WHO/RHR/08.11 WHO Sexual and Reproductive Health RevisedWHO Sexual and Reproductive 2008–2009 Budget

WHO combines groundbreaking research and the implementation, especially in developing countries, of new solutions to sexual and reproductive health problems. The Organization aims to strengthen the capacity of countries to WHO Sexual and Reproductive Health enable people to promote and protect their own health as it relates to sexuality and reproduction and to have access to, and receive, sound sexual and reproductive health care when needed. To achieve this, WHO: Revised Budget 2008–2009 conducts research to identify sexual and reproductive health problems and to find evidence-based solutions to them;

uses new research knowledge to develop norms, guidelines, tools and interventions for sexual and reproductive health programmes in countries;

develops mechanisms for the delivery and implementation at the country level of the new tools and interventions;

undertakes advocacy work to promote a rights-based approach to sexual and reproductive health and the social and other changes needed for sound sexual and reproductive health for all.

The specific thematic areas of work of the Organization, selected on the basis of its comparative advantage, include: promoting family planning; improving maternal and perinatal health; controlling sexually transmitted and reproductive tract infections; preventing unsafe abortion; advancing gender equality, reproductive rights, sexual health and sexual and reproductive health of adolescents; and monitoring and evaluating sexual and reproductive health.

For more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20, CH-1211 Geneva 27 Switzerland Fax: +41 22 791 4171 E-mail: [email protected] www.who.int/reproductive-health

Front and back cover photos: (from top) 1. WHO - C. Gaggero 2,3,4. WHO - P. Virot 5. WHO - J. Vizcarro WHO Sexual and Reproductive Health revised Budget 2008–2009 WHO Sexual and Reproductive Health Revised Budget 2008–2009 © World Health Organization 2008

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Introduction 1 Facts and figures 2 Trends 4 WHO’s work in sexual and reproductive health 5 WHO’s strategic objectives and Organization-wide expected results 6 WHO’s sexual and reproductive health budget 2008–2009 8 Monitoring and accountability 10 External evaluation of the Special Programme of Research, Development and Research Training in Human Reproduction 10 Promoting family planning 11 Issues and challenges 11 WHO’s work in promoting family planning 12 Product listing 15 Improving maternal and perinatal health 19 Issues and challenges 19 WHO’s work in maternal and perinatal health 20 Product listing 24 Preventing unsafe abortion 27 Issues and challenges 27 HRP’s work in preventing unsafe abortion 28 Product listing 31 Controlling sexually transmitted and reproductive tract infections 33 Issues and challenges 33 WHO’s work in controlling sexually transmitted and reproductive tract infections 33 Product listing 36 Gender, reproductive rights, sexual health and adolescence 39 Issues and challenges 39 WHO’s work in gender, reproductive rights, sexual health and adolescence 40 Product listing 42 Technical cooperation with countries 45 Issues and challenges 45 Headquarters 46 Regional Office for Africa 57 Regional Office for the Americas 60 Regional Office for South-East Asia 63

iii Regional Office for Europe 66 Regional Office for the Eastern Mediterranean 70 Regional Office for the Western Pacific 72 Strengthening linkages between sexual and reproductive health and HIV 75 Issues and challenges 75 WHO’s work in strengthening linkages between sexual and reproductive health and HIV infection 77 Product listing 80 Research coordination and support 83 General technical activities 85 Programme management 89 Budget tables and figures 91 References 97

iv 1 INTRODUCTION

World leaders, scientists, politicians and the general public are demanding greater attention to sexual and repro- ductive health in view of the critical linkages between this area of health and HIV infection, gender equality, poverty alleviation and other Millennium Development Goals (MDGs).

• The Millennium Project’s Investing in development: a practical plan to achieve the Millennium Development Goals1 formally recognizes that sexual and reproductive health is essential for reaching all eight of the MDGs derived from the 2000 Millennium Declaration. This report, which was presented to the Secretary-General of the United Nations, underscores the importance of ensuring universal access to sexual and reproductive health informa- tion and services for achieving the MDGs and recommends “a focus on women’s and girls’ health (including reproductive health).” Furthermore, the section of the report describing “Quick Wins”—those interventions that can be implemented immediately for a high short-term impact—recommends expansion of “access to sexual and reproductive health information and services, including family planning and contraceptive ser- vices, and close existing funding gaps for supplies and logistics.”

. At the 2005 World Summit, the High-level Plenary Meeting of the 60th Session of the United Nations General Assembly held on 14–16 September 2005, world leaders resolved to achieve universal access to reproduc- tive health by 2015, promote gender equality and end discrimination against women. In particular, the world leaders agreed to integrate the goal of access to reproductive health into national strategies to attain the MDGs.2 The resolve of world leaders to achieve universal access to reproductive health for all is a landmark, as it reaffirms the vision of the Programme of Action adopted at the International Conference on Population and Development, held in Cairo in 1994, which recognizes the central role of sexual and reproductive health in achieving international goals for education, poverty alleviation and gender equality.

. In the fight against HIV infection as well, there is growing recognition of the central role of sexual and repro- ductive health in halting the HIV pandemic. In June 2006, at the United Nations General Assembly Special Session, Member States declared "the need to strengthen policy and programme linkages and coordination between HIV/AIDS and sexual and reproductive health".3 Providers in sexual and reproductive health already offer a wide range of services to the millions of women who are now at the centre of the global HIV pandemic, and they are expanding their reach to adolescents and to men. Greater attention is being paid to the benefits that would accrue from integrating HIV-related activities into sexual and reproductive health services and from designing comprehensive programmes to reach those who are most vulnerable to both sexual and reproduc- tive health problems and HIV infection, such as young people. Such integration would make it possible to extend HIV services, including HIV testing and counselling, safer-sex counselling and condom promotion, and would open up care and treatment of HIV infection to those in need. It would also help reduce the stigma commonly associated with dedicated HIV services and address inequities in access to treatment, especially for

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women and young people. At the same time, integrating sexual and reproductive health services into the care and treatment of HIV infection would help people living with this infection to achieve their sexual and repro- ductive health goals, and, in so doing, would help contain the spread of HIV. The success of some of the most promising interventions to prevent further spread of HIV, including male circumcision, use of microbicides and treatment of infections with herpes simplex virus type 2 (HSV-2), will require strong linkages with sexual and reproductive health services.

• The Special Session of the African Union Conference of Ministers of Health, held in Mozambique on 18–22 September 2006, focused on universal access to comprehensive sexual and reproductive health services in Africa. The Ministers concluded that African leaders have a special obligation to respond to the sexual and reproductive health needs and rights of their people, and they endorsed an action plan to demonstrate their commitment to that end.4

WHO is taking these developments on board in its long-term vision, goals and objectives. In her address on assuming office in January 2007, Dr Margaret Chan, WHO’s Director-General, stated that “…I want my leadership to be judged by the impact of our work on the health of two populations: women and the people of Africa.” By working closely with Member States, United Nations agencies, development agencies, nongovernmental orga- nizations and other partners to strengthen policy and programmes for sexual and reproductive health, WHO will strive to ensure that Dr Chan’s commitment to the health of women is realized.

The hurdles facing work in sexual and reproductive health are substantial but not insurmountable. Indeed, real improvements are within reach. In 2008, there is no excuse for allowing women to die in childbirth; people can be taught to practise safe sex; family planning can work even in the poorest, most remote areas of countries. The problem is not a lack of resources or expertise; the problem is too often that we fail to act. WHO is committed to changing that, and the programme of work proposed in these pages sets out concrete steps for improving the sexual and reproductive lives of women and men, girls and boys, around the world.

FACTS AND FIGURES

Globally, contraceptive use has increased dramatically during the past four decades, from less than 10% of cou- ples in developing countries in the 1960s to 64% in 2005.5 In spite of these gains, however, at least 120 million couples are still not using any method of contraception, despite an expressed desire to space pregnancies or limit their fertility,6 and the variation among regions is high: in sub-Saharan Africa, for example, the contraceptive prevalence rate is only 21%.7 Furthermore, even those who have access to contraception may still not be able to choose a suitable, safe, effective method: there are still around 400 million married women who lack access to the full range of safe, effective, modern contraceptives.8 As a result, close to 40% of pregnancies are unplanned, and some 42 million of them are terminated each year by induced abortion; about 20 million of these abortions are unsafe, with high risks of severe morbidity or death for the woman.9 Complications of unsafe abortion account for about 13% of the deaths that occur as a result of pregnancy and childbirth. In developing countries, some 40% of unsafe abortions concern girls aged 15–24 years. Preventing unplanned pregnancies alone could avert around one quarter of maternal deaths, including those that result from unsafe abortion.

Over half a million women die annually as a result of causes related to pregnancy and childbirth, and 96% of these deaths occur in Africa and Asia.10 Furthermore, it is estimated that about 50 million women experience major obstetric complications, and for some the suffering is permanent.11 In addition, more than 4 million infants die within 28 days of coming into the world, and some 3.3 million are born dead.12 More than 20 million infants worldwide, representing 15.5% of all births, are born with low birth weight, and 96% of these are in developing countries.13 The rate of low birth weight in developing countries (16.5%) is more than double that in developed

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regions (7%). Most of this suffering is preventable, as cost-effective interventions are known and affordable; all too often, however, they are not made available because of scarce resources for effective health care.

Pregnancies, in particular those among very young women, may present risks for the health of the woman and newborn. In developed countries and in Eastern Asia, fewer than 30 births per 1000 adolescent women occur per year, but in developing regions, adolescent birth rates are often well above 30 or even 60 births per 1000 ado- lescent women. Declining trends were evident since the 1990s in developed regions, the countries in transition, Northern Africa, Eastern Asia and South-Eastern Asia, regions where the adolescent birth rate was already below 55 per 1000 in 1990. In contrast, in sub-Saharan Africa, Southern Asia and Latin America and the Caribbean, the high adolescent birth rates have not declined significantly despite the continued reduction in total fertility that those regions have experienced.

Sexually transmitted infections (STIs) are a major cause of acute illness, infertility, long-term disability and death. WHO has estimated that 340 million new cases of syphilis, gonorrhoea, chlamydia and trichomoniasis occurred in the world in 1999 among men and women 15–49 years of age.14 To this figure must be added the millions of cases of viral (incurable) STIs, foremost among them infections with HIV, the cause of AIDS. The HIV epidemic is raging unchecked, with 2.5 million new infections in 2007, mostly in developing countries.15 It is estimated that 33.2 million people in the world live with HIV infection, of whom 15.4 million are women and 2.5 million are children under the age of 15 years. HIV infection resulted in 2.1 million deaths in 2007, of which 330 000 were of children under 15 years of age. Yet, the upward trend in the prevalence of HIV infection can be reversed, as demonstrated in countries that have adopted aggressive policies for the primary prevention of HIV infection. In the absence of a vaccine or cure for HIV infection, primary prevention remains the key to containing the epidemic.

An estimated 420 000 children under 15 years of age were newly infected with HIV in 2007, the majority by trans- mission of HIV from their infected mother during pregnancy, delivery or breastfeeding. In the absence of any intervention, the rates of mother-to-child-transmission of HIV are 15–25% in developed countries and 25–40% in populations where breastfeeding is common.16 The rates of HIV transmission from mother-to-child can be reduced to 2–5%, as has occurred in some developed countries with use of antiretroviral treatment, elective caesarean section and avoidance of breastfeeding.17,18

Other viral infections contribute to sexual and reproductive ill-health. HSV‑2 is the primary cause of genital herpes and the commonest cause of genital ulcer disease in the developed world. In developing countries, the public health relevance of HSV-2 lies in its potential role in facilitating HIV transmission.19 There are few data on the prevalence of HSV-2, but it appears to be higher in developing than developed regions; in many countries of sub- Saharan Africa and the Caribbean, the prevalence in adults is around 50%.20 Furthermore, epidemiological studies indicate that 50% of women who become sexually active contract, within 2 years, an infection with genital human papillomavirus (HPV), which is the main cause of cervical cancer.21,22 In 2002, cervical cancer, with an estimated 493 000 new cases, was responsible for more than 273 000 deaths. Around 85% of these deaths occurred in devel- oping countries, where, in many regions, cervical cancer is the commonest cancer among women.23

Some 170–190 million people in the developing world (excluding China) are infertile. Approximately 2.5% of couples in these areas are affected by primary involuntary infertility, while the rate of secondary infertility is 24% or more, depending on the geographical area.24 A large proportion of primary and secondary infertility among women in developing countries is attributable to tubal damage from infectious diseases. In many societies, infer- tility is perceived as a stigma, and the burden is heavier on women as they are usually considered to be the source of the problem, while evidence suggests that infertility is as prevalent among men as among women.

Female genital mutilation is practised primarily in 28 countries in Africa but also in other parts of the world, among immigrant populations from countries where it is a tradition. Findings from an HRP-supported study published in The Lancet in 200625 showed that women who have undergone genital mutilation are significantly

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more likely to have serious complications during childbirth, including the need for a caesarean section, danger- ously heavy bleeding after parturition and prolonged hospitalization after the birth. Newborn babies of women who had undergone genital mutilation suffered also: more needed to be resuscitated after birth, and perinatal mortality was higher than among infants born to mothers who had not been mutilated. The study further showed that the degree of complications increased according to the extent and severity of mutilation. On the basis of information available in 2000, it was estimated that 100–140 million women and girls have undergone genital mutilation and that 3 million girls are at risk annually. It is known from various sources that the practice is under- going changes, and estimating the prevalence is extremely difficult. Analysis of data for 1995 and 2002 from four countries showed a measurable decrease in the prevalence of female genital mutilation in one country, Eritrea.26 Other forms of gender-based and sexual violence, frequently perpetrated by partners or close acquaintances, also cause suffering to countless millions of children, women and, to a lesser extent, men.

In all, sexual and reproductive ill-health, including HIV/AIDS but excluding stillbirths, is thought to have accounted, in 2002, for 22% of disability-adjusted life years lost by women and 16% by men. Developing countries accounted for 95% of disability-adjusted life years lost by both men and women as a result of sexual and reproductive ill- health.27

TRENDS

According to the current United Nations estimates, the world population will continue to increase, to reach 9 bil- lion people in 2050, virtually all the population growth occurring in less developed countries.28 Thus, during the next 40–50 years, persons of reproductive age will represent over 40% of the total population. The number of ado- lescents (aged 10–19 years) is predicted to grow to 1.3 billion by the year 2030, before starting to decline gradu- ally.28 At the same time, the ageing of the population, already tangible in some countries, is about to become a worldwide phenomenon, as, between now and 2050, the proportion of people aged 60 years and over will more than double, from the current level of about 10% to 21% (from 0.7 to 1.9 billion).28 Fulfilling the sexual, reproduc- tive and post-reproductive health needs of these various population groups will require a wider range, than is currently available, of sexual and reproductive health products and services tailored to diverse cultural and social backgrounds.

Trends in mortality and morbidity associated with sexual and reproductive health are notoriously difficult to assess, but available data suggest that there has been only minor improvement globally in maternal mortality, incidence of unsafe abortion or the prevalence of curable STIs during the past decade. Projections of the toll of the HIV pandemic are even more dire.15 Various scenarios have been proposed to describe the progression of the epidemic in Africa during the next 25 years. If responses to the HIV/AIDS epidemic continue to be fractured and short-term, fail to reflect the realities of everyday life and therefore fail to deliver a lasting solution, by 2025 the epidemic will have depleted the resources of many households and communities. The prevalence of HIV infection will be similar to that today and will continue to reduce life expectancy in many countries. The number of people living with HIV infection and AIDS will increase by more than 50%, and only 20% of people who need antiretroviral therapy will have access to it.29

Other developments in sexual and reproductive health should be monitored closely to ensure that they have positive effects and benefit developing countries as much as the developed world. For example, the potential role, usefulness and impact of new techniques, such as the HPV vaccine and genomics, proteomics and transcrip- tonomics research, must be evaluated. Equally, the place given to sexual and reproductive health on the global international development agenda must be monitored, including the impact of modalities such as sector-wide approaches, poverty reduction strategies and credits and health sector reform on provision of and access to sexual and reproductive health information and services.

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WHO’S WORK IN SEXUAL AND REPRODUCTIVE HEALTH

The international mandate that drives the work of WHO in sexual and reproductive health is based on the Global strategy to accelerate progress towards the achievement of international goals and targets in reproductive health, which was approved by the World Health Assembly in May 2004, on agreements adopted at the International Conference on Population and Development (Cairo, 1994) and the Fourth World Conference on Women (Beijing, 1995) and their respective 5-year and 10-year follow-ups, and on the MDGs. In 2006, WHO’s mandate in this area was further strengthened when the World Health Assembly adopted the Global strategy for the prevention and con- trol of sexually transmitted infection: 2006–2015, which provides a framework for countries to improve and acceler- ate their programmes for the control of STIs and to ensure that these programmes are well integrated and linked with other sexual and reproductive health services. And, in 2007, the important role of sexual and reproductive health in achieving the MDGs was formally recognized through the adoption, by the United Nations General Assembly, of the ICPD goal of “universal access to reproductive health by 2015” as a second target alongside the reduction of maternal mortality under MDG5 “improving maternal health”.

On the basis of these agreements, statements and strategies, WHO works “to ensure that by 2015 all primary health-care and family planning facilities are able to provide, directly or through referral, the widest achievable range of safe and effective family planning and contraceptive methods; essential obstetric care; prevention and management of reproductive tract infections, including sexually transmitted diseases; and barrier methods, such as male and female condoms and microbicides, if available, to prevent infection”.30

Within WHO, the Department of Reproductive Health and Research at WHO headquarters and the network of sex- ual and reproductive health and HIV/AIDS advisers in WHO regional and country offices are charged with respond- ing to these international calls to action. The headquarters Department of Reproductive Health and Research includes the United Nations Development Programme (UNDP)/United Nations Population Fund (UNFPA)/WHO/ World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP). The headquarters Department of Reproductive Health and Research is part of the WHO Cluster on Family and Community Health and works closely with the other departments and programmes in the cluster: Making Preg- nancy Safer; Child and Adolescent Health and Development; Gender, Women and Health; Immunization, Vaccines and Biologicals; and Healthy Ageing and the Life-course. It also collaborates with other departments at WHO headquarters, in particular the Department of HIV/AIDS.

In order to contribute optimally to the achievement of the MDGs and other international goals in sexual and reproductive health, and taking into account the comparative advantages of WHO, priorities were set in 2002 to define the Organization’s work in this field for the period 2004–2009.31 The programme budget for 2008–2009 was drawn up in the context of this 6-year plan. In setting priorities on the basis of a number of logical frameworks, six objectives were identified, which characterize the aims of the Organization’s work in sexual and reproductive health (see box on page 6) and which provided the framework for the budgets for 2004–2005, 2006–2007 and again for the present biennial budget 2008–2009.

