in the South-East Asia Region

Transcription

1 in the South-East Asia Region The Regional Context 3

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3 in the South-East Asia Region 28

4 WHO Library Cataloguing-in-Publication data World Health Organization, Regional Office for South-East Asia. A framework for implementing the reproductive health strategy in the South-East Asia Region. 1. Reproductive Health Services. 2. Family Planning Services. 3. Maternal Mortality. 4. Perinatal Mortality. 5. Adolescent Health Services. 6. Pregnancy Complications prevention and control. 7. Sexually Transmitted Diseases prevention and control. ISBN (NLM classification: WP 63) World Health Organization 28 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications - whether for sale or for noncommercial distribution - can be obtained from Publishing and Sales, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 11 2, India (fax: ; publications@searo.who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in India, August 28

5 Abbreviations and acronyms 4 Foreword 5 1 Introduction 7 2 The Regional Context Situational analysis Barriers to progress 12 Pregnancy, childbirth, post-partum and health of newborns 8 Family Planning 1 Unsafe abortion 11 Sexually transmitted infections, including HIV and reproductive tract infections 11 Inequalities related to access to skilled health care 12 Adolescents exposure to risks 12 Expenditure on reproductive health 12 Human resource for reproductive health 13 Inequalities related to gender 13 Organization of health service delivery 13 3 Goal and Objectives 14 4 Areas of Action and Partnership Strengthening health systems capacity Improving information for priority-setting Mobilizing political will Creating supportive legislative and regulatory frameworks Strengthening monitoring, evaluation and accountability 17 5 Indicators for Evaluating Progress Improving antenatal, delivery, postpartum and newborn care High-quality services for family planning Eliminating unsafe abortion Combating sexually transmitted infections, cervical cancer and other gynecological morbidities Promoting sexual health Conclusion 22 References 23 Annexes Country Reproductive Health Data Sheets: South-East Asia 25 A Framework for Implementing the RHS in the South-East Asia Region 3

6 AIDS ANC CPR FP GDP HIV ICPD IEC MCH MDGs MOH NGO RTI RH SBA SRH STI SEA UNAIDS UNDP UNFPA UNICEF WHA WHO Acquired Immune Deficiency Syndrome Antenatal care Contraceptive Prevalence Rate Family planning Gross Domestic Product Human Immunodeficiency Virus International Conference on Population and Development Information-education-communication Maternal and child health Millennium Development Goals Ministry of Health Nongovernmental organization Reproductive tract infection Reproductive health Skilled birth attendant Sexual and reproductive health Sexually Transmitted Infection South-East Asia Joint United Nations Programme on HIV/AIDS United Nations Development Programme United Nations Population Fund United Nations Children s Fund World Health Assembly World Health Organization 4 A Framework for Implementing the RHS in the South-East Asia Region

7 Reproductive and sexual health is fundamental for individuals, couples and families, as well as for social and economic development of communities and nations. Everyone has the right to enjoy reproductive health, which is the basis for having healthy children, a healthy reproductive life and happy families. Women living in developing countries suffer disproportionately from unintended pregnancies, maternal death and disability, sexually transmitted infections, including HIV, genderbased violence and other problems related to their reproductive system and their partner s sexual behaviour. Young people often face barriers in trying to get the information and care they need, which places adolescent reproductive health as another issue that needs attention. The critical importance of reproductive health to development has been acknowledged at the highest level with the commitment to achieve universal access to reproductive health by 215. This is the culmination of more than a decade of advocacy since the consensus at the International Conference on Population and Development held in Cairo in At the 25 World Summit, 189 Member States agreed to integrate access to reproductive health into national strategies to attain universal access to reproductive health as a part of the achievement of the relevant Millennium Development Goals. The global reproductive health community is fully committed to mobilize support and scale up efforts to make reproductive health for all a reality by 215. The Fifty seventh World Health Assembly adopted the first Global Reproductive Health Strategy in May 24 with the aim to accelerate progress towards reproductive health by 215. For the successful implementation of the Global Strategy, it is necessary to foster wide-range collaboration and commitment towards attaining reproductive health targets. This can be done by translating global strategies into concrete actions in the countries based on their national and sub-national priorities and situation. This framework provides guidance to countries in implementing the Global Reproductive Health Strategy considering the regional context, country situations and needs. It is intended to guide policy makers, reproductive health programme managers and development partners in accelerating the achievement of reproductive health targets. The document provides country reproductive health data sheets, which would be useful in understanding the reproductive health challenges in each country of the Region. The document is a result of extensive consultations in the South-East Asia Region with representatives from the ministries of health, United Nations partner agencies, and other key stakeholders. We thank all Member Countries and development partners for their involvement in finalizing this framework, as well as their commitment to use it as a basis for future collaboration in accelerating the achievement of reproductive health targets in the Region. Dr Samlee Plianbangchang, M.D., Dr. P.H. Regional Director 5

