher level of care when needed. WHO stimulates and supports research in reproductive health, particularly in the area of fertility regulation, safe motherhood, and reproductive tract infections including STDs and HIV/AIDS prevention. WHO's research is aimed at identifying gaps in addressing reproductive health needs, at adapting technologies and applying existing knowledge, and at developing new approaches and interventions for better reproductive health. WHO works with a worldwide network of collaborating centres to build national research capabilities, develop innovative methodologies and disseminate the results of research to policy-makers, planners, health care providers, women's health advocates, non-governmental organizations and scientists. As part of its normative function WHO develops policies, strategic approaches, norms and standards. WHO has developed a range of guidelines dealing with technical, managerial and clinical aspects of reproductive health, including family planning guidelines, maternal health care, management of obstetric complications, prevention and management of abortion complications, prevention and treatment of STDs including HIV/AIDS, and detection and management of cervical cancers. The objective is to disseminate appropriate and relevant up-to-date information to those working in the field and to promote adherence to the highest attainable standards of quality health care. WHO's normative work includes guidance on the elimination of harmful practices such as female genital mutilation and the development of standard definitions and guiding protocols on data collection and analysis. WHO provides support to the development of training materials, and works with national and international professional and educational bodies on different aspects of health curriculum development. Such training materials must now be adapted to incorporate the concept of reproductive health and to assist the many categories of health care providers in responding to reproductive and sexual health needs in a more integrated way. Within the broader reproductive health framework WHO is currently paying increased attention to ethical issues in reproductive health; appropriate technologies; gender equity, women's perspectives and the roles and responsibilities of men; the particular needs of women and young people; the interrelationships between reproductive health and other public health issues such as nutrition and the environment; indicators for assessing progress and monitoring and evaluation of reproductive health programmes. In its technical support to Member States WHO's underlying philosophy is that policies, strategies and programmes must be country-owned, build national capacity and self-reliance, and be sustainable. WHO promotes and supports programme development that is based on a consultative process which brings together all concerned constituencies in reproductive health, particularly those whose voices have hitherto remained unheard -women, young people, the poor, the marginalized, refugees and the displaced. WHO's governing bodies have given increased attention to reproductive and women's health, and have requested a greater role for the Organization. WHO has started a series of specific activities as follow-up to the Programme of Action of ICPD. The goals and objectives of the Programme of Action of Cairo are being integrated into WHO's 9th General Programme of Work which runs from 1996 to 2001. WHO has identified reproductive health a priority for the Organization. This will be reflected in the 1996-97 programme Budget and the area of reproductive health will receive increased resources effected by a 5% shift of Regular Budget funds. The World Health Assembly has requested the Director-General to develop a coherent programmatic approach for research and action in reproductive health and reproductive health care within WHO. United Nations Population Fund (UNFPA) ln its support for reproductive health, UNFPA will continue to underscore a number of basic programming concepts including, in particular, efforts to: o involve women, women's organizations, and other groups working for women's needs in the planning, implementation and monitoring of reproductive health services and programmes; o promote men's participation in reproductive health programmes and responsibility for their sexual and reproductive behaviour; o assure the highest level of quality of care in providing information and services; o promote an approach that provides a constellation of linked or integrated services to meet the needs of clients; o make available as wide a range as possible of safe and effective modern methods of family planning technically approved by the World Health Organization (WHO); o create a better understanding of the social, cultural and behavioural context within which reproductive ill-health occurs; and o promote the coordination of national reproductive health programmes among Governments, multinational and bilateral agencies, NGOs and the private sector. UNFPA supports the concept of sexual and reproductive health as a human right. Women and men must therefore be provided with the necessary information and services to exercise this right. UNFPA support for reproductive health will be based on a public-health, pragmatic and participatory approach. Such an approach: (a) responds to the reproductive health needs of individuals and involves them in the programming process; (b) promotes sustainability: and (c) identifies interventions that have the