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WHO’s objectives in sexual and reproductive health, 2004–2009

Objective 1: Broaden the provision of high-quality services that are cost-effective, available, accessible, affordable, evidence-based, gender-sensitive and respectful of reproductive rights.

Objective 2: Ensure the availability and widen the range of safe, effective health products and techniques on the market in sufficient quantities, at affordable prices.

Objective 3: Strengthen health management and support systems (public and private) to ensure that health programmes are executed efficiently, given the resources available.

Objective 4: Foster a supportive, enabling environment at individual, family and community levels.

Objective 5: Promote sound national policies and laws, and conducive policy and legal processes.

Objective 6: Ensure effective international efforts and collaboration, including effective global initiatives and sound implementation of international development plans.

WHO’S STRATEGIC OBJECTIVES AND ORGANIZATION-WIDE EXPECTED RESULTS

At the Health Assembly in May 2007, a 6-year WHO medium-term strategic plan 2008-201332 was considered and approved by WHO Member States. The plan covers three biennial budget periods and will form the basis of WHO’s results-based management for the coming years. Specifically, the plan: (i) provides the strategic direction for the Organization for the six-year period in advancing the health agenda established in the 11th General Pro- gramme of Work, which covers the decade 2006–2015; (ii) defines medium-term objectives and approaches for the Organization, providing a multi-biennial framework to guide and ensure continuity in preparation of biennial programme budgets and of operational plans for each biennium; (iii) provides a programme structure that better reflects how regional and country offices function, thereby facilitating more effective coordination and collabora- tion at all levels of the Organization; and (iv) results in a simpler budget process, freeing many of the technical units from the work of strategic planning every two years. An important contribution is the reduced number of strategic objectives, consolidating the work of the whole Organization, and a series of concrete Organization-wide expected results (OWERs) or outputs that will be delivered during the biennium, with indicators, baselines and targets for assessing achievement of each expected result. The OWERs to which the work in the field of sexual and reproductive health will contribute, which are fully consistent with the objectives identified in 2002, are shown in the box on the next two pages. They also appear in the approved WHO programme budget 2008–2009.

In order to achieve the Organization-wide expected results shown in the box, and in line with the priorities set in 2002, a consolidated, product-oriented work plan has been drawn up that includes explicit products, budget information and clear operational plans, including defined activities. These products are described in later sec- tions of this document.

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Sexual and reproductive health: WHO strategic objectives and Organization-wide expected results (OWERs)

Strategic objective 2: To combat HIV/AIDS, malaria and tuberculosis

OWER 2.1: Guidelines, policy, strategy and other tools developed for prevention of, and treatment and care for, patients with HIV/AIDS, tuberculosis and malaria, including innovative approaches for increasing coverage of the interventions among poor people, and hard-to-reach and vulnerable populations.

OWER 2.4: Global, regional and national systems for surveillance, evaluation and monitoring strengthened and expanded to keep track of progress towards targets and allocation of resources for HIV/AIDS, tuberculosis and malaria control and to determine the impact of control efforts and the evolution of drug resistance.

OWER 2.6: New knowledge, intervention tools and strategies developed and validated to meet priority needs for the prevention and control of HIV/AIDS, tuberculosis and malaria, with scientists from developing countries increasingly taking the lead in this research.

Strategic objective 3: To prevent and reduce disease, disability and premature death from chronic noncommunicable conditions, mental disorders, violence and injuries

OWER 3.3: Improvements made in Member States’ capacity to collect, analyse, disseminate and use data on the magnitude, causes and consequences of chronic noncommunicable conditions, mental and behavioural disorders, violence, injuries and disabilities.

Strategic objective 4: To reduce morbidity and mortality and improve health during key stages of life, including pregnancy, childbirth, the neonatal period, childhood and adolescence, while improving sexual and reproductive health and promoting active and healthy ageing for all individuals

OWER 4.1: Support provided to Member States to formulate a comprehensive policy, plan and strategy for scaling-up towards universal access to effective interventions in collaboration with other programmes, paying attention to reducing gender inequality and health inequities, providing a continuum of care throughout the life-course, integrating service delivery across different levels of the health system and strengthening coordination with civil society and the private sector.

OWER 4.2: National research capacity strengthened as necessary and new evidence, products, technologies, interventions and delivery approaches of global and/or national relevance available to improve maternal, newborn, child and adolescent health, to promote active and healthy ageing, and to improve sexual and reproductive health.

OWER 4.7: Guidelines, approaches and tools made available, with provision of technical support to Member States for accelerated action towards implementing the strategy to accelerate progress towards the attainment of international development goals and targets related to reproductive health, with particular emphasis on ensuring equitable access to good-quality sexual and reproductive health services, particularly in areas of unmet need, and with respect for human rights as they relate to sexual and reproductive health.

Strategic objective 6: To promote health and development, prevent and reduce risk factors for health conditions associated with tobacco, alcohol, drugs and other psychoactive substance use, unhealthy diets, physical inactivity and unsafe sex

OWER 6.2: Guidance and support provided in order to strengthen national systems for surveillance of major risk factors through development and validation of frameworks, tools and operating procedures and their dissemination to Member States where a high or increasing burden of death and disability is attributed to these risk factors.

OWER 6.6: Evidence-based and ethical policies, strategies, interventions, recommendations, standards and guidelines developed and technical support provided to Member States to promote safer sex and strengthen institutions in order to tackle and manage the social and individual consequences of unsafe sex.

Strategic objective 7: To address the underlying social and economic determinants of health through policies and programmes that enhance health equity and integrate pro-poor, gender-responsive, and human rights-based approaches

OWER 7.4: Ethics- and rights-based approaches to health promoted within WHO and at national and global levels.

OWER 7.5: Gender analysis and responsive actions incorporated into WHO’s normative work and support provided to Member States for formulation of gender-sensitive policies and programmes.

Strategic objective 10: To improve health services through better governance, financing, staffing and management, informed by reliable and accessible evidence and research

OWER 10.1: Management and organization of integrated, population-based health-service delivery through public and nonpublic providers and networks improved, reflecting the principles of integrated primary health care, scaling up coverage, equity and quality of health services, and enhancing health outcomes.

OWER 10.3: Coordination of the various mechanisms (including donor assistance) that provide support to Member States in their efforts to achieve national targets for health system development and global health goals improved.

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WHO’S SEXUAL AND REPRODUCTIVE HEALTH BUDGET 2008–2009

This budget builds on the work of the department of Reproductive Health and Research for 2006–2007, as out- lined in the Reproductive health and research programme budget 2006–2007, and the work of the WHO regional and country offices during the biennium. For the first time, therefore, the budget represents WHO’s work in sexual and reproductive health at both headquarters and regional levels.

As in the previous biennium, a list of products is presented for which specified resources are required. While the work of HRP is integrated into the headquarters department of Reproductive Health and Research, the activities of HRP, which is a Special Programme cosponsored by UNDP, UNFPA, WHO and the World Bank, are clearly identified throughout this document, in accordance with administrative and financial accounting requirements.

On the basis of guidance from HRP’s Standing Committee in December 2006, both a full budget level and a contingency level were estimated; similarly, for products in the area of programme development in reproductive health (PDRH), full and contingency level budgets are presented. A HRP revised budget will be submitted for approval to HRP’s Policy and Coordination Committee in June 2008.

The budget priority levels and totals are shown in Table 1.

Table 1. WHO sexual and reproductive health budget, 2008–2009*

Budget (US$ million)

Priority level Total reproductive HRP PDRH health and research

WHO Programme Budget level (full budget) 43.2 22.4 65.6

Contingency plan 40.2 21.2 61.4

*Figures exclude WHO programme support costs.

The breakdown of the full budget by section is shown in Figure 1, and a breakdown of the full budget by Organi- zation-wide expected result is shown in Figure 2. A detailed breakdown by budget section and source of funding and a comparison with the budget levels for 2006–2007 are shown in the budget tables in section 12.

Each section of this budget document includes a detailed product listing, describing each of the products sched- uled for implementation during the biennium and the activities planned for its achievement. The tables also show the source of funding (HRP or PDRH), the WHO strategic objective and the Organization-wide expected result to which the product contributes (see box on previous page).

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Figure 1. RHR budget summary for 2008-2009, by budget section (full budget level)

Improving Maternal and Preventing Unsafe Abortion Perinatal Health 10.2% Promoting Family Planning 6.5% 13.7% Controlling Sexually Transmitted and Reproductive Tract Infections Programme Management 11.0% 8.1%

Gender, Reproductive Rights, Sexual Health and General Technical Activities Adolescence 4.7% 6.4% Research Coordination 3.7% Technical Cooperation with Strengthening Linkages Countries between Sexual and 33.7% Reproductive Health and HIV 1.9%

Figure 2. RHR budget summary for 2008-2009, by Organization-wide expected result (US$ million)

OWER 2.1 STI/HIV prevention

OWER 2.2 STI/HIV technical support

OWER 2.4 STI surveillance

OWER 2.6 HIV/AIDS prevention research

OWER 3.3 Violence against women

OWER 4.1 Universal access (health systems)

OWER 4.2 Research in sexual and reproductive health

OWER 4.7 Programme development in SRH

OWER 6.6 Unsafe sex

OWER 7.4 Reproductive rights

OWER 10.1 Health service research

OWER 10.3 Health services capacity strengthening

5 10 15 20 25 30 35 40 45

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MONITORING AND ACCOUNTABILITY

The success of WHO’s work in sexual and reproductive health depends on its scientific and ethical rigour, its gender sensitivity and its ability to address priorities in sexual and reproductive health in countries, particularly developing countries. This is monitored by a number of complementary advisory bodies:

. The Scientific and Technical Advisory Group meets annually to review progress, to recommend priorities and to advise on the allocation of resources.

. The Gender and Rights Advisory Panel reviews the work from the perspective of gender and reproductive rights.

. The Regional Advisory Panels monitor and evaluate the work in their respective geographical regions.

. At an annual meeting of relevant staff from headquarters and regional offices, progress is reviewed and evalu- ated, and joint plans for the coming year are made for headquarters and for each region.

. The Scientific and Ethical Review Group Panel provides an independent ethical assessment of research pro- posals submitted.

. HRP is evaluated further at the annual meetings of the Policy and Coordination Committee, thrice-yearly meet- ings of the Standing Committee and periodic external independent evaluations (see below).

Each of the above bodies is in a position to assess, from differing points of view, the achievement of the pro- gramme objectives and expected results. Beginning in 2008–2009, WHO’s work in sexual and reproductive health will be rigorously managed and monitored by WHO’s Oracle©-based global management system, which will be launched in July 2008.

EXTERNAL EVALUATION OF THE Special Programme of Research, Development and Research Training in Human Reproduction

HRP is also evaluated in periodic independent external evaluations, most recently in 2002–2003. This last evalu- ation covering the period 1990–2002 was conducted by Management Sciences for Health, a private nongovern- mental organization in the USA, and the Swiss Centre for International Health of the Swiss Tropical Institute in Basel, Switzerland.

The evaluation focused on four key issues: (1) the relevance and effectiveness of HRP-supported research in repro- ductive health; (2) the dissemination, global use and impact of the results of HRP’s research; (3) strengthening by HRP of reproductive health research capacity and the use and impact of HRP’s work at country level; and (4) HRP governance, management, administration and efficiency. The conclusions and recommendations of the evalua- tion team were based on document review, analysis of selected publications, seven country visits and input from more than 300 informants, of whom 249 provided detailed information during interviews and in e-mail question- naires. Two thematic case studies—one on emergency contraception and one on mainstreaming gender and women’s perspectives—were performed to gain further information on specific aspects of HRP’s work.

The report from the external evaluation33 strongly endorsed the direction and management of the Special Pro- gramme. The overall conclusion was that, during 1990–2002, HRP had clearly met expectations in terms of its core mission to coordinate, promote, conduct and evaluate international research in reproductive health and that it had achieved its objectives. The Special Programme maintained its position as the global leader in generating research results and establishing the scientific consensus needed to advance reproductive health policies and practices, especially for developing countries. The report made numerous recommendations, which have been implemented to further enhance performance.

A new external evaluation of HRP is under way, which will focus on the contributions that HRP’s research has made to global public goods. The initial results will be available in late 2007, and a full report will be submitted to the Policy and Coordination Committee in June 2008. 10 2 PROMOTING FAMILY PLANNING

Issues and challenges

Family planning is often considered one of the success stories of the twentieth century in public health. As described above, use of contraceptives increased worldwide from less than 10% of couples in the 1960s to over 60% at the turn of the century, and, in 2005, more than 660 million women aged 15–49 years who were mar- ried or in union were using contraception. These global figures, however, mask significant regional disparities. In 2004, the fertility rate remained at more than five children in 31 of the 148 developing countries, 28 of which are in sub-Saharan Africa, and surveys show that up to 35% of women who are fecund are not using any method of contraception, despite an expressed desire to space pregnancies or limit their fertility. Another indicator of the challenge facing family planning programmes is the estimated 42 million women who resort to induced abortion each year, 20 million of them putting their lives at risk because the abortions are carried out illegally or under unsafe conditions, by unskilled providers.

Thus, the challenge for family planning programmes is to provide a wider range of methods that better address people’s needs and preferences and to find better ways of delivering high-quality services to the millions of people who would use family planning if they had access to it. If programmes could meet all the unmet need for acceptable family planning among sexually active people, irrespective of their marital status, about half a billion more women and men would be able to achieve their reproductive intentions, effectively and safely. Family plan- ning is, however, a victim of its own success and no longer attracts the international funding required. Clearly, forceful advocacy is needed. As stated in The Lancet’s series on sexual and reproductive health published in 2006: “Promotion of family planning in countries with high birth rates has the potential to reduce poverty and hunger and avert 32% of all maternal deaths and nearly 10% of childhood deaths. It would also contribute substantially to women’s empowerment, achievement of universal primary schooling, and long-term environmental sustain- ability.”

The objectives set in this area at the International Conference on Population and Development and detailed in its Programme of Action (paragraph 7.14) are:

• to help couples and individuals meet their reproductive goals in a framework that promotes optimum health, responsibility and family well-being, and respects the dignity of all persons and their right to choose the num- ber, spacing and timing of the birth of their children;

• to prevent unwanted pregnancies and reduce the incidence of high-risk pregnancies and morbidity and mor- tality;

• to make high-quality family planning services affordable, acceptable and accessible to all who need and want them, while maintaining confidentiality;

11 WHO Sexual and Reproductive Health Revised Budget 2008–2009

• to improve the quality of family planning advice, information, education, communication, counselling and services;

• to increase the participation and sharing of responsibility of men in the actual practice of family planning; and

• to promote breastfeeding to enhance birth spacing.

These objectives were reaffirmed at the Twenty-first Special Session of the United Nations General Assembly in 1999 devoted to a 5-year review of implementation of the ICPD Programme of Action, where specific goals (see box) were set, which guide the Organization’s work in family planning to this day.

Goals

To ensure that by 2015 all primary health-care and family planning facilities are able to provide, directly or through referral, the widest achievable range of safe and effective family planning and contraceptive methods.

(Programme of Action, paragraph 53)

Where there is a gap between contraceptive use and the proportion of individuals expressing a desire to space or limit their families, countries should attempt to close this gap by at least 50 per cent by 2005, 75 per cent by 2010 and 100 per cent by 2015.

(Programme of Action, paragraph 58)

These [family planning] programmes are an essential part of services to reduce maternal and perinatal morbidity and mortality because they enable women to postpone, space and limit pregnancies. As these services are directly concerned with the outcomes of sexual relationships, they also have great potential for leading the way in promoting sexual health and efforts to prevent sexually transmitted infections and HIV transmission.

(Reproductive health strategy to accelerate progress towards the attainment of international development goals and targets, paragraph 38, World Health Assembly Resolution WHA57.12)

In 2004, the World Health Assembly adopted a global reproductive health strategy that highlights the pivotal role of family planning in sexual and reproductive health (see box). In order to fulfill this role, other sexual and reproductive health services (such as counselling and testing for HIV, diagnosis and treatment of STIs or sexual health care) should be integrated into family planning programmes. Further, integration of family planning into HIV infection and STI services would make it possible to reach men and women who lack access to such services. Multidisciplinary research is required to meet these challenge effectively.

WHO’s work in Promoting Family Planning

The unmet need in family planning is due to lack of services or barriers to their access; poor quality of services (inappropriate client–provider interactions, substandard technical competence of providers, inadequate informa- tion, poor design and management of service delivery systems); technical issues (limited or inappropriate choice of available methods and fear, or experience, of side-effects); and broader social issues (lack of knowledge, socio- cultural, religious and gender barriers, power imbalances within couples and families). Furthermore, a number of

12 WHO Sexual and Reproductive Health Revised Budget 2008–2009

trends are reshaping the context of family planning and the magnitude and type of needs to be met, including high rates of transmission of STIs and HIV, the changing patterns of adolescent sexuality and fertility and the large numbers of persons living in poverty and other vulnerable situations.

In order to meet the family planning needs of the millions of individuals and couples who are poorly served or not served at all, WHO must ensure that its programme of work contributes meaningfully to improving the quality of family planning globally through the research and programme development activities outlined below.

National research capacity strengthened as necessary and new evidence, products, technologies, interven- OWER tions and delivery approaches of global and/or national relevance available to improve maternal, newborn, child 4.2. and adolescent health, to promote active and healthy ageing, and to improve sexual and reproductive health.

A multidisciplinary research agenda, strengthening of research capacity and more attention to dissemina- tion of research results in such a way as to facilitate their translation into practice will improve the quality of family planning methods and services, and sexual and reproductive health generally.

The agenda will include:

• social and behavioural research to identify barriers to the uptake and continued use of family planning methods and services (including infertility treatment), especially among groups of underserved or vul- nerable populations; further understanding of the strategies used for dual protection by individuals and couples and of the pattern of contraceptive use;

• operations research to evaluate selected strategies for improving the quality of care, on the basis of the results of social and behavioural research and including evidence-based guidance;

• epidemiological research on the safety and efficacy of existing methods, particularly for persons receiv- ing long-term treatment (e.g., antiretrovirals) for chronic diseases, and systematic reviews of the evi- dence;

• development of new contraceptive methods, including pre-coital, dual protection and long-acting hor- monal and non-hormonal methods for women and long-acting hormonal methods for men;

• evaluation of new techniques for treating infertility that are suitable for resource-poor settings; and

• basic science investigations to identify new targets for contraceptive research (depending on the avail- ability of funds).