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9 1 The World Health Organization s first Global Reproductive Health Strategy to accelerate progress towards the attainment of international development goals and targets was adopted by the Fifty seventh World Health Assembly in May 24. The strategy was developed through extensive consultations in all WHO regions with representatives from the ministries of health, professional associations, nongovernmental organizations (NGOs), United Nation s partner agencies and other key stakeholders. The strategy recognizes the crucial role of sexual and reproductive health in social and economic development in all communities. It aims to improve sexual and reproductive health and targets the following five core elements: Improving antenatal, delivery, post-partum and newborn care. Providing high-quality services for family planning, including infertility services. Eliminating unsafe abortion. Combating sexually transmitted infections (STIs), including HIV, reproductive tract infections (RTIs), cervical cancer and other gynaecological morbidities. Promoting sexual health. The strategy outlines the principal actions necessary to attain the Millennium Development Goals (MDGs) and other international goals relating to reproductive health, particularly those set by the International Conference on Population and Development (ICPD) in 1994, and its five-year follow-up (ICPD+5). A new MDG Monitoring Framework adopted by the Sixty-second United Nations General Assembly in October 27 includes a new target, "Achieve, by 215, universal access to reproductive health" and related indicators under the MDG 5, which recognizes the centrality of reproductive health and reproductive rights in improving maternal and infant health and in reducing poverty (Table 1). To attain the MDGs and the global reproductive health targets, the strategy calls for actions in five key areas: strengthening health systems capacity; improving information for priority-setting; mobilizing political will; creating supportive legislative and regulatory frameworks; and strengthening monitoring, evaluation and accountability. The strategy is targeted at a wide range of policy-makers in governments, international agencies, professional associations, nongovernmental organizations and other institutions. Table 1: Millennium Development Goal 5 Targets and Indicators Goal 5: Improve maternal health 1 Targets 5.A: Reduce by three quarters, between 199 and 215, the maternal mortality ratio 5.B: Achieve, by 215, universal access to reproductive health Indicators 5.1 Maternal mortality ratio 5.2 Proportion of births attended by skilled health personnel 5.3 Contraceptive prevalence rate 5.4 Adolescent birth rate 5.5 Antenatal care coverage (at least one visit and at least four visits) 5.6 Unmet need for family planning 1 Sixty-second UN General Assembly, Official Records, Annex II, Revised Millennium Development Goal Monitoring Framework, United Nations, 27 Introduction 7

10 8 A Framework for Implementing the RHS in the South-East Asia Region

11 Situational Analysis Pregnancy, childbirth, post-partum and health of newborns Pregnancy and childbirth and their consequences are the leading causes of death, disease and disability among women of reproductive age in developing countries more than any other single health problem. Maternal mortality in developing countries is more than 1 times higher than in industrialized countries. The South-East Asia (SEA) Region accounted for 174, maternal 2 and 1.4 million neonatal 3 deaths in 2, which were 33% and 35% of the global figures respectively. Two thirds of the neonatal deaths, about one million, occur within the first week of life and two thirds of these, almost 7,, within the first 24 hours. In addition, one million stillbirths occur in the Region. More than 9% of neonatal deaths in the Region occur in Bangladesh, India, Indonesia, Myanmar and Nepal. Globally, 6-8% of maternal deaths are due to obstetric haemorrhage, sepsis (infection), obstructed labour, hypertensive disorders of pregnancy (including eclampsia), and complications of unsafe abortion. In the SEA Region, available data show that the causes of death are similar to the global picture with severe bleeding being a major cause of death in all the countries. Data from three countries of the Region show that 5-8% of pregnancies end in abortion and more than 2% in stillbirths. Neonatal infections, such as sepsis, meningitis, pneumonia, tetanus and congenital syphilis are responsible for 33% of newborn deaths, while birth asphyxia and trauma account for about 28% deaths and contribute to life-long disability of those infants who survive 4. Pre-term birth and low birth weight are associated with approximately 24% of newborn deaths, commonly due to asphyxia or infections. Immediate and effective professional care before, during and after delivery can make the difference between life and death for both women and their newborns. There are sharp differences in antenatal care coverage (given by doctors, midwives and nurses) in different countries of the Region. Findings of the surveys show that not only are more women receiving antenatal care, they are also seeking more visits than before. A marked increase has been observed in Bangladesh, Indonesia and Maldives over a period of 5-1 years. Urban women are more than twice as likely as rural women to have four or more antenatal visits. In general, however, antenatal care services currently provided in many countries fail to meet the standard recommended by WHO. There is a lot of disparity within the Region with regard to the proportion of deliveries by skilled attendant, which ranges from 13% in Bangladesh and Nepal to almost universal coverage in Sri Lanka, Thailand and DPR Korea. An analysis of the relationship between the proportion of deliveries assisted by skilled birth attendants and maternal/neonatal mortalities in the Region shows that both newborns and mothers have a better chance of survival if they have skilled attendance at birth (Figures 1 and 2). The higher the proportion of deliveries by a health professional, the lower is the maternal mortality ratio and neonatal mortality rate. Maternal morbidities, such as fistula, are also more frequent in countries with a low proportion of deliveries by skilled attendants. 2 Maternal Mortality in 2: Estimates developed by WHO, UNICEF and UNFPA, WHO, Geneva, 24 3 Neonatal and Perinatal Mortality: Country, Regional and Global Estimates, WHO, Geneva, 26 4 Strategic Directions to Improve Newborn Health in the South-East Asia, WHO-SEARO, 24 The Regional Context 9