greatest impact for the most people at an affordable price. It also encourages partnerships between Governments, NGOs, and the private sector to maximize both coverage and quality of services and to stimulate innovative ideas. This will best be achieved, in practice, through an incremental approach that builds on the system that is currently in place, identifies gaps and inadequacies in that system and strengthens links between programmes in order to respond better to the reproductive health needs of individuals. The rationale for using such an incremental approach is that it makes the most efficient and cost-effective use of existing staff and health-care facilities. In fact, it is often the same primary care worker, working out of the same facility, who provides family planning care and many of the other components of reproductive health. UNFPA will thus work to integrate reproductive health care information and services into the various other services provided at the service-delivery level and to assure that the health-care personnel working in such facilities receive training in integrated reproductive health care. Activities supported by UNFPA in reproductive health include: o the full spectrum of family planning information and services, including counselling and follow-up services, aimed at all couples and individuals; o prenatal, delivery (including assisted delivery) and postnatal care of mothers at the primary health care level with appropriate referral for the management of obstetric complications; o prevention of abortion, management of the consequences of abortion, and post-abortion counselling and family planning; o prevention of reproductive tract infections (RTIs) including STDs and HIV/AIDS through preventive counselling, condom distribution and treatment of symptomatic infections, as part of primary health care, with appropriate referral for follow-up; o prevention of infertility and sub-fecundity, as part of primary health care, with appropriate referral for follow-up; o routine screening for other women's reproductive health conditions such as urinary tract infections, cervical infections, and cervical and breast cancer, where primary level treatment is available or referral for follow-up exists; o active discouragement of harmful practices such as female genital mutilation. The fund strongly encourages the further strengthening of collaborative and coordination arrangements with WHO, UNICEF, other UN systems partners, bilateral agencies and non-governmental organisations, in order to assist countries in the development of reproductive health programmes in the most effective and effective manner. The World Bank Reproductive health activities constitute a significant portion of all World Bank lending for population, health and nutrition activities: o In the Bank's 1994 fiscal year, over 40 percent of all lending for population, health and nutrition supported reproductive health activities. o Over the past 25 years, the Bank has lent more than $2.5 million to support reproductive health components of more than 130 projects in almost 70 countries. Although the number of new commitments have varied from year to year, the trend has been steadily upward. o In recent years, Bank lending has Integrated reproductive health projects with its population programmes, financing an average of nearly $400 million in such programmes each year since 1992. Research sponsored by the Bank also often provides the analytical basis for reproductive health policy and action: o Bank operations research, situation analyses, and field- based pilot projects aid program managers in assessing needs, instituting or modifying services, and in determining the effects of interventions on health systems and health status. o The Bank's Special Grants programs represent another mechanism for support of large-scale, long-term efforts that are too costly for most developing countries to undertake independently. For example, the Bank already has contributed $18 million to the Special Programme of Research, Development and Research Training in Human Reproduction (HRP) which is being co-sponsored by UNFPA and WHO. o The Bank is also involved in sector work, in which Bank staff analyse data that enable more informed policy decisions and program development Sector analyses in Brazil, India and Uganda have helped identify the dimensions of women's health problems, as well as constraints on their use of health services. o In addition to support provided for reproductive health activities through project lending, the Bank's Economic Development Institute organizes training activities that strengthen national capacities to design and implement policies and programs in the field. These activities serve to foster the exchange of ideas and experiences that support the improvement of reproductive health information and services. Importantly, the World Bank actively seeks and supports collaboration among donor agencies and local non-governmental organizations (NGOs) to spread awareness of reproductive health issues and improve the effectiveness of projects with reproductive health components: o Special Grants Programs for Population NGOs and Safe Motherhood, for example, provide a coordinating mechanism for safe motherhood programs. o Bank projects in Bangladesh, Indonesia, and Zimbabwe have strengthened collaboration among multilateral, bilateral, and NGOs, thereby improving the delivery of maternal health and family planning services. International Labour Organisation (ILO) Relevant ILO