WHO will continue to ensure that the results of this research are widely disseminated, not only to the scien- tific community in peer-reviewed scientific journals, but also on the Internet and at meetings and workshops, including with policy-makers and programme managers. In addition, HRP will continue to help countries strengthen their capacity for undertaking research.

Guidelines, approaches and tools made available, with provision of technical support to Member States for accel- erated action towards implementing the strategy to accelerate progress towards the attainment of international OWER development goals and targets related to reproductive health, with particular emphasis on ensuring equitable 4.7. access to good-quality sexual and reproductive health services, particularly in areas of unmet need, and with respect for human rights as they relate to sexual and reproductive health.

Programme activities, implemented in accordance with gender and human rights implications, will contrib- ute to the achievement of the MDG target of ensuring universal access to reproductive health. Quality will

13 WHO Sexual and Reproductive Health Revised Budget 2008–2009

be improved by the creation and use of evidence-based tools and guidelines and evaluation of the impact of the guidance on access to, choice of and informed consent for family planning. High-quality services will also be based on social and behavioural science and operations research on use of family-planning services, the barriers to uptake and strategies to address them.

Provision of high-quality services requires the support of a strong health system. Guidelines for management and service delivery will be drawn up, and technical support will be given to help countries adapt and imple- ment evidence-based norms and tools. Much of WHO’s work in strengthening health systems to promote sexual and reproductive health, including family planning, will involve applying the WHO strategic approach, the initiative for implementing best practices, the WHO-UNFPA Strategic Partnership Programme and other mechanisms for the provision of technical support to countries.

Supportive national environments are imperative for the success of family planning programmes and plans. As the legal and policy framework for family planning is best analysed in the broader context of sexual and reproductive health, this work is carried out in the Department under Gender, Reproductive Rights, Sexual Health and Adolescence.

Specific planned programme development activities include:

• provision of evidence-based guidelines that focus on ensuring high-quality, accessible, acceptable and affordable family planning services, includingMedical eligibility criteria for contraceptive use34, Selected practice recommendations for contraceptive use35, Decision-making tool for family planning clients and providers36 and Family planning: a global handbook for providers37; these must be monitored continuously and new evidence appraised to ensure that the guidelines remain current and are based on the best available science;

• development of educational materials to support pre- and in-service training;

• support to strengthen national health system capacity, including helping countries to implement WHO's family planning norms, tools and standards;

• development of managerial guidelines for family planning programmes and services;

• support to strengthen linkages between family planning and other components of sexual and repro- ductive health and to promote comprehensive care; and

• support to foster an enabling environment at family, community, national and international levels for addressing unmet needs and for promoting access to high-quality services for those who desire them, including guidance from the perspective of those served.

Advocacy is needed for increased international commitment to sexual and reproductive health, including family planning. Specific activities will include support to countries in designing advocacy materials and a strategy for their dissemination and use.

OWER Guidelines, policy, strategy and other tools developed for prevention of, and treatment and care for patients with, HIV/AIDS, tuberculosis and malaria, including innovative approaches for increasing coverage of the 2.1. interventions among poor people, and hard-to-reach and vulnerable populations.

Unprotected intercourse can result not only in unintended pregnancy but also accounts for up to 80% of HIV infections worldwide. A further 10% of HIV infections result from mother-to-child transmission of the virus. Many pregnancies are unintended and could be prevented by more widely available family planning ser- vices. Women and men both need protection from unwanted pregnancy and against HIV infection and other STIs. Strengthening the linkages between HIV/AIDS services and sexual and reproductive health in general

14 WHO Sexual and Reproductive Health Revised Budget 2008–2009

and with family planning in particular will reduce the number of missed opportunities to provide services for persons who need them. It will also offer more holistic care, tailored to the needs of the population, including persons living with HIV infection, and increase access to and coverage and quality of both family planning and HIV/AIDS services. Support will be given to countries to strengthen linkages between family planning and HIV/AIDS services, in part by implementing the guidance of the Department for the provision of family planning to HIV-positive individuals.

PRODUCT LISTING

Funding source and Product Product title Product description Organization-wide identification expected result

001 Evidence-based guidance Continuous identification of research evidence PDRH, Organization- on family planning to update medical eligibility criteria for wide expected result contraceptive use, practice recommendations 4.7 for contraceptive use and other family planning guidelines. Evaluation of system for continuous identification of research evidence

Activities 1. Continuing continuous identification of research evidence 2. Convening expert working group meeting to update medical eligibility criteria and selected practice recommendations 3. Convening meeting of the Guidelines Steering Group 4. Printing and translating guidelines 5. Publishing of family planning guidance updates 6. Evaluating system for continuous identification of research evidence (implemented under full budget)

002 Social science research Studies on the perspectives of users, non-users, HRP, Organization- on users’ and providers’ potential users and providers on family planning wide expected result perspectives on family methods and services; on quality of care; and on 4.2 planning methods and fertility and contraception preferences among services people living with HIV infection

Activities 1. Completing studies on the quality of family planning services (China, Nigeria) 2. Completing a study of fertility preferences of HIV-positive women (Brazil, South Africa) 3. Initiating two new studies 4. Initiating one additional study (implemented under full budget)

003 Social science research Studies on the strategies used for dual protection HRP, Organization- on the prevention of the by individuals and couples living in areas of wide expected result dual risks of unintended generalized HIV infection 4.2 pregnancy and STIs, including HIV infection

Activities 1. Completing of a study on the dynamics of condom negotiation and use in marital relationships in areas of generalized HIV infection (South Africa, Uganda) 2. Initiating of two new studies 3. Initiating of one additional study (implemented under full budget)

004 Social science research on Studies of discontinuation, switching, uptake HRP, Organization- dynamics of contraceptive after emergency contraception, uptake of wide expected result use contraceptives postpartum or postabortion 4.2

Activities 1. Initiating two new studies 2. Undertaking secondary analysis of data from Demographic and Health Surveys comparative reports 3. Initiating one additional study (implemented under full budget) 15 Continued on next page WHO Sexual and Reproductive Health Revised Budget 2008–2009

Funding source and Product Product title Product description Organization-wide identification expected result

005 Operations research to Operations research to improve the quality of PDRH, Organization- improve quality of care in care in sexual and reproductive health services (in wide expected result sexual and reproductive collaboration with the United States Agency for 4.7 health services International Development)

Activities 1. Evaluating community-based distribution programmes for family planning 2. Initiating two operations research studies 3. Holding three workshops 4. Adapting STI guidelines to local context in one country 5. Completing the synthesis of evidence on quality of care (implemented under full budget)

006 Updating of WHO Updating of existing WHO andrology guidelines to PDRH, Organization- evidence-based reflect new evidence and changing practices wide expected result guidelines in andrology 4.7 and assessment of their impact on providers’ practices

Activities

1. Updating the WHO manual for the standardized investigation, diagnosis and management of the infertile male (2000); expert meeting in 2008; finalizing revised guideline in 2009

2. Updating the Guidelines for the use of androgens in men (1992); holding expert meeting in 2008; finalizing revised guideline in 2009

007 Clinical testing of Evaluation of clinical performance and acceptability HRP, Organization- hormonal contraceptives of various hormonal combinations for male wide expected result for men contraception 4.2

Activities 1. Conducting a multicentre phase IIb clinical trial of the combination testosterone undecanoate– norethisterone enanthate 2. Organizing annual meeting of the Research Group on the Regulation of Male Fertility

008 Development of new Continued development of a progestogen HRP, Organization- injectable contraceptive (levonorgestrel butanoate) for male and female wide expected result products for men and contraception and of an immunocontraceptive for 4.2 women women

Activities 1. Initiating and coordinating studies on pharmacokinetics of levonorgestrel butanoate in men and women (in collaboration with CONRAD and the United States National Institute of Child Health and Human Development) 2. Providing technical support to a phase I clinical trial of a beta-human chorionic gonadotropin immunocontraceptive (Sweden) 3. Convening meeting of the Research Group on Immunocontraception

Continued on next page

16 WHO Sexual and Reproductive Health Revised Budget 2008–2009

009 Development of new Development of levonorgestrel as a pre-coital HRP, Organization- pre-coital methods of contraceptive wide expected result contraception 4.2

Activities 1. Supporting a study of the pharmacodynamic effects of levonorgestrel on cervical mucus, sperm motility and other reproductive markers 2. Organizing a multicentre study of the efficacy of levonorgestrel as a pre-coital contraceptive 3. Convening investigators’ meeting

010 Targeted basic research on Review of evidence on mechanisms of endometrial HRP, Organization- reproductive physiology bleeding and on novel targets for male wide expected result of men and women contraception, in order to plan further contraceptive 4.2 research and drug development

Activities 1. Convening expert meeting to review the latest evidence on mechanisms of endometrial bleeding, as a basis for planning further research and drug development (in collaboration with the United States National Institute of Child Health and Human Development) 2. Initiating studies on novel targets for male contraception (implemented under full budget)

011 Development of Development of methods of contraception HRP, Organization- improved, long-acting based on existing ones, with use of modified wide expected result methods for female manufacturing processes to reduce their cost and 4.2 contraception make them more accessible

Activities 1. Completing the phase III clinical trial of a 1-year nestorone/ethinyl estradiol vaginal ring in two centres (in collaboration with the Population Council) 2. Initiating a phase III clinical testing of a levonorgestrel-releasing intrauterine device (implemented under full budget)

012 Research on safety Longitudinal studies of the safety and efficacy of HRP, Organization- and efficacy of existing hormonal contraceptive methods for women wide expected result contraceptive methods 4.2

Activities 1. Continuing the multicentre comparative study of the safety and efficacy of two implantable contraceptives, Jadelle and Implanon, and a control group of intrauterine device users 2. Conducting a multicentre comparative study of the effect of injectable contraceptives (Cyclofem, depot medroxyprogesterone acetate) on bone metabolism

013 Normative work on Standardization of diagnostic definitions for PDRH, Organization- infertility infertility; definition of a low-cost assisted wide expected result reproduction technology protocol 4.7

Activities 1. Standardizing diagnostic definitions for infertility 2. Defining a low-cost assisted reproduction technology protocol

014 Development of Development of managerial guidelines for family PDRH, Organization- managerial guidelines planning programmes and services, with partners wide expected result for family planning 4.7 programmes and services

Activities 1. Convening an expert working group to reach consensus on standards and critical components 2. Drafting guidelines in collaboration with partners 3. Printing, disseminating and translating 4. Providing support for implementation

Continued on next page

17 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Funding source and Product Product title Product description Organization-wide identification expected result

015 Supporting improvement Improving quality of care through introduction, PDRH, Organization- of quality of care in family translation, adaptation and implementation of wide expected result planning services and evidence-based guidance 4.7 programmes in countries

Activities 1. Introducting, translating and adapting evidence-based guidelines in three countries 2. Adapting evidence-based guidelines for use by community-based workers; pilot-testing in two sites 3. Providing technical assistance to countries for implementing an advocacy package for family planning 4. Introducing evidence-based guidelines in two additional countries (implemented under full budget)

016 Improving training in Development of pre-service and in-service curricula PDRH, Organization- sexual and reproductive for sexual and reproductive health, in collaboration wide expected result health with partners 4.7

Activities 1. Convening a consultation for defining competencies 2. Developing pre-service curricula 3. Developing in-service curricula 4. Introduction of evidence-based guidelines to two additional countries (implemented under full budget)

017 Studies on interactions Studies of the impact of hormonal contraceptives HRP, Organization- between antiretroviral on the clinical course of HIV infection in women on wide expected result therapy and steroid antiretroviral therapy; studies on the interaction 4.2 hormone contraception between hormonal contraception and antiretroviral agents

Activities 1. Conducting a long-term observational study of HIV-infected women in developing countries using steroidal contraception while on antiretroviral therapy 2. Conducting studies on the pharmacokinetics and pharmacodynamics of interactions between hormonal contraceptives and antiretroviral therapy in HIV-infected women in developing countries

018 Strengthening linkages Technical support to countries to strengthen PDRH, Organization- between sexual and linkages between sexual and reproductive health wide expected result reproductive health (family planning and STIs) and HIV/AIDS services 4.7 services and HIV infection and programmes services and programmes

Activities 1. Providing technical support to four countries in sub-Saharan Africa

18 3 IMPROVING MATERNAL AND PERINATAL HEALTH

ISSUES AND CHALLENGES

The sexual and reproductive health status of women living in developed and developing countries differs widely. This disparity is one of the starkest examples of inequity in our time and is particularly strong with respect to maternal and perinatal health. Approximately 530 000 pregnant women and 4 million newborn babies die each year due to complications related to pregnancy and childbirth, and almost all of these deaths occur in developing countries. These alarming numbers, and the health discrepancies they represent, indicate that the current global status of women’s sexual and reproductive health is no longer simply a public health concern but has acquired the dimensions of a major social injustice.

Although significant progress has been made in research in maternal and perinatal health in recent years, most of the progress has been driven by the health systems of the richest countries. The interventions related to preg- nancy and childbirth are therefore often inappropriate for low-resource settings, exacerbating the gap in women’s sexual and reproductive health conditions around the world. The paucity of research on conditions that dispro- portionately affect women in developing countries has limited the number of effective, affordable and feasible preventive strategies available. Pre-eclampsia, eclampsia and preterm delivery are pregnancy-related conditions that are still poorly understood, receive little international funding and greatly contribute to the high maternal and perinatal morbidity and mortality rates in many developing countries. Therefore, the research and develop- ment agenda for maternal and perinatal health should be more widely focused, to target the needs of all popula- tions and especially those that are more vulnerable and in greater need of affordable preventive and therapeutic interventions. Implementation of an agenda with a wider focus could lead to significant reductions in maternal and perinatal mortality, a goal that has not been reached despite decades of international commitment. This new focus could have the additional benefit of substantially reducing the underlying causes of morbidity, disabilities and associated health-care costs in the more developed world.

Goals

To reduce maternal mortality by 75% from 1990 levels by the year 2015. (International Conference on Population and Development Programme of Action, paragraph 8.21; MDG 5)

To reduce infant mortality rate below 35 per 1000 live births in all countries by the year 2015 [which will be strongly dependent on achieving a reduction in newborn mortality]. (International Conference on Population and Development Programme of Action, paragraph 8.16)

To reduce child mortality by two-thirds from 1990 levels by the year 2015 [which will be strongly depen- dent upon achieving a reduction in newborn mortality]. (MDG 4)

19 WHO Sexual and Reproductive Health Revised Budget 2008–2009

HRP will use this broad-based, more equitable approach to improving maternal and perinatal health by taking advantage of WHO’s capacity to convene external partners. Through collaboration with prestigious institutions and individuals worldwide, HRP has been able to define lines of research that will benefit health systems globally, coordinate translation of research from the laboratory to the health system, make research accessible to scientists in low-income countries and institutions and stimulate new thinking.

Because achieving significant progress in maternal and newborn health is possible only with the support of civil society and political leaders, the Department is also formulating several innovative activities that go beyond public health to the areas of politics and culture.

WHO’s work in MATERNAL AND PERINATAL HEALTH

National research capacity strengthened as necessary and new evidence, products, technologies, interven- OWER tions and delivery approaches of global and/or national relevance available to improve maternal, newborn, child 4.2. and adolescent health, to promote active and healthy ageing, and to improve sexual and reproductive health.

For this Organization-wide expected result, research on maternal and perinatal health has been structured into three main themes: hypertensive disorders of pregnancy, including the global programme to conquer pre-eclampsia; improving perinatal health; and postpartum care. In addition, four cross-cutting activities are planned: a global survey of maternal and perinatal health; synthesis of research results; operations research; and capacity-building and advocacy. The plan of work focuses on research activities because country-level implementation of programmes to improve maternal and perinatal health is the mandate of the WHO Department for Making Pregnancy Safer.

Global programme to conquer pre-eclampsia The WHO global programme to conquer pre-eclampsia and eclampsia is a highly structured research ini- tiative in the international research community on maternal and perinatal health and continues to foster productive collaboration with the most prestigious institutions worldwide. The innovative approach of the programme is to select promising hypotheses for research on the basis of systematic literature reviews and then to use appropriate epidemiological study designs to test the hypotheses. A multicentre clinical trial on the treatment of mild-to-moderate hypertension with labetalol to prevent pre-eclampsia is being carried out in Argentina, Egypt, India, South Africa and the United Kingdom, with 2000 women. A multicentre observa- tional study was initiated recently to determine whether changes in serum and urinary angiogenic proteins during pregnancy, detected with an easy-to-use urine screening test, can be used to identify women at very high risk for pre-eclampsia. The study is under way in Argentina, Colombia, India, Italy, Kenya, Peru, Switzer- land and Thailand and will involve recruitment of more than 12 000 women.

The most recent collaboration of the global programme is with the University of British Columbia in Vancou- ver, Canada, to conduct a study in Fiji, South Africa and Uganda to validate a model of maternal and fetal clinical variables that predict adverse maternal and perinatal outcomes in women with pre-eclampsia. The objective is to define the clinical picture of women with pregnancy-related hypertensive disorders more clearly than in existing classification systems. An improvement in the classification and subclassification of women according to their true risk will not only modify direct patient care (e.g. timing of delivery, place of care) but will also be a prerequisite for the design of future randomized controlled trials and basic biomedical investigations in the field of pre-eclampsia. In addition, at full budget level, guidelines will be drawn up, on the basis of the results of the study.

20 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Improving perinatal health Preterm birth and birth asphyxia account for two-thirds of the 4 million neonatal deaths occurring every year, and intrauterine growth restriction is an underlying factor in approximately 60% of newborn deaths. To address the problem of preterm birth, with a research strategy similar to that for pre-eclampsia, HRP has joined the Preterm Birth International Collaborative (PREBIC), the purpose of which is to support and enhance international networking among researchers investigating preterm birth and to establish multi- national research projects, with open dialogue and active contribution by all participants. The 2006 annual meeting of the Collaborative was organized in Geneva by HRP and drew more than 50 researchers represent- ing most of the advanced research teams currently working on preterm birth. Collaborative projects with HRP include establishment of a non-profit organization for research on the genetic factors associated with preterm birth, called the Preterm Birth and Genetics International Alliances, and publication of systematic reviews of the literature. A multicentre collaborative observational study of the interaction between genetic and environmental factors associated with preterm birth is planned for 2008–2009. HRP will also collaborate with the Global Network for Women’s and Children’s Health Research of the United States National Institutes of Health to carry out a clinical trial on increased use of antenatal corticosteroids in developing countries, as part of an effort to implement more widely in developing countries effective interventions to decrease mortality due to preterm delivery.