12 Figure 1: Relationship between proportion of births assisted by skilled attendant and maternal mortality ratio 1 8 SBA (%) MMR (per 1 live births) THA SRL KRD MAV INO MMR IND TLS BHU BAN NEP Proportion of births assisted by skilled attendant (SBA) Maternal mortality ratio (MMR) Source: World Health Statistics 26, WHO Figure 2: Relationship between proportion of births assisted by skilled attendant and neonatal mortality rate SBA (%) NMR (per 1 live births) 1 5 THA SRL KRD MAV INO MMR IND TLS BHU BAN NEP Proportion of births assisted by skilled attendant (SBA) Neonatal mortality rate (NMR) Source: World Health Statistics 26, WHO There is a lot of disparity within the Region with regard to skilled birth attendance (Table 2). Many deaths of neonates are related to the poor health of the woman and inadequate care during pregnancy, childbirth and the postpartum period. It has been argued that nearly three quarters of all neonatal deaths and stillborn could be prevented if women were adequately nourished and received appropriate care during pregnancy, childbirth and the postpartum period. Furthermore, a mother s death can seriously compromise the survival of her children. Postpartum care often receives less attention by service delivery systems, especially, after the discharge of women and their newborns from the facility. If the onset of postpartum complications occurs outside the health facility, the role of established active health service delivery practices in the immediate postpartum 1 A Framework for Implementing the RHS in the South-East Asia Region

13 Table 2: Maternal and newborn deaths in 2 and proportion of births attended by skilled personnel in the South-East Asia Region Proportion (%) of births attended by skilled health personnel Neonatal mortality rate (per 1, live births) No. of neonatal deaths () No. of stillbirths () Maternal mortality ratio (per 1, live births) No. of maternal deaths Bangladesh , Bhutan DPR Korea India ,98 1, , Indonesia , Maldives 7 37 <1 < Myanmar ,3 Nepal 11 a b 6, Sri Lanka Thailand Timor-Leste Source: World Health Report 25; Maternal Mortality in 2 estimates developed by WHO, UNICEF and UNFPA; Neonatal and Perinatal Mortality: Country, Regional and Global Estimates, WHO 26 a 18.7 (Source: Nepal, DHS 26) b 81 (Source: Nepal, DHS 26) as well as within the period of six weeks becomes crucial. Provision of high quality postpartum care also helps to address post-abortion care and counselling for contraception. Strengthening the supply side should be linked to the efforts focussed on building capacity of individuals, families and communities to help them recognize danger signs and seek timely professional care for both the mother and her newborn. Family planning It is estimated that guaranteeing access to family planning alone could reduce the number of maternal deaths by 25% and child mortality by up to 2%. The decline in fertility levels in all countries of the Region is a consequence of the increasing use of modern methods of contraception among women. Some countries, for example, Bangladesh, Bhutan, Indonesia, Myanmar and Nepal have demonstrated a marked increase in their contraceptive prevalence rates (CPR). However, in some of these countries, there is a tendency for CPR to stagnate. All countries in the Region support family planning programmes aimed at making contraceptive services widely available at affordable costs. CPR among married women in the year age group varies widely among countries. While in 25 more than 7% of women used any modern method of contraception in Thailand, only 7% are using them in Timor-Leste and about one third are using them in Maldives, Myanmar and Nepal (Figure 3). The use of any method is usually influenced by availability, or the method promoted by the family planning programme of the country. For example, injectable contraceptives are popular in Indonesia (28% in 22-23) and Thailand (22% in 2), but are not available in India. Female sterilization is the most popular method (34.2% 5 ) used in India. The negligible use of male methods for contraception, such as condoms and male sterilization, is the only similarity in all the countries. This does not, however, include condom use for prevention of STIs and HIV infection. 5 Reproductive Health Profile, WHO-SEARO, 23 The Regional Context 11