policies and programmes are based on the premise that success in protecting and promoting reproductive health is linked to social and economic factors including education, training, employment, working conditions and gender equality in labour markets. It is accordingly affected by the adequacy of measures designed to protect workers; the levels of success achieved by attempts to promote and ensure equality of opportunity and treatment and the effectiveness of policies to promote employment opportunities. Each of these policies, measures and programmes in various ways promotes the empowerment of women - through legal protection (standard setting and application); all improved access to resources and opportunities, including education, information, employment and incomes. At the same time the ILO recognizes that reproductive health and related outcomes (in terms of timing of births and levels of morbidity and mortality) are important factors affecting gender equality; the levels of living of workers and their families; family responsibilities and workers' ability to cope with them; employment opportunities and career development; and the viability and profitability of enterprises. ILO promotes and provides technical support to its constituents to enable them to design, develop and implement comprehensive policies and programmes which link population and reproductive health concerns to social and economic goals and achievements. Accordingly governments are assisted to analyse, identify and address the relevant aspects of population, development and employment policies and to ratify and apply existing International Labour Standards relevant to maternity protection, safety and health at work, and promotion of equality and employment opportunities. Employers are helped to adopt appropriate workplace rules and mechanisms, both to eliminate reproductive health hazards in places of work and to promote family welfare and planning through education and access to supports and services. Workers' organizations are strengthened to promote and implement workers' education on population, reproductive health and gender issues. United Nations Children's Fund (UNICEF) UNICEF has been active in developing appropriate strategies and programming interventions in the area of reproductive health, specifically safe motherhood, family planning and in the prevention of HIV/AIDS and other STDs. UNICEF support to women's health activities emphasises working with women's organisations at the community level. The focus is on promoting linkages with the health sector, assisting women's organisations in implementing information, education, communication efforts and in developing financing mechanisms for purchasing health care. UNICEF programmes of assistance will also include support to national-level mobilization on safe delivery. National commissions or task forces on safe delivery will serve to monitor progress toward reducing maternal mortality, rationalise medical practices, and mobilize political and community commitment to women's health. In close collaboration with WHO, UNICEF support is provided to strengthen essential obstetric care services and referral of women with complications in pregnancy and delivery, including the life- threatening complications of unsafe abortion. Increasing emphasis will be placed on the role of nurses and midwives, specifically training in life-saving skills, maternal and newborn care, pre- and post-natal counselling diagnosis and treatment of reproductive tract infections, and family planning. UNICEF efforts in the area of adolescent health seek to build stronger dialogue and partnership among young people, parents, educators, health providers and community leaders on health, including reproductive health. They also seek to help assure that adolescents have access to the information, skills and services they need to protect and promote their own health and eventually the health of their children. UNICEF supports school health programmes which emphasise skills-based health education, including reproductive health education, health and nutrition services, water and sanitation on school premises, and extra-curricular activities which promote the health of school-age children. Working closely with parents and community organisations, increasing emphasis will be placed on expanding adolescents' access to and utilisation of quality health care and counselling services. UNICEF will work with governments and NGOs to support increased outreach to vulnerable adolescents, training of health workers on adolescent health, and strengthening linkages between the health sector and NGOs. The health needs of girls and young women, specifically preventing early and unwanted pregnancy, eliminating harmful traditional practices, like female genital mutilation and nutrition are becoming an increasingly important part of UNICEF efforts. IEC efforts with boys and young men will emphasise healthy practices, including responsible sexual behaviour. Office of the United Nations High Commissioner for Refugees (UNHCR) The mission of the United Nations High Commissioner for Refugees (UNHCR) is to assist and protect refugees worldwide. Based in Geneva, Switzerland, UNHCR was created by the UN General Assembly and began work in 1951, aiding millions of European refugees in the aftermath of World War II. Since then, the agency was twice awarded the Nobel Prize - has aided tens of millions of desperate and needy people who have been forced to flee their countries because of persecution, war, or