In order to address the problem of intrauterine growth restriction, HRP is implementing a multicentre study on fetal and newborn growth standards, which extends the scope of the WHO Multicentre Growth Refer- ence Study to fetal life. The WHO Multicentre Growth Reference Study was implemented at country level by ministries of health to monitor child growth from 0 to 5 years and resulted in the release by WHO of child growth standards in April 200638. The objective of the new multicentre study is to construct a set of standards (curves and tables), from conception to delivery, to be adopted as a framework for assessing fetal and new- born growth (including preterm infants) and related levels of neonatal morbidity and mortality internation- ally. The study design incorporates the recommendations of the 1995 WHO Expert Committee on Physical Status39, the 2002 WHO Meeting of Experts on Life-course and Health, and the 2002 WHO Meeting of Experts on Birth Weight.40 The international standards derived from the study will improve assessment of fetal and newborn growth at individual and population levels and ultimately improve the clinical management of fetuses and pregnant women.

In another study for improving perinatal health, a community-level diagnostic tool for birth asphyxia, one of the three major causes of newborn mortality, is being developed. This two-phase study addresses one of the main difficulties in collecting accurate epidemiological data on birth asphyxia: lack of a common defini- tion that can be used in low-resource settings. This limitation has in particular impeded efforts to map the burden of birth asphyxia at the community level in developing countries. In the first phase of the study, a new diagnostic tool being used in health-care facilities in Pakistan and South Africa will be validated. In the second phase, the validated diagnostic tool will be used at community level to estimate the prevalence of morbidity and mortality related to birth asphyxia. The outcome of this study—a validated diagnostic instru- ment for correct identification of morbidity and mortality related to birth asphyxia—will form the basis of future community-based research on risk factors for birth asphyxia and will facilitate randomized trials to test preventive and therapeutic interventions.

Postpartum care One of the most dangerous complications of the postpartum period is postpartum haemorrhage, a poten- tially fatal condition that affects 1–3% of all deliveries and requires prompt medical intervention or referral. HRP will collaborate with the safe motherhood programme at the University of California at San Francisco, USA, in a randomized trial to test the effectiveness of a non-pneumatic anti-shock garment in reducing the risk for hypovolaemic shock during referral to tertiary care of women with postpartum haemorrhage.

21 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Because late cord-clamping after delivery might be beneficial for newborn babies, funds will be allocated to a clinical trial to test the effectiveness of cord clamping 3 min after delivery, with oxytocin, in preventing maternal blood loss, postpartum haemorrhage and neonatal anaemia and other maternal and perinatal outcomes.

Global survey of maternal and perinatal health There is a significant lack of accurate, reliable, up-to-date data on maternal and perinatal health, and, even when the data are available, their usefulness is often questionable because of limited coverage and poor methods of collection and analysis. Frequently, estimates are used that have been extrapolated from data collected in different settings and at different times. This situation limits efforts to improve the health -con ditions of large populations, as solid epidemiological evidence is the first requirement for planning and implementing effective interventions.

Is it possible to collect reliable, accurate, up-to-date data in low resource-settings? The 2005 WHO global survey on maternal and perinatal health41 has shown that this can be done. The survey was based on short- term (3 months) data collection in randomly selected health facilities in randomly selected countries, in which data were collected in real time by trained research teams using an on-line system and simple forms (maximum two pages) focusing on topics of interest. This systematic data collection effort represents an important shift from estimates or proxy measures. In 2005, data were collected on about 180 000 deliveries in seven countries in Africa (Algeria, Angola, Democratic Republic of the Congo, Kenya, Niger, Nigeria, Uganda) and eight in Latin America (Argentina, Brazil, Cuba, Ecuador, Mexico, Nicaragua, Paraguay, Peru) to document the relation between mode of delivery and perinatal mortality and morbidity.

This global survey has been widely acclaimed and has attracted attention to the work of HRP. A new global survey, aimed at collection of data on rates, management and risk factors for preterm birth and congenital malformations, with data on mode of delivery, is being planned and will be conducted in the Asian region. These topics were suggested at two meetings of experts held at WHO in 2006: the fourth meeting of The International PREterm BIrth Collaborative (PREBIC)42 and a meeting on management of birth defects and haemoglobin disorders organized jointly by WHO and the nongovernmental organization March of Dimes.43 Collection of reliable data on preterm delivery and congenital malformation rates at the international level were identified as priorities at these meetings.

Research synthesis Research synthesis is critical to the evaluation of available evidence, identification of situations that warrant further research, determination of which health-care practices are useful or harmful and to keep health- care practitioners up to date. In this area of work, HRP has had an effective collaboration with the Cochrane Library, from which the WHO Reproductive Health Library44 originated. In 2008–2009, new systematic reviews on important topics in maternal and perinatal health will be conducted by HRP and collaborating institu- tions. The reviews will not only appear in the Cochrane Library and the WHO Reproductive Health Library but will also indicate areas in which further research is needed to help guide WHO’s research agenda for the next few years. At full budget level, systematic reviews of screening and diagnostic methods will also be compiled.

Operations research Operations research during the biennium 2008–2009 will focus on two areas of interest: obstetric fistula and conditions related to maternal nutrition, such as anaemia in pregnancy.

22 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Obstetric fistula is a neglected condition that affects more than 2 million women in the most disadvantaged populations in the world. A research agenda on obstetric fistula is being set up in collaboration with UNFPA and Johns Hopkins University (Baltimore, USA). A multicentre study involving five countries in Africa (Benin, Ethiopia, Mali, Niger and Nigeria) and one in Asia (Bangladesh) will be conducted during the biennium 2008–2009 to address three areas of research critical to the elimination of obstetric fistula: prevention of the problem, including analysis of underlying sociocultural and economic factors and timely medical interven- tions such as caesarean section and effective labour management techniques; review and assessment of the surgical and other medical procedures used currently; and evaluation of existing post-surgical reintegration strategies, taking into account demographic and other mitigating factors that might affect recovery and women’s ability to reintegrate their communities. A further outcome of the study will be a standardized scheme for classifying fistula, which will facilitate the development of best practices for clinical management of fistula and the coordination of research among treatment centres.

The implementation, acceptability, feasibility, affordability and health-system implications of nutritional interventions will be addressed by operations research. A study is being planned, in collaboration with the WHO Department of Essential Health Technologies, to determine the benefit of introducing a package com- prising a haemoglobin colour scale, training activities and appropriate treatment for increasing the capacity of health-care workers to identify anaemia and to provide appropriate management, including referral of severely anaemic pregnant women at district level. The study will also involve a cost–benefit analysis of introducing the haemoglobin colour scale for screening women with anaemia at antenatal clinics in five developing countries (Afghanistan, Lao People’s Democratic Republic, Mongolia, Myanmar and Uganda).

At full budget level, a protocol will be prepared for a clinical trial on best practices in obstetric care.

Capacity-building and advocacy HRP will continue to promote capacity-building in research on sexual and reproductive health, and specifi- cally maternal and perinatal health, by co-organizing the postgraduate course on sexual and reproductive health research in collaboration with the WHO Collaborating Centre at the Geneva Foundation for Medical Education and Research. The course has been given since 1992 and has resulted in the training of more than 300 participants from countries in Africa, America, Asia and Europe. Several of the students who attended the course joined the WHO Maternal and Perinatal Health Research Network and have contributed to WHO-coor- dinated multicentre studies. Capacity-building also continues by dissemination of the WHO From Research to Action folders, which cover four issues: antenatal care, nutrition in pregnancy, pre-eclampsia and eclampsia, and prevention of postpartum haemorrhage. The series presents the scientific results of HRP’s work in mater- nal and perinatal health in a format that facilitates translation of research results into clinical practice. They are distributed in binders, which are periodically updated. At full budget level, activities for distance learning by means of on-line electronic courses will be implemented.

The current status of women’s sexual and reproductive health not only represents health and social dispari- ties but also reflects inequity in awareness. International political forums and public events on global health issues tend to focus on high-profile conditions such as HIV/AIDS, malaria and tuberculosis or diseases such as severe acute respiratory syndrome or avian flu that attract media attention because of their immediate threat and dramatic implications. It is important that initiatives be put in place to maintain political and public awareness of the consequences of sexual and reproductive ill-health and of the associated burden of disease in the poorest populations of the world. Greater advocacy and support for sexual and reproductive health, including information campaigns, could lead to significant changes. The intent of the ‘Art for Health’ project, initiated in the spring of 2006, was to contribute in an innovative way, using contemporary art to increase people’s awareness of sexual and reproductive health issues and particularly those that negatively

23 WHO Sexual and Reproductive Health Revised Budget 2008–2009

affect women and their families. The paintings prepared for this project depict women from diverse ethnic and social backgrounds and include messages from the women themselves, calling on the viewer to join them in a unified effort to better their lives and the lives of future generations. The positive, appealing images of women created for the `Art for Health’ project stimulate viewers to reconsider stereotypical notions of underprivileged women as hapless victims, asking them instead to regard them as willing partners in the advancement of women’s sexual and reproductive health. The paintings will be shown in the context of a touring exhibit in several cities around the world throughout 2008–2009. The exhibitions will create oppor- tunities for organizing advocacy events aimed at increasing awareness and promoting action for improving maternal and perinatal health.

PRODUCT LISTING

Funding source Product and Organization- Product title Product description identification wide expected result

019 Global programme to Coordination of research activities from biomedical HRP, Organization- conquer pre-eclampsia to health system research focusing on prevention wide expected and treatment of pre-eclampsia result 4.2

Activities 1. Conducting a multicentre study to evaluate the use of angiogenic factors in screening for pre-eclampsia 2. Conducting a multicentre trial on a model to predict maternal and perinatal outcomes in women with hypertensive disorders of pregnancy 3. Conducting a clinical trial for treatment of hypertension in pregnancy 4. Preparing new observational and experimental studies 5. Preparing guidelines for management of pre-eclampsia (implemented under full budget)

020 Improving perinatal Research on major factors responsible for perinatal HRP, Organization- health mortality (preterm birth, intrauterine growth wide expected restriction, birth asphyxia) result 4.2

Activities 1. Developing fetal growth standards for international application 2. Conducting studies of genetic and environmental determinants of preterm birth (collaboration with United States National Institute of Child Health and Human Development) 3. Developing a diagnostic tool for birth asphyxia applicable at community level (collaboration with Saving Newborn Lives and Chiesi Foundation) 4. Conducting a clinical trial to increase the use of antenatal corticosteroids in developing countries (collaboration with the Global Network for Women’s and Children’s Health Research of the United States National Institutes of Health)

021 Postpartum care Research to test interventions to improve maternal HRP, Organization- and perinatal health postpartum wide expected result 4.2

Activities 1. Participating in a randomized cluster trial of a non-pneumatic anti-shock garment for treatment of postpartum haemorrhage (collaboration with University of California at San Francisco, USA) 2. Preparing a clinical trial for management of the third stage of labour 3. Preparing a protocol for a study on postpartum haemorrhage (implemented under full budget)

Continued on next page

24 WHO Sexual and Reproductive Health Revised Budget 2008–2009

022 Global survey of maternal and Development of a global system of data collection HRP, Organization- perinatal health to conduct topic-specific surveys on maternal and wide expected perinatal health result 4.2

Activities 1. Completing the 2007 Global Survey in the Asian region 2. Undertaking secondary analysis of 2005 Global Survey in Africa and Latin America

023 Operations research Operations research on topics relevant to HRP, Organization- improvement of maternal and perinatal health wide expected globally result 4.2

Activities 1. Conducting a multicentre study on the clinical and social implications of obstetric fistula (in collaboration with UNFPA and Johns Hopkins University, USA) 2. Conducting a multicentre study for field evaluation of the haemoglobin colour scale in improving the management (diagnosis and treatment) of anaemic pregnant women (in collaboration with WHO Department of Essential Health Technologies) 3. Preparing a clinical trial on implementation of best practices in obstetric care (implemented under full budget)

024 Research synthesis Systematic reviews of the literature on topics HRP, Organization- relevant to the improvement of maternal and wide expected perinatal health globally result 4.2

Activities 1. Preparing Cochrane systematic reviews 2. Preparing systematic reviews to assess the need for new clinical trials or observational studies 3. Compiling systematic reviews on screening and diagnostic methods (implemented under full budget)

025 Capacity-building, advocacy, Activities to strengthen the WHO Maternal HRP, Organization- collaborations, identification and Perinatal Health Network and to increase wide expected of new areas of work awareness of and promote action to improve result 4.2 maternal and perinatal health globally

Activities 1. Holding a postgraduate course in sexual and reproductive health 2. Continuing ‘Art for Health’ and other advocacy activities 3. Convening meetings to plan future activities 4. Initiating e-learning activities (implemented under full budget)

25 WHO Sexual and Reproductive Health Revised Budget 2008–2009

26 4 PREVENTING UNSAFE ABORTION

Issues and challenges

A woman dies every eighth minute in developing countries because of a botched abortion. Globally, some 68 000 women die each year as a consequence of unsafe abortion, and a further 5 million suffer temporary or perma- nent disability.45 This devastating toll on women’s lives is occurring at a time when techniques to end the silent pandemic of unsafe abortion are available. Ending this pandemic is, therefore, an urgent imperative for public health and human rights.

Each year, an estimated 205 million women throughout the world become pregnant and some 133 million deliver a liveborn infant.46 An estimated 42 million pregnancies are voluntarily terminated each year, corresponding to approximately 29 abortions per 1000 women aged 15–44 years. Of the 42 million abortions, 20 million are estimated to be unsafe,9 due to inadequate skills, use of hazardous techniques or unsanitary conditions. Lack of adequate care results in much higher risks for morbidity and mortality than is the case for abortions carried out by skilled health-care personnel under hygienic conditions.

In contexts where access to safe abortion is restricted, mortality and morbidity due to abortion are high. For example, for every 100 000 live births there are 110 deaths due to unsafe abortion in Africa and almost none in developed countries47. Seven in 1000 women undergoing unsafe abortion would die in Africa. The persistence of high numbers of unintended pregnancies is the root cause of women’s recourse to abortion. Unintended pregnancies occur for several reasons, including lack of access to, non-use or incorrect and inconsistent use of a contraceptive method and failure of the method. More complex reasons include unwanted or forced sexual intercourse and lack of empowerment of women in sexual and reproductive matters.

The growing number of women of reproductive age and the increasing desire to regulate fertility require correct and consistent use of effective contraceptive methods. Difficulties in access to and correct, consistent use of pre- ferred methods of contraception and failure of contraceptive methods are not, however, easy to overcome. Social norms, economic conditions and other systemic factors, such as the legal status of abortion, also affect recourse to abortion and especially to unsafe abortion. Postabortion care is often inadequate or lacking and might not prevent further unintended pregnancies.

The International Conference on Population and Development outlined the issues and challenges for work on abortion. Its Programme of Action urges governments and relevant organizations “to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family planning services” (paragraph 8.25). It further states that “prevention of unwanted preg- nancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compas- sionate counselling…. In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion. Postabortion counselling, education and family planning services should be offered promptly, which will also help to avoid repeat abortions.” (paragraph 8.25)

27 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Goals

“In circumstances where abortion is not against the law…to ensure that such abortion is safe and acces- sible.”

(Key actions, 5-year review of International Conference on Population and Development, paragraph 63)

“In all cases, women should have access to quality services for the management of complications arising from abortion.”

(Key actions, 5-year review of International Conference on Population and Development, paragraph 63)

The key actions adopted by the Twenty-first Special Session of the United Nations General Assembly for further implementation of the ICPD Programme of Action noted: “In recognizing and implementing the above, and in circumstances where abortion is not against the law, health systems should train and equip health-service pro- viders and should take other measures to ensure that such abortion is safe and accessible. Additional measures should be taken to safeguard women’s health.” [paragraph 63 (iii)]32

In 2004, the World Health Assembly endorsed the global reproductive health strategy, in which the consequences of unsafe abortion were highlighted as a preventable cause of maternal mortality and morbidity, as part of MDG 5 on improving maternal health. The strategy specifies actions that will reduce unsafe abortion and its consequences, including “strengthening family planning services to prevent unintended pregnancies, and, to the extent allowed by law, ensuring that [safe abortion] services are available and accessible. Also to the extent allowed by law, pro- vision of safe abortion services requires training health-service providers in modern techniques and equipping them with appropriate drugs and supplies, all of which should be available for gynaecological and obstetric care; providing social and other support to women with unintended pregnancies; and, to the extent allowed by law, providing abortion services at the primary health care level. For those women who suffer complications of unsafe abortion, prompt and humane treatment through postabortion care must be available.”47

HRP’s work in preventing unsafe abortion

The Special Programme’s work in preventing unsafe abortion is unique and is addressed neither by other depart- ments within WHO nor by its cosponsors. HRP’s experience and expertise in conducting rigorous biomedical, epi- demiological, social science and programmatic research on preventing unsafe abortion is widely acknowledged by experts in the field and by other agencies. HRP is especially well suited to conduct multidisciplinary research on preventing unsafe abortion, develop evidence-based tools and guidelines and provide technical assistance on abortion-related issues.

HRP pursues several interrelated activities: mapping evidence; improving technology; testing interventions; devel- oping norms, tools and guidelines; and providing technical support to countries, professional associations and international agencies. The work thus focuses on generating scientifically sound information on abortion-related issues for policies and programmes, formulating new and improved regimens of safe abortion, and promoting best practices and high-quality abortion and postabortion services. HRP collaborates with other organizations, such as the Concept Foundation, the Guttmacher Institute, Gynuity Health Projects and Ipas. Regular exchanges of information with these agencies enable HRP to address issues and undertake activities that complement and reinforce the global aim of preventing unsafe abortion.

28 WHO Sexual and Reproductive Health Revised Budget 2008–2009

National research capacity strengthened as necessary and new evidence, products, technologies, interven- OWER tions and delivery approaches of global and/or national relevance available to improve maternal, newborn, child 4.2. and adolescent health, to promote active and healthy ageing, and to improve sexual and reproductive health.

The aims of the proposed work are to improve the safety, efficacy and acceptability of methods of abortion and postabortion care and support safe abortion services and postabortion care in accordance with WHO best practices and with national law. In its technical support work, HRP uses an adaptation of the WHO strategic approach to preventing unsafe abortion and to introducing medical abortion. With this approach, countries are assisted in designing, testing and implementing strategies to improve the quality and safety of abortion and postabortion care, including the provision of information and counselling for informed decision-making and contraceptive services. Evidence will be sought on the safety of abortion procedures conducted by trained mid-level health-care providers and on the barriers to expanding access to medical abortion, in order to design appropriate interventions.

To meet the goal of preventing unsafe abortion, HRP will conduct clinical research to improve methods of abortion and postabortion care. Improved methods of medical and surgical abortion will reduce complica- tions, pain and bleeding. Ascertaining the acceptability of methods is critical in determining their potential demand and in meeting the preferences of users or potential users.