14 Figure 3: Percentage of married women using modern contraception in the SEA Region, Thailand CPR (All Methods) India cc DPR Korea Maldives Indonesia Sri Lanka Bangladesh Nepal Myanmar 2 1 Bhutan Timor-Leste s Source: World Population Data, 25 Notwithstanding the increase in contraceptive prevalence in recent years, the large proportion of births in some countries of the Region is unplanned, mistimed or unwanted. Despite the state-supported family planning programmes in many countries and the availability of modern methods of contraceptives free of cost or at subsidized rates, the unmet need is high. The proportion of women reporting unmet need ranged from 8.6% in Indonesia in 23 to 28% in Nepal in 21 and 37% in Maldives in Unsafe abortion A significant proportion of unwanted pregnancies result in induced abortion under unsafe conditions. A few studies exploring the context of abortion among young women in the SEA Region indicate a widespread prevalence of unsafe abortions, serious adverse consequences to women s health and a significant contribution to the deaths of women, who are either on the verge of adulthood or are in the prime of their lives. It has been reported that 22 abortions per 1, women take place in South-East Asia and unsafe abortion is particularly an issue for young women in some countries of the Region 7, while in other countries the majority were older married women. The legal situation of abortion varies considerably within the SEA Region. Abortion is legal in DPR Korea, India and Nepal, while in most other countries of the Region abortion is permitted only to save a woman s life. Even when the abortion laws are in place, the access to safe services remains limited for a vast majority of women. For example, in India, where a liberal abortion law is in place since 1972, unsafe abortions, including sex selective abortions, still outnumber safe abortions. Sexually transmitted infections, including HIV and reproductive tract infections In general, the rates of STIs are high in the Region. Epidemiological patterns of STIs vary, with some countries reporting high prevalence of curable STIs, and others indicating high rates of ulcerative STIs or high prevalence of gonorrhea and chlamidya. Sexworkers, high-risk men and pregnant women represent high-risk population groups for acquiring and spreading STIs. Overall, STI control programmes in the Region need further strengthening, with particular attention to improving surveillance, which is incomplete in most countries, and intervention coverage with selective approaches based on the country-specific epidemiological patterns. 6 Family Planning Fact Sheets, WHO-SEARO, 25 7 Improving Maternal and Neonatal Health, WHO A Framework for Implementing the RHS in the South-East Asia Region

15 The 26 report on global AIDS epidemic estimates about 6.9 million people living with HIV in the South- East Asia Region with an increase of about.5 million since 23. About two million out of the total cases are women aged 15 plus. About 5.7 million of the total cases are contributed by India. An estimated.5 million 8 have died due to AIDS in the Region. Although HIV prevalence among pregnant women remains relatively low in many countries in the Region, it has been increasing for several years. In 24, in Asia there were an estimated 155,4 pregnant women infected with HIV and 46,9 children became infected with HIV while about 31, children developed AIDS. The situation will become worse if there is no adequate intervention, because more women of reproductive age are contracting HIV infection. Between 21 and 24, the estimated number of HIV-infected women increased by 16% to over two million compared to the average global increase of about 8%. The ratio of infected women to men is also increasing, from 25% at the end of 21 to 28% at the end of 24. The low status of women often makes them especially vulnerable to HIV and makes it difficult for them to protect themselves. urban population has five times more access to skilled care than the rural. The richest quintile is 14 times more likely to have a skilled birth attendant at delivery than the poorest in Bangladesh. Similarly, poor women are much more likely to deliver at home in India, Indonesia and Nepal. Adolescents exposure to risks A large proportion of girls marry early in Bangladesh, India, Nepal and Indonesia. More than half of girls are married before they are 18 years old bearing the risks associated with early sexual activity, i.e. sexuallytransmitted infections and pregnancy. Adolescents lack information and skills and often engage in risky behaviours including higher proportion of sexual experiences before marriage, high unprotected sexual activity, low rates of condom use, and unsafe injection practices among injecting drug users (IDUs), thus making them one of the most vulnerable groups in terms of growing HIV infection. In Thailand, the 21 estimates of HIV prevalence among youth of age group years were as high as.88% among males and 1.32% among females; and.22% and.46% respectively in India in There is a great disparity in the countries of the Region about the knowledge related to HIV/AIDS. Women living in countries where the literacy rate is high have better knowledge. Generally, younger men and women are more likely to have this knowledge. A low level of knowledge among ever-married women of India explains high prevalence of HIV in the country. Inequalities exist within the countries. In Bangladesh, for example, only 29% of women belonging to the poorest wealth quintile had heard of HIV/AIDS, compared to 92% in the richest wealth quintile Barriers to Progress Inequalities related to access to skilled health care Besides disparities among countries in the Region, a marked difference can be observed in access to skilled attendance at birth by urban and rural populations and the rich and the poor within the countries. In Nepal the Data in 25 showed that childbirth among women aged less than 2 years was highest in Bangladesh, Timor-Leste, Thailand and India, ranging from 15% to 25%. For both physiological and social reasons, girls aged years are twice as likely to die in childbirth as those in their 2s as observed in Bangladesh, India and Indonesia. In Nepal, 19% of maternal deaths occur during adolescence. Girls under 15 are five times as likely to die as those in their 2s. Expenditure on reproductive health Often a sufficient proportion of GDP is not made available for expanding the availability of reproductive health services. Adequate financing and efficient management of those resources is not observed in countries with the poorest reproductive health status. Total government expenditure on health in 24 ranged from 2.2% to 11.2% of GDP in countries of the Region 1. In many countries, out-of-pocket expenditure 8 As per 26 AIDS Epidemic Update, although the proportion of people living with HIV in India is lower than previously estimated, the epidemic continues to affect large number of people (between 2 million and 3.1 million in 26) 9 Health Related Millennium Development Goals 25, WHO 1 World Health Statistics 27, WHO The Regional Context 13