massive human rights abuse. The total number of people who come under UNHCR's concern has risen from 17 million in 1991 to more than 27 million at January 1, 1995: one out of every 205 people on this planet. Roughly three-quarters of those destitute displaced people are women and their dependent children. Their role within their family and their community is pivotal. But, in areas of the world often deeply scarred by suffering, exploitation and ill-health these refugee women and children - deprived, by definition of the protection of their state are hard-hit by the violence and uncertainty of displacement. Many have already survived situations of extreme pain. They are among society's most vulnerable members. For them, food, water, shelter, sanitation and preventive health care are a priority. So is protection: refugees need to be protected from being returned against their will to a country where their lives and fundamental rights are under threat. However, reproductive health care is also among the crucial elements that can give refugees the basic human welfare and dignity that they deserve. The key issues are safe and adequate maternity care; access to family planning and child spacing, treatment and prevention of sexually transmitted diseases (including HIV/AIDS); prevention of - and response to - sexual violence; gynaecological care; and prevention and treatment of complications arising from the genital mutilation of girls and unsafe abortion. The range of reproductive health services required by refugees are similar to those needed by any other population. The differences: refugees' needs are likely to be more influenced by trauma, in part because, amid the chaos of displacement and exile, refugees are more vulnerable to abuse. Compared to those of other populations, the reproductive health care needs of refugees are therefore likely to be both more urgent and more acute. UNHCR is committed to improving the reproductive health situation of refugees, particularly of women and adolescents. Recently, UNHCR and UNFPA jointly sponsored an inter-agency symposium specifically to address the reproductive health of refugees. It has also issued guidelines on the prevention and follow-up of rape and has taken a series of steps to better empower and assist refugee women. Together with the non-governmental organizations that operate as UNHCR partners in many refugee situations. UNHCR field staff in areas as far-flung as Tanzania and Nepal have set up medical services specifically intended to begin work on improving reproductive health. Staff are also working to develop a field manual, grounded in the practical experience of hundreds of refugee aid-workers. The manual will define the how, where and what of future reproductive health services to refugees. This basic guide should be an invaluable practical tool for UNHCR's more than 3000 field workers. It will be completed before the end of 1995. United Nations Educational, Scientific and Cultural Organization (UNESCO) UNESCO continues to work in close co-operation and collaboration with UN agencies and its partners including NGOs to enhance the quality of life of human populations through effective educational, scientific and cultural development policies and programmes. UNESCO supports the educational, scientific and cultural dimensions of reproductive health. The interdisciplinary project on environment, population and development (EPD) has drawn expertise from all the relevant sectors of UNESCO to enrich and enhance the EPD programmes. It is believed that EPD will develop its programme further to include the present and emerging issues related to reproductive health in its various population environment, and other educational programmes through effective training and communication strategies to meet the needs of developing and developed countries. Much success has been achieved in human sexuality education, adolescent/youth participation in development programmes. EPD has focussed through its various programmes and projects on the development of relevant education, training and information activities that deal with the complex and interlinked issues of population, environment and development. There has been growing emphasis on integrated activities and on national capacity building UNESCO supports and also actively participates to better understand the multicultural aspect of social development that includes reproductive health, because it is crucial to the improvement of quality of life and human resources development programmes. Reproductive health issues involve active participation of individuals, communities and societies and this can be successfully achieved through UNESCO continued support through its education, information, communication training and research policies and programmes at the global, regional and country level. In the current biennium (1994-1995) and in the forthcoming biennium (1996-1997), EPD proposes enhanced activities in relevant reproductive health issues, through it inter-agency, inter- disciplinary and inter-sectoral projects/programmes in all regions. This task is being and will continue to be achieved in closely collaboration with the UNFPA TSS/CST programme. New programmes are under preparation that will focus on the follow-up on the reproductive health aspects as stated in ICPD and efforts are being made to focus on those areas where best results can be expected through collaborative expertise and activities of UNESCO and its partners in the UN system, NGOs and others.