Following publication of Frequently asked clinical questions about medical abortion48 and inclusion of the medical abortion regimen in the WHO Model List of Essential Medicines, research is needed to address areas in which evidence-based guidance is still needed. The results of HRP’s research on medical abortion were instrumental in the registration of mifepristone and misoprostol at an affordable price for the public sector in developing countries. As vaginal administration of misoprostol might not be acceptable or feasible in some countries, effective regimens for sublingual or buccal administration of misoprostol after pretreat- ment with mifepristone are needed. If studies by collaborators testing various new drug combinations for pregnancy termination suggest major improvements in medical abortion, these leads will be further tested for termination of first- and second-trimester pregnancies. Ways to reduce bleeding associated with medical abortion and to reduce pain related to medical and surgical abortion will continue to be studied. Contingent on the results of studies under way, misoprostol-only regimens will be studied and compared with sequential regimens of mifepristone plus misoprostol in terms of safety, effectiveness and acceptability for pregnancy termination. Studies on the role of antibiotics as adjuncts in the treatment of non-viable pregnancy or incom- plete abortion and on the optimal method for termination of non-viable pregnancies will be conducted. Ascertaining acceptability and users’ and providers’ perspectives will be an integral part of all these studies.

Guidelines, approaches and tools made available, with provision of technical support to Member States for accel- erated action towards implementing the strategy to accelerate progress towards the attainment of international OWER development goals and targets related to reproductive health, with particular emphasis on ensuring equitable 4.7. access to good-quality sexual and reproductive health services, particularly in areas of unmet need, and with respect for human rights as they relate to sexual and reproductive health.

Clinical, programme and managerial guidelines and tools will be developed and integrated into global, regional and national strategies. Regions and Member States will be supported in applying the guidelines for improving sexual and reproductive health. Through WHO’s strategic approach, technical assistance will be given to countries in applying technical and policy guidance on safe abortion. Research will also be under- taken to document implementation of abortion laws and policies, the impact of changes in abortion laws and policies on women’s health, and access to abortion for an unintended pregnancy. Research will also be conducted to estimate the costs to the health system and to individuals of providing or not providing safe abortion.

29 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Evidence-based and ethical policies, strategies, interventions, recommendations, standards and guidelines devel- OWER oped and technical support provided to Member States to promote safer sex and strengthen institutions in order 6.6. to tackle and manage the social and individual consequences of unsafe sex.

Unsafe abortion is one of the gravest consequences of unsafe sex. HRP will assist in the development of national health policies based on up-to-date understanding of the determinants and consequences of unsafe abortion. The main product under this expected result is evidence-based ethical policies, strategies, interventions, recommendations, standards and guidelines and technical support to Member States to pro- mote safer sex and strengthen institutions to tackle and manage the social and individual consequences of unsafe sex. Evidence will be generated on the magnitude, determinants and consequences of unsafe sex in developing and developed countries, especially among the most vulnerable groups.

This work will provide information for policies and programmes, including information on the cost and cost- effectiveness of different methods of abortion, by type of provider and type of procedure, and evidence on the safety of abortions performed by trained mid-level health-care providers. The programme of work under this objective includes generating, collating and synthesizing evidence on the determinants and con- sequences of unsafe abortion, for informed policies, programmes and appropriate interventions. HRP will document and regularly monitor the incidence of unsafe abortion and its associated mortality, with updates every 2–3 years. It will also assist governments to devise or revise national policies that reflect international, evidence-based standards. Special attention will be paid to the most vulnerable population subgroups.

OWER Ethics- and rights-based approaches to health promoted within WHO and at national and global levels. 7.4.

Technical commentaries on sexual and reproductive health will be provided for the Convention on the Elimi- nation of All Forms of Discrimination against Women and other international treaty monitoring bodies, and capacity will be built in regional and country offices and in Member States for application of treaty moni- toring to improve sexual and reproductive health. Evidence-based advocacy and action will be conducted to create an enabling legal and policy environment to prevent unsafe abortion. HRP will also assist in the development of appropriate programmes by determining which laws and policies assist or impede access to safe abortion services and postabortion care.

In addition, HRP will provide reports on women’s health, including mortality and morbidity resulting from unsafe abortion, to United Nations human rights treaty bodies and other agencies or treaty bodies, as needed, and will conduct seminars with treaty monitoring bodies.

30 WHO Sexual and Reproductive Health Revised Budget 2008–2009

PRODUCT LISTING

Funding source Product and Organization- Product title Product description identification wide expected result

026 Mapping and generating Map evidence on abortion incidence and generate HRP, Organization- evidence evidence on the determinants and consequences wide expected of abortion result 6.6

Activities 1. Documenting and regularly monitoring the incidence of unsafe abortion and related mortality and morbidity 2. Generating evidence on the determinants and consequence of unsafe abortion 3. Determining access to abortion and postabortion care 4. Documenting the perspectives of women and providers on quality of abortion and postabortion services 5. Studying barriers to safe abortion 6. Assessing costs to the health systems of safe and unsafe abortion and cost by type of method and type of provider (implemented under full budget)

027 Expand access to medical Improve access to medical abortion by generating HRP, Organization- abortion evidence and implementing interventions wide expected result 4.2

Activities 1. Generating evidence on the provision of medical abortion by mid-level health-care providers 2. Generating evidence on the barriers to accessing medical abortion 3. Testing interventions for improving access to medical abortion

028 Development or Clinical trials for developing or improving HRP, Organization- improvement of techniques techniques for medical abortion wide expected for abortion and result 4.2 postabortion care

Activities 1. Identifying safe methods for treating non-viable pregnancies 2. Investigating first-trimester medical termination of pregnancy with a sequential regimen (mifepristone followed by misoprostol) and testing of buccal vs. vaginal and different intervals of misoprostol administration 3. Assessing the safety and effectiveness of misoprostol-alone regimen between 10 and 12 weeks of pregnancy 4. Assessing the safety and effectiveness of misoprostol-alone regimen during the first 63 days of pregnancy 5. Testing promising sequential mifepristone-misoprostol regimens and misoprostol-alone regimens for termination of first- and second-trimester pregnancies (implemented under full budget)

029 Adaptation of the strategic Development of national strategies to improve the HRP, Organization- approach to preventing quality of abortion services by assisting countries in wide expected unsafe abortion using the strategic approach result 4.2

Activities 1. Providing financial and technical support to countries in using the strategic approach to prevent unsafe abortion and to strengthen abortion, postabortion and contraceptive services 2. Developing national strategies to introduce medical abortion by assisting countries in using the strategic approach 3. Conducting regional workshops on use of the strategic approach in the prevention of unsafe abortion 4. Enhancing technical and financial support to countries in using the strategic approach for preventing unsafe abortion (implemented under full budget)

Continued on next page

31 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Funding source Product and Organization- Product title Product description identification wide expected result

030 Technical and policy Guidelines and dialogues on removing barriers to HRP, Organization- guidance on safe abortion accessing safe abortion services wide expected result 4.7

Activities 1. Assisting countries in adaptation and implementation of safe abortion guidance, including dialogue with policy-makers on preventing unsafe abortion 2. Documenting the impact of abortion laws and of changes in laws on women’s health 3. Updating Safe abortion: technical and policy guidance for health systems49 4. Developing standards for safe abortion service delivery 5. Providing further assistance to countries for adapting and implementing technical and policy guidance on safe abortion (implemented under full budget)

031 United Nations human rights Preparation and submission of reports on women’s HRP, Organization- treaty bodies and human health and unsafe abortion to United Nations wide expected rights related to abortion human rights treaty bodies result 7.4

Activities 1. Providing reports on women’s health and unsafe abortion to United Nations human rights treaty bodies 2. Conducting seminars with treaty monitoring bodies 3. Conducting further workshops with United Nations treaty bodies and with other international and regional actors on women’s health and rights and unsafe abortion (implemented under full budget)

32 CONTROLLING SEXUALLY TRANSMITTED AND 5 REPRODUCTIVE TRACT INFECTIONS

Issues and challenges

STIs and reproductive tract infections (RTIs) constitute an important health threat, both directly and by poten- tiating HIV transmission. WHO has estimated that 340 million new cases of syphilis, gonorrhoea, chlamydia and trichomoniasis occurred throughout the world in 1999 in men and women 15–49 years of age, most of which were asymptomatic, particularly in women. In addition, many millions of incurable viral STIs, including an estimated 4.3 million new HIV infections, occur annually. Twenty-five years into the HIV/AIDS epidemic, the impact of the disease is evident, with the greatest burden in developing countries. In southern Africa, life expectancy fell from 62 years in 1990–1995 to 48 years in 2000–2005, and it is projected to decrease further to 43 years during the next decade.14

In many countries, STIs are among the main five conditions for which both men and women seek care, represent- ing a considerable drain on health services. Appropriate diagnostic facilities and resources for case management are frequently lacking, contributing to avoidable morbidity. The consequences of incurable STIs are even more serious. In the 1960s and 1970s, control of STIs was considered primarily from the perspective of preventing infertility. In the late 1980s, STI control was highlighted as one of the key approaches to controlling the HIV pan- demic. Currently, the main focus is on expanding access to antiretroviral drugs and providing sustainable care for people living with HIV/AIDS. These developments have not been accompanied by a corresponding acceleration in primary prevention of HIV infection, of which control of STIs is an essential element.

The recent evidence on the effect of male circumcision on reducing the risk for HIV infection50 raises new chal- lenges, such as ensuring that male circumcision services are expanded in a safe, acceptable and sustainable manner in countries that decide to promote circumcision for prevention of HIV infection. Circumcision services also provide one of the few opportunities to reach young men with information and counselling about safe and responsible sexual behaviour. It is presently still unclear how this opportunity to improve the sexual and repro- ductive health of young men and women should be addressed.

WHO’s work in controlling Sexually transmitted and reproductive tract infections

Activities for the prevention and care of STIs and RTIs and their complications include global advocacy, country support and technical issues (research, guideline development and normative functions). The core functions are to:

33 WHO Sexual and Reproductive Health Revised Budget 2008–2009

. promote and develop guidelines and tools for STI and RTI policy, programme planning and implementation;

. establish the evidence for new and cost-effective STI policy, programming and implementation;

. establish the evidence for new and improved STI and RTI control strategies; and

. advocate for the importance of effective STI and RTI control.

The three MDGs of reducing child mortality, improving maternal health and combating HIV/AIDS, malaria and other diseases are all addressed in the control of STIs and RTIs.

Goal

To reduce the global burden of sexually transmitted and reproductive tract infections.

Specific goal

To reduce the prevalence of congenital syphilis by 90% in four countries by 2009 as a step towards elimi- nation.

Important recent developments and opportunities in STI prevention and control must be assessed and imple- mented in countries in a cost-effective manner. For example, the role of rapid, point-of-care tests for selected STIs in public sector programmes should be determined. Similarly, new evidence on the effect of continuous treat- ment to suppress HSV-2 infection on HIV viral load and shedding in co-infected women should be incorporated into treatment guidelines and national STI control strategies.

OWER Guidelines, policy, strategy and other tools developed for prevention of, and treatment and care for patients with, HIV/AIDS, tuberculosis and malaria, including innovative approaches for increasing coverage of the 2.1. interventions among poor people, and hard-to-reach and vulnerable populations.

WHO's work in sexual and reproductive health in relation to this expected result includes new and updated guidelines for the prevention and control of STIs that have a direct impact on the risk for HIV infection or on the epidemiology of HIV. Tools and guidelines will be drawn up for men and women in vulnerable situations who are at high risk for STIs, including HIV infection, and for men and women living with HIV infection, in the context of providing the best sexual and reproductive health care for such people and reducing the risk for further transmission of the virus.

OWER Global, regional and national systems for surveillance, evaluation and monitoring strengthened and expanded to keep track of progress towards targets and allocation of resources for HIV/AIDS, tuberculosis 2.4. and malaria control and to determine the impact of control efforts and the evolution of drug resistance.

For this expected result, the Department of Reproductive Health and Research will formulate a global framework for surveillance of STIs, making linkages where possible with existing surveillance mechanisms and systems for monitoring and evaluating national programmes. Systematic collection and compilation will permit monitoring of trends and regular updating of global and regional estimates of the STI burden. Countries will be assisted in the use of national surveillance systems to improve the quality of STI treatment and services. The Department will also support national and regional reference laboratories for etiological monitoring of selected STI syndromes, so that regional and national syndromic treatment algorithms can be validated.

34 WHO Sexual and Reproductive Health Revised Budget 2008–2009

New knowledge, intervention tools and strategies developed and validated to meet priority needs for OWER the prevention and control of HIV/AIDS, tuberculosis and malaria, with scientists from developing 2.6. countries increasingly taking the lead in this research.

Within WHO, HRP is responsible for research on the prevention of mother-to-child transmission of HIV and other STIs, planned in the context of general country support in maternal health by WHO’s Making Preg- nancy Safer initiative and technical support to countries led by the headquarters Department on HIV/AIDS in collaboration with regional and country offices. As the focal point in the United Nations system for all work on microbicides, the Department is also responsible for research on safe, effective microbicides and facilitat- ing the registration and rapid deployment in countries of safe, effective products. Regular monitoring and evaluation are required, sometimes supplemented by further targeted research, to improve and refine STI control continuously.

HRP contributes to the evidence base on the safety, efficacy and effectiveness of combination antiretroviral drugs for the prevention of mother-to-child transmission of HIV during late pregnancy and during breast- feeding by coordinating a large multicentre trial in three African countries.

WHO’s work for the development, testing and introduction of novel microbicide products for use by women to prevent HIV infection includes supporting new leads and fostering an enabling environment at commu- nity and national levels for testing and introducing new products.

National research capacity strengthened as necessary and new evidence, products, technologies, OWER interventions and delivery approaches of global and/or national relevance available to improve maternal, 4.2. newborn, child and adolescent health, to promote active and healthy ageing, and to improve sexual and reproductive health.

In the WHO work plan for introducing the human papilloma virus (HPV) vaccine, HRP is responsible for research to assess the impact of various counselling strategies for adolescents to accompany HPV vaccine introduction, the usefulness of new rapid tests to improve cervical cancer screening and the value of such tests for monitoring the effect of HPV immunization programmes in resource-limited settings. Research will also be carried out to evaluate the effect of linking various services on the quality, coverage and acceptability of sexual and reproductive health programmes.

Guidelines, approaches and tools made available, with provision of technical support to Member States for accelerated action towards implementing the strategy to accelerate progress towards the attainment OWER of international development goals and targets related to reproductive health, with particular emphasis 4.7. on ensuring equitable access to good-quality sexual and reproductive health services, particularly in areas of unmet need, and with respect for human rights as they relate to sexual and repro- ductive health.

WHO provides normative guidance and technical support to countries with regard to STI and RTI prevention, management and control. This includes synthesis of the evidence on STI management and formulation of evidence-based guidelines and their associated training tools; development of policy and programmatic guidance on interventions within and outside the health sector to improve the quality, coverage and acces- sibility of STI treatment in sexual and reproductive health-care services; and synthesis of evidence and policy guidance on interventions for STI prevention. The “Global strategy for the prevention and control of sexually transmitted infections’51 provides a framework for countries to review and adapt their advocacy, policies and services to reduce the burden of STIs. Policies and services must be adapted to local epidemiological and

35 WHO Sexual and Reproductive Health Revised Budget 2008–2009

social contexts to ensure sustainable improvements in STI prevention and control. WHO provides technical assistance to countries to select and adapt the most appropriate interventions and policies for their situa- tion.

This expected result covers work on developing and updating clinical and programme guidance for the prevention and management of STIs and RTIs, training tools and technical support to countries for review- ing, adapting and adopting the guidelines. It also includes promoting pre- and in-service training in STIs for health-care providers, supporting the collection and use of data on STI prevalence, supporting HPV vaccine introduction and improved cervical cancer control, and supporting implementation of the global strategy for the elimination of congenital syphilis.

The expected result will also be achieved by supporting the expansion of safe male circumcision services, by drawing up technical guidance, training manuals and other teaching materials. A certification framework is being devised to ensure that health facilities that offer male circumcision services meet certain minimum standards of quality and competency. This framework is important to ensure appropriate training and to broaden the types of health-care provider allowed to perform circumcision.