16 on health constitutes a large percentage of total health expenditure. The poor are particularly vulnerable having to spend large proportions of their income on health. Nevertheless, some countries, for example Maldives and Thailand, provide social security on health to their people and contribute a large proportion of general government expenditure to provide services. Human resource for reproductive health It is generally agreed that appropriately trained human resources in the right quantity in both the public and private sectors, and their optimal use is key to the provision of comprehensive health care. The correlation between the number of workforce and coverage of health interventions, such as deliveries by skilled birth attendants, shows that the health of the population suffers when the workers are scarce. According to international estimates, 2.28 health care providers (doctors, nurses and midwives) per 1, population is a threshold to achieve 8% coverage for skilled attendance during deliveries 11. Four countries of the SEA Region (Bangladesh, Bhutan, Nepal and Indonesia) 12 have less than one health care provider per 1 population. Weak and poorly skilled health workers are often a reality in countries of the SEA Region. The work environment and conditions of employment, training and supervision, including the levels of remuneration are also inadequate in some settings. The resulting poor motivation means that retaining skilled health personnel becomes a problem. Migration of the health workforce in the context of SEA Region began several years ago, particularly from India, Sri Lanka, Bangladesh, and Nepal. Recent studies indicate that out of the annual output of qualified medical professionals in India, 2.8% had gone abroad for employment. In Sri Lanka, out of a total of 826 graduates, 22% (185) did not return from their postgraduate training abroad during Added to the problems of supply and distribution of the health workforce, inadequate skill-mix, lack of cultural and interpersonal skills, inadequate technical knowledge and skills are also major challenges in many countries of the Region. Health staff in some countries of the Region are not able to rely on a functioning health infrastructure that can ensure suitable facilities, continuous availability of reproductive health commodities, essential medicines and supplies. Inequalities related to gender Violence, which includes physical, sexual and emotional abuse against women, often persists and sometimes may start during pregnancy, with serious implications for the mother and child. Studies in the Region show that in some countries, 4-1% of women who had ever been pregnant had experienced physical violence during their pregnancies or physical abuse became worse during a pregnancy. In almost all cases the perpetrator was an intimate partner. Organization of health service delivery While each country in the Region has its own problems in organization of service delivery, there are a few common features related to the provision of reproductive health services. Inefficient use of resources is one of the issues. Often, allocation of resources in the health sector is heavily skewed, with major regional disparities and with most resources spent on in-patient care. In some countries the full package of essential reproductive health services is not available at primary health care level with some elements missing or given less attention (i.e. safe abortion, prevention of STIs/ HIV infection, management of STIs, etc). Further, there is a poor functioning referral system. Lack of linkages between reproductive health and other health programmes and services, including nutrition, prevention and treatment of frequent diseases, such as malaria is common. 11 World Health Report 26, WHO 12 World Health Statistics 26, WHO 14 A Framework for Implementing the RHS in the South-East Asia Region

17 3 The goal of this document is to provide a strategic framework and guidance to countries of the Region for implementing the Global Reproductive Health Strategy to improve sexual and reproductive health programmes in the context of the South-East Asia Region. The specific objectives are to: provide an information base for understanding the reproductive health situation and challenges in countries of the Region; facilitate an analysis of the situation and challenges of reproductive health programme in countries of the Region; and facilitate identification of priority reproductive health issues, needs and problems and formulate strategies for accelerated action in countries of the Region. Goal and Objectives 15

