UN Population Division, Department of Economic and Social Affairs,
with support from the UN Population Fund (UNFPA)
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| UN Population Division, Department of Economic and Social Affairs, with support from the UN Population Fund (UNFPA) |
|
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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: pierce@unfpa.org
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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.