PRODUCT LISTING

Funding source Product and Organization- Product title Product description identification wide expected result

032 Health system capacity Enhanced STI surveillance, including reference PDRH, to improve monitoring, centres, laboratories and capacity for monitoring Organization-wide evaluation and surveillance and evaluation of STI programmes expected result 2.4 for STI control

Activities 1. Supporting development of country-level STI surveillance systems and collating data for global advocacy, including periodic review of evidence and creation of guidance as required 2. Mapping facilities and needs for regional and national reference laboratories to support effective, high- quality STI control programmes, identifying resources and strengthening laboratories through networks and partnerships 3. Advocating for and facilitating STI prevalence studies, with emphasis on young people, to improve quality and relevance of national STI data to support STI and RTI interventions

032a Global Strategy for Plan and tools to mobilize partnerships and PDRH, Prevention and Control of networks to implement Global Strategy for Organization-wide STIs Prevention and Control of STIs expected result 4.7

Activities 1. Designing action plan and tools to mobilize partnerships and networks to implement Global Strategy for Prevention and Control of STIs 2. Developing indicators and a monitoring and evaluation process to support global elimination of congenital syphilis 3. Compiling and disseminating information on costs and benefits of improved STI control strategies at the global, regional and national levels 4. Supporting and monitoring comprehensive pre- and in-service training of health-care providers on STI prevention and care 5. Providing technical support to countries to implement Global Strategy for Prevention and Control of STIs

Continued on next page

36 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Funding source Product and Organization- Product title Product description identification wide expected result

032b Tools and guidelines for the Tools and guidelines for the prevention and control PDRH, prevention and control of of STIs and HIV Organization-wide STIs and HIV expected result 2.2

Activities 1. Preparing tool kits to identify and guide appropriate interventions 2. Updating guidelines for the management of STIs 3. Formulating tools and guidelines for Positive Prevention 4. Developing and disseminating guidance on sexual and reproductive health for people living with HIV

032c Tools and guidelines for the Tools and guidelines for effective collaboration PDRH, control of STIs across programmes to achieve STI control and Organization-wide sexual and reproductive health objectives expected result 4.7

Activities 1. Preparing tools and guidelines for effective collaboration across programmes to achieve STI control and sexual and reproductive health objectives 2. Developing guidelines on use of new screening tools in control of STIs, and prevention of pelvic inflamatory disease, cervical cancer and other complications 3. Updating guidelines for the management of STIs to reflect new knowledge and technologies

033 HPV vaccine introduction Introduction of HPV vaccines to reduce HPV-related PDRH, mortality and morbidity, particularly that due to Organization-wide cervical cancer expected result 4.7

Activities 1. Supporting regional meetings to review and implement HPV vaccine introduction and develop guidance on decision-making 2. Supporting countries in strengthening decision-making for HPV vaccine introduction 3. Improving national cervical cancer prevention programmes by implementation of ‘see-and-treat’ approach

034 Ensure reliable supply of Increase access to STI and RTI medicines, PDRH, commodities and medicines commodities and condoms Organization-wide for STIs and RTIs, including expected result 4.7 male and female condoms

Activities 1. Exploring, documenting and promoting global and regional strategies to facilitate access to affordable STI and RTI medicines and commodities 2. Developing technical standards for condoms, evaluating new condoms and supporting condom quality assurance systems

035 Conduct programmatic Generate and compile evidence on programme HRP, Organization- research in sexual and approaches to improving sexual and reproductive wide expected reproductive health health result 4.2

Activities 1. Assessing validity and usefulness of various indicators to monitor congenital syphilis rates and assessing impact of interventions to eliminate congenital syphilis 2. Assessing added value of introducing comprehensive sexual and reproductive health counselling in adolescent HPV immunization programmes 3. Compiling evidence on use of HPV rapid tests to improve cervical cancer prevention and monitor impact of HPV immunization programmes 4. Compiling evidence on integration strategies, and conducting literature review and compiling experience on partner notification strategies 5. Evaluating impact of integrated sexual and reproductive health programmes on service delivery, client and health-care provider satisfaction and national programme objectives (implemented under full budget)

Continued on next page

37 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Funding source Product and Organization- Product title Product description identification wide expected result

036 Research for the prevention Eliciting evidence on safety and effectiveness of HRP, Organization- of HIV infection mother-to-child transmission interventions and wide expected male circumcision result 2.6

Activities 1. Generating evidence on safety and effectiveness of antiretroviral drugs for prevention of mother-to-child transmission of HIV during breastfeeding 2. Generating and compiling evidence on safety of existing methods and on simple, safe techniques for circumcision in resource-limited settings 3. Compiling evidence on health effects of circumcision, other than on risk of HIV infection

037 Microbicide development Development and introduction of microbicides to PDRH, and introduction prevent HIV infection Organization-wide expected result 2.6

Activities 1. Supporting development of novel microbicides and evaluating the safety of selected products in potential users 2. Supporting research to understand and develop interventions to reduce prevalence of vaginal practices that might increase risk for HIV infection or reduce acceptability and use-effectiveness of new microbicide products 3. Strengthening capacity of national regulatory authorities to oversee and regulate microbicide research, and reaching regional consensus on ethical issues in microbicide development, assessment and product introduction 4. Supporting ethical and policy dialogue on ethical issues in microbicide and other research for the prevention of HIV infection, and facilitating registration and introduction of safe, effective microbicides

038 Safety of male circumcision Support expansion of safe male circumcision PDRH, services services Organization-wide expected result 4.7

Activities 1. Developing technical guidance and training tools and supporting countries to expand safe circumcision services 2. Developing and disseminating certification framework to facilitate expansion of safe circumcision services; supporting countries in adapting, adopting and implementing male circumcision quality assurance and improvement systems 3. Supporting case studies on approaches to integration of traditional and clinical circumcision services

038bis Partnerships and coalitions Development of partnerships and coalitions and PDRH, for scaling-up for universal collaborative arrangements for scaling-up for Organization-wide STI prevention and control universal STI prevention and control expected result 4.7

Activities 1. Partnerships and coalitions for scaling-up for universal STI prevention and control

38 6 GENDER, REPRODUCTIVE RIGHTS, SEXUAL HEALTH AND ADOLESCENCE

Issues and challenges

Gender roles are central to sexual and reproductive health. As it is women who become pregnant and give birth, the risk factors and exposures of women and men are fundamentally different from the outset, the burden of ill- health being much greater for women. In addition, many of the health issues related to sex and sexuality depend on the nature of men’s and women’s relationships. Often, for economic, political and social reasons, women have less power in relationships than do men and are therefore not in a position to protect themselves from unwanted sex, from transmission of infections or from coercion and violence. The extent and nature of violence against women is now well documented in many countries; however, the ways in which sexual and reproductive health services can help to identify and care for victims of violence and to prevent it should be further explored.

Men can also be constrained by social expectations of manhood and masculinity, which can have a negative impact on their health and that of women. These aspects must be understood and taken into account if research, policies and programmes are to address problems in sexual and reproductive health effectively. Health services have a potentially critical role to play in promoting sexual health through counselling and other ways of encour- aging a positive approach to sexuality.

For adolescents (aged 15–19 years), gender roles are particularly important. Adolescence is the time when chil- dren start to mature and become inquisitive about sexuality, among other things. How they experience this and what support they receive is critical to their health both during adolescence and in later life. For instance, for a substantial number of adolescent girls, and even for some boys, early sexual activity is not consensual: case studies52 suggest that about 10% of boys and up to 40% of girls undergo a sexually coercive experience, and a substantial percentage are raped. Both non-consensual sex and sexual relations in which young people do not protect themselves, for whatever reason, can lead to large numbers of unintended pregnancies and to STIs, including HIV infection.

Maternal mortality ratios are high and pregnancy-related causes are still the leading cause of death among ado- lescent girls. Many unintended pregnancies end in induced abortion, and, although the data on abortion are notoriously incomplete, in one study of selected countries for which data were available there were 23–36 abor- tions per 1000 women aged 15–19 years. The share of unsafe abortion in developing countries is estimated to be 14 percent in the age group 15–19 years and 26 percent in the age group 20–24 years9. Higher figures were estimated for adolescent girls in Africa (25%) and Latin America (14%) than in Asia (8%). Unsafe abortions among young women aged 15–24 years account for 40% of the estimated 20 million unsafe abortions that occur each year. In Africa, about 60% of all unsafe abortions are conducted among women in this age group. About one-half of all people infected with HIV are under the age of 25 years, and, in developing countries, up to 60% of all new infections are in young people, with twice as many in females than in males.

39 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Respect, protection and fulfilment of human rights related to sexual and reproductive health for adult and adoles- cent women and men can be achieved only if national laws and policies reflect recognition of those rights. Laws that violate human rights—for instance, restriction of access to health services that only women need, such as those relating to pregnancy and childbirth—have a negative impact on health. The absence of laws and policies to protect human rights, such as prohibition of female genital mutilation and punishment and social condemna- tion of perpetrators of violence against women, has also been shown to contribute to negative health outcomes. Thus, taking concrete action to ensure that people’s rights in public health interventions are protected by laws and policies should have a positive impact on health.

Goal

To ensure that research, policy and programmes in sexual and reproductive health protect and promote human rights and foster equity and equality between women and men, both adolescents and adults.

The International Conference on Population and Development in 1994 and the Fourth World Conference on Women in 1995 both emphasized the importance of promoting gender equity and equality in sexual and repro- ductive health policies and programmes and the promotion and protection of human rights, including those of adolescents. These agreements were reinforced in the 5-year reviews of both conferences, in 1999 and 2000, respectively. Among the key issues singled out for greater attention were: measures to promote and achieve gender equality and equity systematically and comprehensively (Key actions for the further implementation of the programme of action of the International Conference on Population and Development, paragraph 3930); incorporation of issues related to sexual and reproductive health into the work of relevant United Nations bod- ies on indicators for the promotion and protection of the rights of women (paragraph 40); the need “to protect and promote the right of adolescents to the enjoyment of the highest attainable standard of health, to provide appropriate, specific, user-friendly and accessible services to address effectively their reproductive and sexual health needs, including reproductive health education, information, counselling and health promotion strate- gies” (paragraph 73a); and the protection and promotion of human rights by ensuring that all health services and workers conform to ethical, professional and gender-sensitive standards in the delivery of women’s health services, including by establishing or strengthening regulatory and enforcement mechanisms (5-year review of the Fourth World Conference on Women, paragraph 72 g). In addition, two of the MDGs are to promote gender equality and empower women (Goal 3) and improve maternal health (Goal 5).

In 2004, the World Health Assembly endorsed the global reproductive health strategy, which states that women’s lack of decision-making power, taboos and norms about sexuality (including practices such as child marriage, female genital mutilation and early sexual initiation) are strong barriers to their receiving the information, sexual and reproductive health services and other support that they need to be healthy. With poverty and lack of edu- cation, these determinants continue to provide a formidable challenge to improving sexual and reproductive health. The global reproductive health strategy is underpinned by the guiding principles of human rights. One of the actions proposed for achieving international development goals for sexual and reproductive health is creation of a supportive legal and regulatory framework, which may involve the removal of unnecessary restrictions from policies and regulations.

WHO’s work in gender, reproductive rights, sexual health and adolescence

The work to promote gender equity and equality, reproductive rights, sexual health and adolescent sexual and reproductive health cuts across all the technical work in sexual and reproductive health, and many of the products listed are carried out in collaboration with other WHO departments.

40 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Improvements made in Member States’ capacity to collect, analyse, disseminate and use data on the magni- OWER tude, causes and consequences of chronic noncommunicable conditions, mental and behavioural disorders, 3.3. violence, injuries and disabilities.

National research capacity strengthened as necessary and new evidence, products, technologies, interven- OWER tions and delivery approaches of global and/or national relevance available to improve maternal, newborn, child 4.2. and adolescent health, to promote active and healthy ageing, and to improve sexual and reproductive health.

The aim of this area of work is to provide evidence to guide health systems in drawing up policies and pro- grammes for key areas of gender inequality in sexual and reproductive health. The areas of particular focus are: operations research to assess ways in which sexual and reproductive health services can best address violence against women; operations research to assess ways in which positive sexuality and sexual health can be promoted; generating evidence on ways to accelerate the abandonment of female genital mutilation; and identifying factors that can improve adolescents’ access to sexual and reproductive health information and services.

Building on the results of the WHO multicountry study on violence against women54 and health systems research initiated in 2006–2007, the Department will conduct operations research to guide health services in responding to victims and survivors of partner violence. It will also design and use operations research to test prototype guidelines on the care of pregnant women who have experienced violence. The WHO data- base will be searched for risk and protective factors for violence by partners and for the health outcomes of violence against women, particularly in relation to HIV infection.

Workable models for promoting sexual health in sexual and reproductive health services will continue to be identified and assessed, and guidance will be provided on the basis of the results.

The multiyear research initiative on female genital mutilation funded by the European Commission will end in mid-2008. During the rest of the biennium, the results of studies on expanding community-based inter- ventions will be disseminated through national or local workshops and other media. The results will also be used to update current guidance for health services. New areas for research are likely to include operations research on birth care for women with female genital mutilation and assessing interventions to halt the increase in the practice of female genital mutilation by the medical profession.

Evidence from many countries suggests that adolescents have limited access to sexual and reproductive health services, products and techniques, especially to contraceptive methods. The Department will con- tinue to build research capacity in developing countries and in countries in transition and to support the test- ing of interventions for broadening the range and increasing the use of products and techniques to improve adolescent sexual and reproductive health. The Department will also continue to build the evidence base for adolescent sexual and reproductive health, especially on issues for which scientific information is lacking.

Guidelines, approaches and tools made available, with provision of technical support to Member States for accel- erated action towards implementing the strategy to accelerate progress towards the attainment of international OWER development goals and targets related to reproductive health, with particular emphasis on ensuring equitable 4.7. access to good-quality sexual and reproductive health services, particularly in areas of unmet need, and with respect for human rights as they relate to sexual and reproductive health.

Work to achieve this objective includes helping governments and their partners to examine laws and poli- cies to see how they could be adapted to improve various aspects of sexual and reproductive health and to ensure that sexual and reproductive health policies and laws are grounded in human rights, including the

41 WHO Sexual and Reproductive Health Revised Budget 2008–2009

right to non-discrimination on the basis of sex. The health and human rights tool will be adapted and applied in a number of countries, focusing on adolescent sexual and reproductive health. Country-based analyses of the effects on sexual and reproductive health of laws and policies, such as those relating to harmful practices, will be undertaken as requested.

Technical support will be provided to Member States, in close collaboration with regional and country offices, to accelerate implementation of the global reproductive health strategy and to attain international develop- ment goals and targets for reproductive health, while ensuring equitable access to high-quality sexual and reproductive health services and respect for human rights.

OWER Ethics- and rights-based approaches to health promoted within WHO and at national and global levels. 7.4.

The WHO training course on gender and rights in reproductive health gives health programme managers the necessary analytical tools and skills to integrate promotion of gender equity and equality and reproductive rights into sexual and reproductive health policies and programmes. Technical assistance will continue to be provided, in collaboration with regional and country offices, to centres that wish to adapt and conduct the course. Work will also continue on integrating gender, sexuality, sexual and reproductive health and human rights into health curricula, in collaboration with wider initiatives.

The human rights treaty monitoring system can be used to support WHO’s work and ensure that human rights related to sexual and reproductive health are promoted and protected. The Department will continue to provide technical reports on sexual and reproductive health in reporting countries to treaty monitoring committees (in particular the Convention on the Elimination of All Forms of Discrimination against Women) and will work with WHO regional and country offices to assist countries in implementing the observations of the committees.

Although there is no international consensus on what constitutes ’sexual rights’, violation of human rights has a direct impact on people’s sexual health. Female genital mutilation and sexual coercion are clear examples. National, regional and international jurisprudence suggests that human rights related to sexual health can and should be elaborated. Research will be undertaken to ascertain the legal basis for establishing human rights related to sexuality and sexual health, and a document will be made available for use by Member States and other partners.

PRODUCT LISTING

Funding source Product and Organization- Product title Product description identification wide expected result

039 Evidence for health services Evidence to formulate guidance for health systems HRP, Organization- on violence against women on addressing violence against women wide expected result 3.3

Activities 1. Conducting interventions research to test prototype guidelines on care of pregnant women who have experienced violence, drawing on the findings of the WHO study on violence against women 2. Conducting operations research to form a basis for guidelines on best practices for health services for victims of partner violence 3. Conducting further research on health systems dealing with violence against women (implemented under full budget) Continued on next page 42 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Funding source Product and Organization- Product title Product description identification wide expected result

039a Technical support on gender Provision of technical support on gender and PDRH, and violence against women violence against women Organization-wide expected result 4.7

Activities 1. Carrying out capacity building workshops and other technical support activities 2. Responding to requests from countries including data collection

040 Evidence for health services Evidence to formulate guidance for health systems HRP, Organization- on aspects of sexual health on various aspects of sexual health wide expected result 4.2

Activities 1. Conducting operations research to form a basis for guidelines on best practices for health systems to implement sexuality counselling 2. Assisting regions and countries to conduct research and evaluation on sexual health 3. Developing indicators to measure sexual health 4. Providing further assistance on research and evaluation of sexual health issues (implemented under full budget)

041 Evidence for programmes that Evidence for programme and policy interventions HRP, Organization- support adolescent sexual to improve adolescent sexual and reproductive wide expected and reproductive health health in developing countries result 4.2

Activities 1. Documenting the situation and needs of vulnerable populations of young people 2. Conducting research on decision-making and behaviour in unintended pregnancy and abortion among adolescent girls 3. Conducting research on the perspectives of adolescent boys and girls on condom use for preventing pregnancy or HIV infection and STIs 4. Documenting the special needs and situation of married adolescents 5. Evaluating the impact of community programmes involving parents and other trusted adults for providing sexual and reproductive health information and services to adolescents (implemented under full budget)

042 Interventions to improve Building adolescent sexual and reproductive HRP, Organization- adolescent sexual and health research capacity in developing countries wide expected reproductive health and countries in transition result 4.2

Activities 1. Supporting a network of developing country researchers by providing technical support and research materials 2. Supporting workshops and meetings 3. Providing additional technical assistance to developing country researchers on adolescent sexual and reproductive health (implemented under full budget)

043 Promotion of human rights Building capacity on the integration of human PDRH, and gender equality in sexual rights and gender equality into sexual and Organization-wide and reproductive health reproductive health policies and programmes expected result 7.4 policies and programmes

Activities 1. Providing support and technical assistance to regions and countries for training in gender and rights in sexual and reproductive health 2. Contributing to the United Nations human rights treaty monitoring mechanisms 3. Providing additional technical assistance for building capacity in gender and rights in sexual and reproductive health at regional and country levels (implemented under full budget)

Continued on next page

43 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Funding source Product and Organization- Product title Product description identification wide expected result

044 Elimination of harmful sexual Research on ways to foster the abandonment of HRP, Organization- practices female genital mutilation wide expected result 4.2

Activities 1. Investigating the relation between female genital mutilation and perceptions of women’s sexuality 2. Investigating decision-making about female genital mutilation, with the objective of behaviour change 3. Conducting operations research on community-based interventions for behaviour change with respect to female genital mutilation and reviewing successful and unsuccessful interventions 4. Conducting operations research on care to reduce harmful consequences of female genital mutilation, including studies of psychological consequences 5. Devising and testing interventions to halt medicalization of female genital mutilation 6. Further analysing data from the study on female genital mutilation and obstetric sequelae 7. Providing additional support to developing country researchers for implementing research on female genital mutilation (implemented under full budget)

045 Implementing human rights Support to countries to analyse human rights in HRP, Organization- and gender equality in sexual and reproductive health legislation wide expected national laws and policies result 4.7

Activities 1. Applying the human rights tool to sexual and reproductive health at country level 2. Investigating the impact of laws, policies and norms on various aspects of sexual and reproductive health 3. Providing further assistance to countries in assessing the impact of laws and policies on sexual and reproductive health (implemented under full budget)

046 Rights-based tools and Development of tools using human rights for HRP, Organization- guidance on sexual and sexual and reproductive health for use at national wide expected reproductive health and regional levels result 7.4

Activities 1. Adapting the maternal and newborn health and human rights tool to other sexual and reproductive health issues 2. Adapting the tool to additional aspects of sexual and reproductive health (implemented under full budget)

047 Global advocacy for gender Promotion of sexual and reproductive health and PDRH, equality and reproductive rights strategies, policies and programmes Organization-wide rights expected result 4.7

Activities 1. Providing global guidance and advocacy for the abandonment of female genital mutilation 2. Participating in international meetings for the development and promotion of sexual and reproductive rights 3. Enhancing support for sexual and reproductive health and human rights programming and advocacy (implemented under full budget)

048 Human rights and sexual Definition of human rights related to sexuality and HRP, Organization- health sexual health wide expected result 7.4

Activities 1. Investigating the legal basis for establishing human rights related to sexuality and sexual health 2. Conducting additional research on human rights related to sexuality and sexual health (implemented under full budget)

44 7 TECHNICAL COOPERATION WITH COUNTRIES

Issues and challenges

The aim of the first WHO global strategy on reproductive health, adopted at the Fifty-seventh Session of the World Health Assembly in May 2004, was to provide guidance and impetus to country activities and rekindle the commitment to ensure universal access to comprehensive sexual and reproductive health services. The inter- national community has recognized that progress in sexual and reproductive health will be critical to achieving international goals and targets, as emphasized at the World Summit in September 2005 and one year later at the Sixty-first Session of the United Nations General Assembly. World leaders agreed to include a new target under Goal 5: “Achieving universal access to reproductive health by 2015, as set out at the International Conference on Population and Development and integrating this goal into strategies to attain the internationally-agreed devel- opment goals, including those contained in the Millennium Declaration….” 1

The challenge facing Member States in the coming decade will be to translate these promises into action, by improving access to effective interventions in sexual and reproductive health at the primary health-care level and strengthening their health systems. In many countries, especially those in the aftermath of complex emer- gencies in the African region, the health system must be rebuilt. Effective interventions will also be required to reach the poorest and marginalized segments of the population. These actions imply not only increased commit- ment to sexual and reproductive health but also the reallocation of commensurate resources, despite competing demands.