18 16 A Framework for Implementing the RHS in the South-East Asia Region

19 4 For implementing the Global Reproductive Health Strategy each country needs to: i) identify problems, ii) set priorities, and iii) formulate strategies for accelerated action. Each country has a unique health system infrastructure, organization of reproductive health services, regulatory framework and capacity of providers. These need to be taken into consideration when setting priorities and formulating strategies for accelerated action. Many countries in the Region have developed a reproductive health strategy. An effort has been made to study the country s reproductive health strategy and assess it in the light of five key action areas outlined in the global strategy. The following are the five key areas for action and partnerships Strengthening Health Systems Capacity The existence of functioning systems of essential health care at the primary, secondary and tertiary levels is a prerequisite for attaining the MDGs relating to maternal and child survival, prevention of HIV/AIDS, as well as broader reproductive and sexual health goals. Planning at national level for reproductive and sexual health is closely related to the performance of the health systems. There are three functions in health systems that are crucial for improving its performance: i) human resource provision, ii) service delivery organization and iii) financing. To oversee these three vital functions, effective stewardship is also required. The priority improvements that are needed within each of these functions to address reproductive and sexual health are described below. Country-specific adaptation will be required based on the analysis of the reproductive health situation and the vital health systems functions. Priority actions: Policy level: ensure that reproductive health is a central element of national planning and strategy development processes, including its incorporation into poverty reduction strategy papers (PRSPs), sector-wide approaches (SWAp) and WHO country cooperation strategies (CCS); adequate and sustainable funding should be made available to foster comprehensive, good quality and accessible reproductive health services; and all stakeholders should be actively involved in decision-making and in identifying priorities throughout the development, planning, implementation and evaluation stages. Human resources: determine essential requirements at all health care levels for numbers, skill mix and distribution of staff needed to provide a comprehensive reproductive health service package; develop a national plan for human resources for health and collaborate with the education sector to ensure a steady supply of new entrants; maximize existing human resources, through improved deployment, supportive supervision, management and strengthening of skills and capabilities of existing staff; develop, review or update policies that enable health professionals to use their skills to the full; update curricula for health professionals to include disciplines such as epidemiology and Areas of Action and Partnership 17

20 public health, health promotion, and theory and practice of counselling skills, as well as appraisal of practices and skills and costeffectiveness of care; strengthen training in reproductive and sexual health at pre-service and post-graduate teaching institutions in addition to a system of continuous education and in-service training; assess and improve work environments and human resources management including conditions of employment and supervision; and put in place efforts to motivate and retain skilled health personnel. Service delivery organization: ensure that: i) basic reproductive health commodities are included in the general health investment plan of the government; ii) a supply system is in place to guarantee continuous replenishing and adequate maintenance of health commodities at all levels of the health care system; iii) the national essential drug list is regularly updated to reflect the needs and standards; ensure appropriate referral and linkages of reproductive health care with STI/HIV infection, nutrition and other related programmes, with special attention to the needs of adolescents and disadvantaged groups; and integrate evidence-based standards and quality improvement mechanisms in provision of reproductive health services and in social health insurance schemes. Financing: design and set up financing mechanisms that facilitate universal access to reproductive health care, especially among the poor and other vulnerable groups Improving Information for Priority-setting Analysis of epidemiological and social science data is needed to understand the type, severity and distribution of reproductive and sexual risks exposure and ill health in the population, to interpret the dynamics that drive poor reproductive and sexual health, and to highlight the links between such ill-health and poverty, gender and social vulnerability. Improved data collection and analysis, including information about costs and costeffectiveness, are essential for selecting priorities and for aiming health system interventions at targets that are most likely to make a difference within the limits of available resources. Priority actions: Research capacity strengthening: improve national research capacities to plan, collect, analyze and distribute results on multifaceted determinants of reproductive and sexual health; and improve health system capacities to carry out operations research, collect and analyze data/ information in order to identify best practices for programme development and management, including priority-setting and identification of subpopulations with special needs. Use of data/information for programme development and management: strengthen capacity of the national, subnational and local management for using all available reproductive health data for planning and decision making and promote an ethos of evidence-based decision-making to change practices of policy-makers, managers, educators and clinicians; and strengthen dissemination strategies to assure that information is shared and analyzed with key actors at all levels so as to assure that information is used for increasing awareness and decision-making Mobilizing Political Will Creating a dynamic environment of strong international, national and local support for rights-based reproductive and sexual health initiatives will help to overcome inertia, galvanize investment and establish high standards and mechanisms for performance accountability. This requires the involvement of not only ministries of health, but also ministries of finance, education and possibly other sectors, and their counterparts at district and local levels. Political commitment and advocacy must be sufficiently strong to sustain good policies and programmes, particularly for underserved groups. 18 A Framework for Implementing the RHS in the South-East Asia Region

21 Priority actions: Advocacy: consolidate advocacy efforts among donors, international standards bodies, and key influential players within the government infrastructure to build a constituency that can promote political and social commitment for attainment of reproductive health; and develop evidence-based strategies for creating awareness of the scale of and consequences to reproductive health and building broadbased support among all key stakeholders in government, academic institutions and nongovernmental organizations, as well as community, women's and young people s groups. Mobilization of public and private stakeholders: establish or revitalize high-level national and sub-national multidisciplinary taskforces or committees, with the responsibility to take action and influence policy change, as well as co-ordinate and oversee stakeholders efforts towards improving reproductive and sexual health; work with private health providers to expand and improve their services, ensuring that these contribute to the national strategies and meet national standards; and build partnership with mass media and other effective channels to highlight the importance of sexual and reproductive health Creating Supportive Legislative and Regulatory Frameworks Removal of unnecessary restrictions (from policies and regulations), to create a supportive framework for reproductive and sexual health, is likely to contribute significantly to improved access to services. Regulations are needed to ensure that commodities (medicines, equipment and supplies) are made available on a consistent and equitable basis and that they meet international quality standards. In addition, an effective regulatory environment is needed to ensure public and private sector accountability for providing high-quality care for the entire population. Priority actions: Review/assess laws and policies as necessary related to reproductive health in collaboration with key ministries and: modify laws and policies to protect reproductive and sexual health and rights, especially taking into consideration interests of vulnerable and disadvantaged groups (e.g. unmarried girls, adolescents, poor, misplaced populations, victims of rape and sexual abuse); and develop regulatory procedures (accreditation, licensing and certification) and establish practical enforcement mechanisms, including civil and criminal laws. Review/assess the overall regulations related to reproductive health in order to: ensure that regulations and guidelines meet international quality standards and facilities/ supplies are available on a consistent and equitable basis; and reinforce and if necessary modify administrative regulations in the ministries, local/district health authorities, hospitals/clinics and professional organizations to remove unnecessary barriers to reproductive health services, information and education Strengthening Monitoring, Evaluation and Accountability Monitoring and evaluation are essential for learning what does and does not work, and why. This may also reveal the changing needs and unexpected impacts, both positive and negative. Priority actions: Ensure that appropriate priority is given continuously to reproductive health at policy level: monitor health-sector reforms, sector-wide approaches, national health accounts and the implementation of other financing mechanisms (such as poverty reduction strategy papers/ PRSPs, cost-sharing and direct budget support) in order to ensure equitable services at all levels; and set performance standards, monitoring and accountability mechanisms for provision of Areas of Action and Partnership 19

22 health services by establishing targets and benchmark in a complementary action among the public and private sectors, as well as international and nongovernmental agencies. Strengthen monitoring and evaluation process/ mechanism: identify appropriate sets of indicators for monitoring progress; strengthen capacity for collecting and analyzing data on reproductive health, its underlying determinants and the functioning of health services at local, district and national levels; ensure that attention is paid to equitable access, especially for the poor and marginalized groups, among others by disaggregating data that reflects inequity; and establish independent accountability mechanisms, including oversight by representatives of civil society. Improve monitoring and information systems: strengthen surveillance systems for reproductive health status; and ensure that monitoring and reporting systems are coordinated and streamlined. 2 A Framework for Implementing the RHS in the South-East Asia Region

23 5 The framework for the Global Reproductive Health Strategy provides a comprehensive list of indicators that are commonly used in monitoring and evaluation of programmes, structured according to the five core elements of sexual and reproductive health. There is a wide array of monitoring and evaluation tools and guidelines developed by WHO and partners to advise policy-makers and programme managers on the generation, interpretation and analysis of data. The set of indicators proposed herewith is neither comprehensive nor does it include descriptions of methodological and practical considerations. Detailed information on indicators for monitoring of reproductive health can be found in many other publications, including, among others, the Reproductive Health Indicators Guidelines for their generation, interpretation and analysis for global monitoring published by the World Health Organization in 26. The list of common indicators for monitoring and evaluation of reproductive health programmes provided includes indicators at different levels, such as input/ process/output and outcome/impact indicators. The list should facilitate the development of monitoring and evaluation plans in countries according to the local situation and needs. 5.1 Improving Antenatal, Delivery, Postpartum and Newborn Care Input/process/output indicators Number of facilities per 5, population providing basic essential obstetric care. Number of facilities per 5, population providing comprehensive EOC. Percentage of population living within one hour travel time of health services offering EOC. Percentage of women attended at least once during pregnancy by skilled health personnel for reasons relating to pregnancy; percentage attended by skilled health personnel at least four times. Percentage of pregnant women counselled and tested for HIV. Percentage of births attended by skilled health personnel. Percentage of births taking place in a health facility. Caesarean sections as percentage of all live births. Percentage of all women with major obstetric complications treated in EOC facilities (met obstetric need). Outcome/impact indicators Case-fatality rates (CFR) for obstetric complications. Maternal mortality ratio (number of maternal deaths per 1, live births). Percentage of live births with low birth weight (less than 25 grams), by sex. Number of HIV-positive women provided with antiretroviral therapy during pregnancy. HIV prevalence among pregnant women aged years. Prevalence of positive syphilis serology in pregnant women attending for antenatal care. Number of neonatal tetanus cases. Rate of congenital syphilis (number of congenital syphilis cases per 1, live births). Indicators for Evaluating Progress 21