Goal

To ensure that each country has adequate capacity to develop and carry out the research and programme development activities required to elevate the national sexual and reproductive health programme to a key position for contributing to the achievement of the MDGs and other internationally agreed develop- ment goals and their respective targets.

The work in support of this goal is carried out by the Organization at country, regional and global levels. This includes work carried out by HRP as well as work in programme development dor sexual and reproductive health. An Organization-wide breakdown of the programme development work is shown in Table 2 in Section 12.

45 WHO Sexual and Reproductive Health Revised Budget 2008–2009

HEADQUARTERS

WHO has pledged to intensify support to countries in strengthening national research capacity, with particular emphasis on action-oriented research; fostering knowledge-sharing and exchange of experience on best prac- tices; and developing or improving effective programmes, policies and interventions for sexual and reproductive health services as part of overall health systems development.

National research capacity strengthened as necessary and new evidence, products, technologies, interven- OWER tions and delivery approaches of global and/or national relevance available to improve maternal, newborn, child 4.2. and adolescent health, to promote active and healthy ageing, and to improve sexual and reproductive health.

Strengthening national research capacity Pursuant to the recommendations of the external evaluation of HRP in 2002–2003 and building on the suc- cesses of the past years, HRP’s work in research capacity strengthening will continue, as this is an important area of cooperation between HRP and the regional and country offices. During 2008–2009, existing mecha- nisms will be used to identify new collaborating institutions in least-developed countries and to support them with various capacity-building grants (see http://www.who.int/reproductive-health/tcc/grants.html). HRP will also consolidate the gains accrued from past investments in strengthening the capabilities of insti- tutions, researchers and networks to enable them to respond to national and regional priorities in sexual and reproductive health, including operations research. Emphasis will continue to be placed on improving the communication and writing skills of researchers and increasing the dialogue with policy-makers, programme managers and other stakeholders, in order to disseminate research findings and ensure their translation into practice.

Policy and programme issues An important area of cooperation with countries is support for national policy and programme development, including use of the WHO strategic approach in strengthening sexual and reproductive health policies and programmes. The strategic approach is a tool that countries can use to assess their sexual and reproductive health needs and priorities, test appropriate interventions to address those needs and then implement suit- able innovations at national level. The method emphasizes use of a participatory process to obtain input from a wide range of stakeholders in identifying, testing and phased expansion of innovative methods to increase access to and improve the quality of sexual and reproductive health care. The WHO strategic approach has been adapted by countries to address a broad range of sexual and reproductive health issues, including fam- ily planning and unsafe abortion, RTIs, STIs including HIV/AIDS, maternal and neonatal health and adolescent sexual and reproductive health, and also for comprehensive policies and programmes with an emphasis on programme integration and access of the poor to services.

The work on policy and programme issues includes accumulating evidence on measures taken to strengthen health systems, including the effects of health sector reform on sexual and reproductive health, strengthen- ing of integrated primary health care (including sexual and reproductive health services) and provision of technical support to countries in reforming their health systems. This area of work involves coordination with other clusters and departments within WHO and with external partners. Programmes are evaluated to ascer- tain the impact of health-care system reform on sexual and reproductive health, including integration with programmes for HIV/AIDS in State and non-State health-care delivery systems. Technical support is provided in the design and evaluation of large-scale changes in health systems to improve sexual and reproductive health outcomes, reduce poverty and bridge gaps in health equity. The strengthening of health systems also includes increasing countries’ capacity to plan and implement development and sectoral planning (poverty reduction strategy and sector-wide approaches) in which sexual and reproductive health has its place.

46 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Support provided to Member States to formulate a comprehensive policy, plan and strategy for scaling- up towards to effective interventions in collaboration with other programmes, OWER universal access paying attention to reducing gender inequality and health inequities, providing a continuum of care 4.1. throughout the life-course, integrating service delivery across different levels of the health system and strengthening coordination with civil society and the private sector.

Guidelines, approaches and tools made available, with provision of technical support to Member States for accelerated action towards implementing the strategy to accelerate progress towards the attainment OWER of international development goals and targets related to reproductive health, with particular emphasis 4.7. on ensuring equitable access to good-quality sexual and reproductive health services, particularly in areas of unmet need, and with respect for human rights as they relate to sexual and repro- ductive health.

Management and organization of integrated, population-based health-service delivery OWER through public and nonpublic providers and networks improved, reflecting the principles of integrated 10.1. primary health care, scaling-up coverage, equity and quality of health services, and enhancing health outcomes.

OWER Coordination of the various mechanisms (including donor assistance) that provide support to Member States in their efforts to achieve national targets for health system development and global 10.3. health goals improved.

Mapping and implementing best practices Coordination of mapping and implementing best practices meets the commitment of WHO to use knowl- edge management to improve access to and use of evidence-based practices at country level. During the past decade, the Department has provided an evidence base for sexual and reproductive health by mapping best practices, and the WHO Reproductive Health Library is an established reference work for evidence-based sexual and reproductive health care, especially for low- and middle-income countries. As the evidence base for clinical practices becomes larger, new challenges are emerging:

• keeping systematic reviews up-to-date and relevant: Systematic reviews must be updated regularly, not only because new evidence may emerge but also to add new technology and to respond to the needs of users of health care.

• changing health professional behaviour: Unfortunately, while new evidence is generated and syn- thesized, its adoption in policy and practice is at best fragmented. Multidisciplinary approaches are required to identify existing practices, barriers to changing practices and strategies to implement change. Research into such strategies is scarce, and the evidence base in this area needs strengthening.

• capacity-building in research and research synthesis: There is a continuing need for a critical mass of health workers who can interpret and appraise research findings.

The complex issue of improving access to and use of research findings, evidence-based practices and pro- grammes proven to be effective must be addressed, so that they effect change in national practice and performance. The Department's response has been to establish an initiative for implementing best practices (IBP), which is a collaborative partnership of 26 international agencies that share resources and tools, har- monize approaches and use cost-sharing to extend effective approaches to the introduction, adaptation, utilization and scaling-up of effective practices for the delivery of sexual and reproductive health services. The initiative has gathered momentum and has formed a consortium, the secretariat of which is provided by the Department. The secretariat coordinates activities within the Department and with other departments

47 WHO Sexual and Reproductive Health Revised Budget 2008–2009

at headquarters, with partners and with regional and country networks to create cooperation for the intro- duction of technical guidelines, knowledge management and techniques for improving performance and changing management to expedite the adoption and use of practices proven to be effective.

The Department, in collaboration with the Department of Management Information Systems (Technology and Telecommunications) and IBP partners, designed, pilot tested and launched the IBP Knowledge Gateway in September 2004. This electronic communication system uses a unique adapted web-based technology known as “edgeofnet” (see www.edgeof.net) that works well in countries with poor connectivity. The IBP Knowledge Gateway is accessed through email with direct links to virtual web-based workspaces. Its goal is to bridge the knowledge-to-practice gap by bringing individuals and groups together at the global and country levels to foster the exchange and transfer of knowledge, research findings, evidence-based practices, experience, success stories and lessons learnt in and among countries. The Department works closely with the Department of Knowledge, Communities and Strategies and IBP partners to support a broad range of virtual Global Discussion Forums, Discussion Boards and other virtual activities on the Knowledge Gateway. Since 2004 the membership of the IBP Knowledge Gateway has grown to10,000 people from over 180 coun- tries around the world.

Each year the IBP Knowledge Gateway is enhanced in accordance with user feedback. This year both Span- ish and French communities have been launched. In addition the technology has been developed in such a way that individual organizations and agencies can own, customize, brand and manage their own global and sub-communities of practice. The Department provides assistance to set up the management of these communities, trains facilitators and adapts the tools and guidelines that have been developed for the IBP Knowledge Gateway. In 2006 the Gateway became a corporate tool of WHO with the brand name “Ezcollab”. Other partnerships, such as the SIGN project, Global Alliance of Nurses and Midwives and Essential Medicines are among the many groups that are now using the Gateway to manage their own communities. As of 2008 the technology of the IBP Knowledge Gateway in being used through these partnerships to reach more than approximately11,000 additional users and support an additional 300 communities of practice.

Monitoring and evaluation The Department monitors progress towards achieving goals and targets for sexual and reproductive health set by international conferences, including the International Conference on Population and Development and the Millennium Summit. The activities are: provision and dissemination of timely information on relevant indicators at global level, improving methods for the generation and interpretation of information on sexual and reproductive health indicators and providing technical support to countries in using the indicators.

As we approach 2015, when the international goals and targets for reproductive health should have been met, it is important to monitor the indicators. The challenge is to provide reliable, up-to-date information that is comparable across countries and over time. This has proven difficult for some indicators, such as the maternal mortality ratio. Decision-makers need to be informed about the areas on which to focus in order to achieve the MDGs, and the methods to be used must be improved. Efforts to attain MDG 5, improving maternal health, will require information about the causes of maternal deaths and morbidity related to preg- nancy and childbirth. Standardized methods for identifying and classifying the causes of maternal deaths and measuring maternal morbidity do not exist, and information is needed from systematic reviews of the available evidence.

The goal of the International Conference on Population and Development of “achieving universal access to reproductive health by 2015” was added as a target in the MDG monitoring framework in 2006 in order to facilitate monitoring of MDG 5. A set of four indicators (contraceptive use, antenatal care coverage, unmet need for family planning and adolescent birth rate) were identified to monitor the progress towards the new target (5.B). The new MDG framework became official from January 2008.

48 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Another challenge is to define a broad set of indicators for countries to measure their own progress in achiev- ing universal access to reproductive health. This set should, in a logical framework, address multiple dimen- sions of sexual and reproductive health, multiple components of access, and both health-care and social determinants of achieving universal access. This framework should be the subject of programmatic research to evaluate its usefulness. Once it is validated, technical assistance should be provided to countries for its application, according to their needs.

PRODUCT LISTING for headquarters

Funding source Product and Organization- Product title Product description identification wide expected result

049 IBP ECS Knowledge Gateway IBP ECS Knowledge Gateway enhanced to PDRH, enhanced and joint programme support French and Spanish communities of Organization-wide of work undertaken with practice and improved user interface for an expected result 4.7 collaborative networks to electronic platform that can support virtual implement strategies to improve workspaces, e-learning, global discussion forums access to and use of information and multiple communities of practice and sharing, exchange and application of knowledge

Activities 1. Performing seventh phase of enhancement of Knowledge Gateway to establish French and Spanish language facilities, e-learning and improved user interface 2. Undertaking technical management of Knowledge Gateway and management and facilitation of virtual communities of practice in and among countries 3. Supporting video conferences and global discussion forums on sexual and reproductive health priorities and strategies to translate knowledge into practice in countries 4. Working with professional nursing and midwifery associations, collaborating centres, private and public sectors to use the Knowledge Gateway to establish communities of practice to improve access to information and translate knowledge into practice 5. Sharing knowledge management strategies with the international nongovernmental organization Non-profit Organizations Knowledge Initiative and other partners to identify synergies and plan expanded use of the Knowledge Gateway 6. Devolving management of the Knowledge Gateway to one regional centre

050 Approaches identified for Technical and programme materials and PDRH, introduction, adaptation, processes for managing change, scaling- Organization-wide implementation and scaling-up up, documenting practices and exchanging expected result 4.7 of effective practices for bringing information developed, tested or produced and changes in clinical practices and disseminated improving access to and quality of sexual and reproductive health services

Activities 1. Organizing meetings of the IBP consortium and steering committee to review the IBP strategy and prepare a joint programme of work 2. Working with partners and national teams to introduce and support application of a guide to fostering change and other managerial and leadership materials and tools proven to be effective in improving clinical practice, quality and access 3. Disseminating the family planning advocacy kit and supporting re-positioning of family planning strategies and linkages with HIV/AIDS prevention programmes 4. Identifying, in collaboration with UNFPA, activities and processes that can improve access of disabled people to sexual and reproductive health services 5. Working with collaborative networks on country strategies to identify and use best practices in sexual and reproductive health 6. Organizing a meeting on global knowledge use in collaboration with IBP partners, WHO Knowledge Communities and Strategies, and other interested WHO departments

Continued on next page 49 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Funding source Product and Organization- Product title Product description identification wide expected result

051 Capacity strengthening for using Support to selected countries, as follow-up to PDRH, evidence to change policy and IBP launches, in establishing national IBP teams Organization-wide practice in countries to enhance collaborative work in strengthening expected result 4.7 capacity for implementing and scaling up selected best practices to improve sexual and reproductive health services

Activities 1. Conducting international exchange of practices for programmes of sexual and reproductive health priorities 2. Introducing IBP and conducting national documentation of best practices in support of activities of the WHO/UNFPA Strategic Partnership Programme (two countries) 3. Following up international meetings and conducting new programmatic exchanges on community-based programmes for family planning, postabortion care, sexual and reproductive health and linkages with HIV/ AIDS prevention 4. Continuing support with small grants and technical assistance to strengthen capacity to scale up effective practices to change policy and practice in at least three countries 5. Working with partners to strengthen pre-service education of health-care providers

052 Support the reproductive health Publication of technical and programmatic PDRH, essential medicines project by tools for prequalification and procurement of Organization-wide establishing a prequalification condoms, intrauterine devices and other essential expected result 4.7 system for essential sexual sexual and reproductive health medicines. Initiate and reproductive health and support resource centres in countries to medicines, development of an promote use of successful strategies to improve electronic resource centre and access to quality essential medicines strengthening of capacity at country level

Activities 1. Updating and finalizing specifications, prequalification procedures and quality-assurance guidelines for the procurement of intrauterine devices and condoms 2. Designing an electronic resource centre to improve access to and use of information on procurement, distribution and logistics management, thereby improving access to and the quality of essential sexual and reproductive health medicines 3. Collaborating with partners in preparation of a kit to improve access to and use of quality essential reproductive health medicines 4. Field testing of the dissemination and use of a kit to improve procurement, distribution and access to essential medicines for sexual and reproductive health (two countries) 5. Working with partners to extend dissemination and use of the resource centre and kit to countries to improve access to essential sexual and reproductive health medicines 6. Supporting the WHO Department of Medicines Policy and Standards in establishing a prequalification system for essential reproductive health medicines Continued on next page

50 WHO Sexual and Reproductive Health Revised Budget 2008–2009

053 Update technical and Technical and programme tools published and PDRH, programmatic tools and disseminated to key stakeholders Organization-wide guidelines to improve the quality expected result 4.7 of sexual and reproductive health care in crisis, conflict and displacement

Activities 1. Revising and re-publishing technical and programmatic tools and guidelines 2. Working with partners to support the introduction and use of technical and programmatic tools and guidelines in at least two countries 3. Convening regular coordination meetings with the Inter-Agency Working Group and collaboratively preparing training materials and tools 4. Providing technical assistance as required and assisting UNFPA/UNHCR in training sexual and reproductive health coordinators 5. Working with partners and key stakeholders to promote coordinated response to sexual and reproductive health needs in all phases of conflict, crisis and displacement

054 Dissemination and promotion Financial and technical support to country teams HRP, Organization- of use of the strategic approach to adapt and implement the strategic approach wide expected for sexual and reproductive for sexual and reproductive health policy and result 4.7 health policy and programme programme development development

Activities 1. Providing technical assistance and other activities to promote and support use of the strategic approach, including technical support to countries 2. Adapting the strategic approach to address specific sexual and reproductive health issues and promote linkages among various aspects of sexual and reproductive health 3. Adapting the strategic approach for comprehensive sexual and reproductive health policy and programmes with an emphasis on issues such as access to and use of services by the poor, service delivery integration and rights-based approaches to service access 4. Conducting introductory and operations research to test recommendations from strategic assessments in countries 5. Organizing meeting of partner international and nongovernmental organizations and countries providing technical support and collaboration on implementation of the strategic approach 6. Enhancing technical and financial support for countries to implement the strategic approach 7. Providing technical support for using tested interventions in countries (implemented under full budget)

055 Increased understanding of the Research conducted on issues influencing the HRP, Organization- determinants of scaling-up pilot process of scaling-up pilot and operations wide expected and operations research projects research projects result 4.2

Activities 1. Convening an expert consultation on monitoring, evaluation and research to support scaling-up 2. Providing research and technical support for scaling-up demonstration projects 3. Enhancing technical and financial support to countries for research on scaling-up 4. Providing additional technical and financial support to countries for research on scaling-up (implemented under full budget) Continued on next page

51 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Funding source Product and Organization- Product title Product description identification wide expected result

056 Improved strategies for scaling- Capacity-building and technical support to HRP, Organization- up pilot projects, demonstration countries for devising successful strategies for wide expected projects and operations research scaling-up pilot and demonstration projects result 4.2

Activities 1. Testing, printing and disseminating of guidelines for programme managers on scaling-up of pilot projects 2. Developing training curricula and holding workshops on scaling-up of pilot and operations research projects 3. Convening meeting of ExpandNet network members on scaling-up to discuss dissemination of guidelines and training curricula 4. Enhancing technical and financial support to countries for scaling-up strategies (implemented under full budget)

057 WHO Reproductive Health Library Preparation, publication, distribution, translation, PDRH, editorial and other technical meetings and Organization-wide presentations of the WHO Reproductive Health expected result 4.2 Library; research on knowledge access and use