24 5.2 High-quality Services for Family Planning Input/process/output indicators Number of family planning service delivery points (SDP) per 5, population offering a full range of contraceptive information, counselling and supplies (at least six methods, including male and female, temporary and permanent, emergency contraception). Number of family planning SDPs located within a fixed distance (e.g. 3 km) or travel time (e.g. two hours) of a given location (e.g. a community). Percentage of primary health care (PHC) facilities providing family planning services. Number of other sources of contraceptive information, supplies and services (pharmacies, private physicians, etc.) per 5, population. Percentage of family planning SDPs offering counselling on dual protection (protection from STIs and unwanted pregnancies). Percentage of family planning SDPs offering diagnosis and treatment of STIs. Percentage of family planning SDPs offering voluntary HIV counselling and testing (VCT). Percentage of family planning SDPs with written, clinical family planning protocols. Percentage of PHC and family planning facilities offering treatment or referrals for infertility. Number of individuals accepting a modern contraceptive method for the first time (new acceptors). Outcome/impact indicators Percentage of women at risk of pregnancy who are using (or whose partner is using) a contraceptive method (contraceptive prevalence rate and methodspecific contraceptive prevalence rate). Percentage of women at risk of pregnancy (currently married or in union who are fecund) and who desire to either terminate or postpone childbearing, but are not currently using a contraceptive method (unmet need). Total fertility rate (TFR). Age-specific fertility rate. 5.3 Eliminating Unsafe Abortion Input/process/output indicators Number/percentage of SDPs providing postabortion care services, by type and geographical distribution. Percentage of SDPs using vacuum aspiration or medical termination for procedures, by gestational age. Number/percentage of practitioners trained in Post-Abortion Care, by type (of specialty) and geographical distribution. Number/percentage of SDPs that offer family planning to patients receiving PAC. Percentage of obstetric and gynaecological admissions owing to abortion. Outcome/impact indicators Abortion rate (number of induced abortions occurring per 1 women of reproductive age). Percentage of maternal deaths attributed to abortion. Percentage of unintended pregnancies (mistimed or unwanted) terminated within 8 and 12 weeks of gestation and beyond 12 weeks Combating Sexually Transmitted Infections, Cervical Cancer and other Gynaecological Morbidities Input/process/output indicators Number of SDPs per 5, population with trained personnel, laboratory equipment and medicines appropriate for the diagnosis and treatment of bacterial and viral STIs and RTIs, including HIV/AIDS. Number of condoms available for distribution nationwide (during the preceding 12 months) per individual aged years. Percentage of family planning SDPs offering counselling on dual protection from STIs/HIV and unwanted pregnancies. Percentage of PHC and family planning facilities offering VCT. Percentage of PHC facilities offering routine screening for cervical and prostate cancer. Percentage of women screened for breast cancer within the past five years. 22 A Framework for Implementing the RHS in the South-East Asia Region

25 Percentage of women screened for cervical cancer within the past five years. Outcome/impact indicators Percentage of relevant population groups who correctly identify the three major ways of preventing the sexual transmission of HIV and who reject three major misconceptions about HIV transmission or prevention, by sex. HIV prevalence in subpopulations with high-risk behavior, by sex. Percentage of men and women who report using a condom the last time they had sex with a nonmarital, non-cohabiting partner (in the last 12 months). Percentage of condom users who report consistent use of the method, by sex. Percentage of women with cervical cancer. Percentage of women and men with secondary infertility Promoting Sexual Health Input/process/output indicators Percentage of health and family planning providers trained to detect (and ask users about) signs of sexual abuse or violence, or of anxiety, shame, anger or depression related to sexual relations. Percentage of SDPs equipped to provide appropriate medical, psychological and legal support for victims of rape or incest. Percentage of SDPs branded youth-friendly. Percentage of adolescents who have received sexual health education in schools, by sex. Outcome indicators Age at marriage (for men and women). Age at first intercourse (for men and women). Percentage of women who have undergone female genital mutilation. Percentage of sexually active adolescents who consistently use condoms, by sex. Indicators for Evaluating Progress 23

26 24 A Framework for Implementing the RHS in the South-East Asia Region

27 6 For implementing the Global Reproductive Health Strategy and attaining international reproductive health goals, including MDGs, each country needs to identify problems, set priorities and formulate strategies for accelerated action. National reproductive health strategies for many countries in the Region are in place. While programmes may vary based on the country situation, the common approach, however, is to foster a wide-range of collaboration and commitment to accelerate the reproductive health agenda by translating global strategies into concrete actions in countries based on their priorities and situation. This framework provides guidance for implementing the Global Reproductive Health Strategy keeping in mind the efforts made by countries of the Region as reflected in their reproductive health strategies. It uses the five key action areas outlined in the Strategy: i) strengthening health systems capacity; ii) improving information for priority-setting; iii) mobilizing political will; iv) creating supportive legislative and regulatory frameworks; and v) strengthening monitoring, evaluation and accountability. The role of health ministries is to provide leadership to their national reproductive health communities, the private sector and other stakeholders to reinforce commitments and streamline priority actions in these five key areas. WHO will continue to provide technical assistance to countries based on a considerable body of knowledge that provides the evidence base for establishing and implementing international norms and standards in reproductive health. Conclusion 25