Activities 1. Annual publication of the WHO Reproductive Health Library in English and Spanish; distribution through up- to-date mailing lists; preparation of new content, such as videos and animations 2. Organizing editorial and technical meetings and presentations for the WHO Reproductive Health Library 3. Conducting knowledge-use research projects 4. Supporting partial translation projects of The WHO Reproductive Health Library into Chinese, French, Russian and Vietnamese (implemented under full budget)

058 Systematic reviews in sexual and Conduct, update and commission systematic HRP, Organization- reproductive health reviews of promising interventions, screening wide expected or diagnostic tests and other relevant questions result 4.2 in sexual and reproductive health; support to collaborating groups and centres

Activities 1. Conducting and updating three systematic reviews per year 2. Providing core support to the Cochrane Fertility Regulation Group and other centres if necessary 3. Supporting guideline development by the Grading of Recommendations Assessment, Development and Evaluation or similar widely used system (implemented under full budget)

059 Capacity strengthening in Conduct training workshops; develop, test and PDRH, evidence-based decision-making implement innovative learning programmes Organization-wide expected result 4.7

Activities 1. Developing, testing and implementing an e-learning programme for evidence-based decision-making with pilot testing in three countries 2. Supporting up to three workshops per year on evidence-based decision-making (implemented under full budget)

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52 WHO Sexual and Reproductive Health Revised Budget 2008–2009

060 Assisting countries to respond to Provision of institutional development grants for HRP, Organization- regional and national priorities in research capacity strengthening and relevant wide expected sexual and reproductive health programme development activities at regional result 4.2 by enhancing their capacity and national levels for research and programme development activities

Activities 1. Supporting countries in identifying priorities in sexual and reproductive health research and programmes 2. Enhancing institutional capacity to respond to national and regional priorities in research and in programme activities 3. Identifying new recipients of grants for strengthening research and programme capacity and developing plans for strengthening research and programme capacity 4. Expanding the role of national research institutions in policy and programme development 5. Maintaining adequate mechanisms for monitoring and evaluating strengthening of research and programme development capacity (implemented under full budget)

061 Develop critical mass of Training grants awarded for researchers and HRP, Organization- individuals at country level to programme staff; group learning activities wide expected conduct improved research and supported, including regional networks result 4.2 programme activities

Activities 1. Strengthening skills and abilities of individuals for sexual and reproductive health research and programme activities 2. Enhancing capacities for operations research 3. Improving ethical standards for sexual and reproductive health research at country and regional levels 4. Supporting national training in policy, technical and programme issues relevant to sexual and reproductive health

062 Develop mechanisms to improve Enhance collaboration among researchers, policy- PDRH, dissemination and use of makers and programme managers for translating Organization-wide research findings and to assist in evidence and knowledge into practice expected result 4.2 incorporating research evidence into policies and programmes

Activities 1. Improving researchers’ and policy-makers’ communication skills 2. Improving mechanisms to enhance the dissemination and use of research findings and evidence-based guidelines 3. Assisting in creating an enabling environment at country level to facilitate increased use of research findings and evidence-based guidelines 4. Systematically introducing and supporting adaptation and adoption of evidence-based guidelines in countries, including extending use of the approach developed in the UNFPA-WHO Strategic Partnership Programme

063 Support implementation of Technical support for active dissemination of the PDRH, the global reproductive health global reproductive health strategy and its use for Organization-wide strategy in countries and regions updating policies to enhance the contribution of expected result 4.7 sexual and reproductive health to achievement of the MDGs

Activities 1. Organizing workshops at national and subregional levels for programme managers and other stakeholders to identify problems, set priorities and formulate strategies for accelerated action, as set out in the global reproductive health strategy 2. Strengthening the use of appropriate indicators in national health information systems to monitor progress in achieving universal access to reproductive health

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53 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Funding source Product and Organization- Product title Product description identification wide expected result

064 Increased understanding of the Support for adapting national sexual and PDRH, effects of health sector reforms reproductive health and HIV/AIDS policy and Organization-wide on sexual and reproductive programmes in health sector reform expected result 4.2 health and HIV/AIDS policy and programmes

Activities 1. Providing technical support to regions and countries on national policy formulation, programme monitoring and evaluation, and sexual and reproductive health project design 2. Convening technical consultations on contemporary policy directions in strengthening of health systems for effects on sexual and reproductive health 3. Publishing policy briefs, guidance notes and other technical documents for evidence-based policy formulation on the effects of health sector reform on sexual and reproductive health 4. Organizing regional and subregional consultations on policy and programmatic topics related to the effects of health sector reforms on sexual and reproductive health and HIV/AIDS policy and programmes (implemented under full budget)

065 Increased understanding of the Support for adapting national sexual and PDRH, effect of health sector reforms reproductive health and HIV/AIDS policy and Organization-wide on sexual and reproductive programmes within health sector reform expected result 4.1 health and HIV/AIDS policy and programmes

Activities 1. Providing technical support to regions and countries on national policy formulation, programme monitoring and evaluation, and sexual and reproductive health project design 2. Convening technical consultations on contemporary policy directions in strengthening of health systems for effects on sexual and reproductive health 3. Publishing policy briefs, guidance notes and other technical documents for evidence-based policy formulation on the effects of health sector reform on sexual and reproductive health

066 Evaluation research on health Evaluation research on health sector reform and HRP, Organization- sector reform and sexual and sexual and reproductive health, including HIV/ wide expected reproductive health, including AIDS result 10.3 HIV/AIDS

Activities 1. Developing and conducting studies to evaluate reforms in countries 2. Providing technical support to regions and countries for the design and analysis of evaluation studies 3. Organizing regional and subregional workshops and training programmes on design and analysis of evaluation of health sector reform and sexual and reproductive health (implemented under full budget)

067 Increased understanding of the Evaluation and analytical studies on targeting HRP, Organization- impact of improved sexual and methods and on interaction between poverty wide expected reproductive health on poverty and core components of national sexual and result 4.2 reduction reproductive health programmes

Activities 1. Evaluating studies of sexual and reproductive health policies and programmes to bridge equity gaps and reduce poverty 2. Undertaking analytical studies on sexual and reproductive health policies and programmes to bridge equity gaps and reduce poverty

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54 WHO Sexual and Reproductive Health Revised Budget 2008–2009

068 Increased understanding of the Evaluation and analytical studies on targeting PDRH, impact of improved sexual and methods and on interaction between poverty Organization-wide reproductive health on poverty and core components of national sexual and expected result 4.2 reduction reproductive health programmes

Activities 1. Providing technical support to countries on reproductive health policies and programmes that are pro-poor and reduce inequity 2. Convening regional and subregional workshops and training programmes on improving understanding of the impact of better sexual and reproductive health on poverty reduction (implemented under full budget)

069 Enhanced prominence and value Technical support provided and analytical work HRP, Organization- given to sexual and reproductive done on country implementation of sexual and wide expected health programming in national reproductive health programmes in the context result 10.1 and sectoral planning (poverty of sector-wide approaches and poverty reduction reduction strategies, sector-wide strategies approaches)

Activities 1. Providing technical support on country implementation of sexual and reproductive health programmes in the context of a sector-wide approach and poverty reduction strategy 2. Publishing policy briefs, guidance notes and other technical documents for evidence-based national and sectoral planning for sexual and reproductive health 3. Convening regional and subregional workshops and training programmes on implementation of sexual and reproductive health programmes in the context of a sector-wide approach and poverty reduction strategy (implemented under full budget)

070 Global monitoring of sexual and Develop, update and disseminate estimates for PDRH, reproductive health monitoring progress towards internationally Organization-wide agreed sexual and reproductive health-related expected result 4.7 goals

Activities 1. Updating databases on skilled birth attendance and antenatal care coverage on annual basis; conducting stratified analyses of skilled attendance at birth and antenatal care coverage; providing estimates of neonatal and perinatal mortality 2. Participating in inter-agency discussions on sexual and reproductive health indicators to monitor internationally agreed goals and targets (including MDGs and International Conference on Population and Development goals) 3. Establishing and maintaining a database to monitor use of the global reproductive health strategy 4. Updating and maintaining web-based database on sexual and reproductive health indicators 5. Supporting regional workshops on dissemination of 2005 maternal mortality estimates (implemented under full budget)

070a Global monitoring of sexual and Activities in support of the monitoring of global PDRH, reproductive health indicators for sexual and reproductive health Organization-wide expected result 4.7

Activities 1. Annual updates of skilled birth attendance and antenatal care coverage databases 2. Inter-agency discussions on sexual and reproductive health-related indicators 3. Establish and maintain database to monitor use of Global Reproductive Health Strategy 4. Update and maintain web-based database on sexual and reproductive health indicators 5. Support regional workshops on dissemination of 2005 maternal mortality estimates 6. Other activities

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55 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Funding source Product and Organization- Product title Product description identification wide expected result

071 Indicator development and Conduct or commission systematic reviews of HRP, Organization- implementation epidemiology and other relevant information on wide expected sexual and reproductive health; obtain scientific result 4.2 consensus on sexual and reproductive health indicators

Activities 1. Convening technical consultations on measuring sexual and reproductive health, including one meeting on identification of the causes of maternal deaths 2. Developing and disseminating guidelines on identification of the causes of maternal deaths 3. Conducting one systematic review per year on sexual and reproductive morbidity 4. Supporting development of sexual health indicators (implemented under full budget)

072 Technical support to countries for Coordinate and support operations research on HRP, Organization- measuring access to sexual and improving access to sexual and reproductive wide expected reproductive health health; provide technical support to countries for result 4.2 collection, analysis and interpretation of data on sexual and reproductive health indicators

Activities 1. Designing and conducting operations research on improving access to and equity of sexual and reproductive health services by identifying and addressing barriers (pilot study in three countries) 2. Providing technical support to countries on collection, analysis and interpretation of data on sexual and reproductive health indicators

072bis Surveillance of unsafe sex Activities in support of the inclusion of unsafe sex PDRH, measures in national monitoring systems Organization-wide expected result 4.7

Activities 1. Assess the inclusion of unsafe sex measures within the framework of sexual and reproductive health indicators in national monitoring systems 2. Facilitate compilation and analysis of data on unsafe sex measures

56 WHO Sexual and Reproductive Health Revised Budget 2008–2009

REGIONAL OFFICE FOR AFRICA

Issues and challenges Lack of access to quality sexual and reproductive health services and to relevant information on sexual and repro- ductive issues, including reproductive rights, is a major obstacle to people’s ability to make informed choices regarding their own sexual and reproductive health. This contributes to high levels of morbidity and mortality due to largely preventable sexual and reproductive health problems. For example, early diagnosis can prevent most of the deaths due to cervical cancer. However, in the WHO African Region, most cases of cervical cancer are diagnosed late owing to lack of access to screening services. With regard to family planning, which is a key component of sexual and reproductive health and the first pillar of safe motherhood, sub-Saharan Africa lags considerably behind the rest of the developing world. For instance, according to United Nations data, the latest prevalence rate for the use of modern contraceptives in less developed regions of the world is 56% (2004 data), whereas that for sub-Saharan Africa is merely 15% (2003 data). The low utilization of services is linked in part to the poor quality of services.

It is against this background that Members States adopted a number of instruments to improve sexual and repro- ductive health, including women’s health, namely: (i) The reproductive health regional strategy (AFR/RC47/R5); (ii) Women’s health strategy (AFR/RC53/R11); (iii) Repositioning family planning in reproductive health services: framework for accelerated action 2005–2014 (AFR/RC54/R2).

The main challenges facing Member States of the WHO African Region towards universal access to sexual and reproductive health services are: lack of skills in the development of comprehensive sexual and reproductive health policies; inadequate provision of sexual and reproductive health services; low coverage of sexual and reproductive health services, including the erratic availability of essential sexual and reproductive health medi- cines and contraceptives; and fragmented programme development and implementation.

WHO’s work in sexual and reproductive health in the African Region Regional objectives and targets in the area of sexual and reproductive health focus on increasing support for scal- ing-up of key interventions to improve sexual and reproductive health and accelerate progress towards achieve- ment of the Millennium Development Goals.

To address the above mentioned challenges, support in the African Region will be provided to countries in the following priority areas:

• development of integrated approach to addressing the sexual and reproductive health issues in the region through comprehensive policies and strategies;

• increasing capacity in monitoring and evaluation of sexual and reproductive health programmes, including improvement of sexual and reproductive health registers and monitoring systems, and undertaking opera- tional research to generate data for evidence-based policy development;

• increasing coverage of sexual and reproductive health services, including prevention of unwanted pregnan- cies, by reducing the unmet demand for contraception and prevention and control of cervical cancer; and

• promoting human rights in sexual and reproductive health including prevention and management of gender- based violence.

These priority areas will be addressed in the context of regional strategic objectives in line with the following WHO Organization-wide expected results (OWERs):

57 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Support provided to Member States to formulate a comprehensive policy, plan and strategy for scaling- up towards to effective interventions in collaboration with other programmes, OWER universal access paying attention to reducing gender inequality and health inequities, providing a continuum of care 4.1. throughout the life-course, integrating service delivery across different levels of the health system and strengthening coordination with civil society and the private sector.

In support of the achievement of this expected result, the African Region will:

• promote the use of the WHO strategic approach for sexual and reproductive health programme develop- ment;

• build capacity in policy and programme development in the context of health sector reforms and the new aid environment to promote harmonization and alignment of support to countries to ensure coordination in the implementation of sexual and reproductive health programmes and maximization of resources; and

• support post-crisis countries in the development of comprehensive plans to address priority sexual and repro- ductive health issues.

National research capacity strengthened as necessary and new evidence, products, technologies, interven- OWER tions and delivery approaches of global and/or national relevance available to improve maternal, newborn, child 4.2. and adolescent health, to promote active and healthy ageing, and to improve sexual and reproductive health.

In support of the achievement of this expected result, the African Region will:

• strengthen national capacity in undertaking operational research on priority sexual and reproductive health issues and support the dissemination and use of research in policy and programme development; and

• contribute to the strengthening of systems for monitoring, surveillance and assessment of progress towards the Millennium Development Goals relating to sexual and reproductive health, at the regional and country levels.

Guidelines, approaches and tools made available, with provision of technical support to Member States for accelerated action towards implementing the strategy to accelerate progress towards the attainment OWER of international development goals and targets related to reproductive health, with particular emphasis 4.7. on ensuring equitable access to good-quality sexual and reproductive health services, particularly in areas of unmet need, and with respect for human rights as they relate to sexual and repro- ductive health.

In support of the achievement of this expected result, the African Region will:

• formulate, develop and adapt appropriate evidence-based techniques, standards and guidelines, in line with the primary health care strategy, to strengthen national capacity in the field of sexual and reproductive health, including family planning, maternal health, cervical cancer, gender analysis and gender-based violence (including elimination of FGM), in coordination with other units in the Regional Office for Africa;

• increase coverage and improve quality and utilization of sexual and reproductive health services by promot- ing integrated approaches at all levels, including the delivery of an integrated community sexual and repro- ductive health package; undertake advocacy for repositioning family planning in sexual and reproductive

58 WHO Sexual and Reproductive Health Revised Budget 2008–2009

health services; establish centres of excellence for training in sexual and reproductive health and support development of skills in sexual and reproductive health; and disseminate sexual and reproductive health tools and guidelines; and

• strengthen interagency cooperation and develop alliances and networks at the global, regional and country levels to promote and support implementation of sexual and reproductive health programmes and promote the involvement of a broad base of stakeholders.

59 WHO Sexual and Reproductive Health Revised Budget 2008–2009

REGIONAL OFFICE FOR the americas

Issues and challenges The distinctive characteristic of the WHO Region of the Americas is its multitude of ethnic groups and cultures. In the 48 countries that comprise the region, there are more than 650 indigenous cultures, living side by side with people of European or African descent. This cultural diversity is overlaid by demographic, social and economic differences that in many cases militate against the human development of populations. Millions of people in the Americas suffer deep-rooted structural discrimination that manifests itself in marginalization, exclusion and poverty.

Following several decades of steep economic decline, the economies of Latin America and the Caribbean (with the sole exception of Haiti) have recently registered strong macroeconomic growth. However, this macroeco- nomic improvement has not trickled down to individuals; on the contrary, it has helped to entrench inequalities, which in this region are the most marked in the world. These inequalities also show up in sexual and reproductive health. For example, a woman in Latin America and the Caribbean is 13 times more likely to die in childbirth or the postpartum period than a woman in Canada. Likewise, a child in Latin America and the Caribbean is 4.5 times more likely to die in the first year of life than a child born in Canada.

The 23 000 maternal deaths in the region every year can be attributed to assisted home births attended by per- sons lacking the required skills, cultural factors, geographical and/or economic factors, poor-quality services or high-risk abortion practices. The problem of unsafe abortions is so acute that, if certain countries were to resolve this issue, they would achieve the Millennium Development Goal (MDG) 5 overnight.

Maternal and infant mortality are part of the unfinished agenda in the region, especially among vulnerable popu- lations. Other problems are the HIV/AIDS pandemic, increase in sexually transmitted infections (STIs), need to eliminate congenital syphilis, unmet demand for contraception, high levels of anaemia, gender violence and deaths from cervical cancer. This unfinished agenda, in addition to safeguarding the progress that has been achieved and tackling new challenges as they arise, constitutes the framework within which technical coopera- tion for sexual and reproductive health will operate throughout the region.

Finally, improving all aspects of epidemiological surveillance remains a priority for many countries in the region, given the impossibility in these countries of assessing the impact of any proposed initiative, or of identifying the biggest problems and possible solutions to them.

WHO’s work in sexual and reproductive health in the Region of the Americas Regional objectives and targets in the sphere of sexual and reproductive health are posited on achieving the MDGs and implementing the regional plans drawn up by the Pan American Health Organization (PAHO) and the WHO global reproductive health strategy.

In view of the epidemiological situation in the region and the challenges referred to above, the priority is to pro- vide a continuum of care from preconception through pregnancy, birth, childhood, adolescence and into adult- hood. All these elements are incorporated into a second continuum of care that focuses on individuals, families and communities, and emphasizes the involvement of health services.

Some of the topics flagged as priorities by PAHO are:

• prevention of unwanted pregnancies by reducing the unmet demand for contraception;

• reduction of maternal and perinatal mortality through promotion of family planning, antenatal check-ups, professionally-attended deliveries and elimination of unsafe abortion;

60 WHO Sexual and Reproductive Health Revised Budget 2008–2009

• elimination of congenital syphilis and reduction of vertical transmission of HIV;

• strengthening strategies for the prevention of cervical cancer;

• strengthening the capacity of the health sector to deal with gender-based violence; and

• improvement of sexual and reproductive health registers and monitoring systems.

These topics will be addressed in the context of regional strategic objectives and the following WHO Organiza- tion-wide expected results (OWERs):

Support provided to Member States to formulate a comprehensive policy, plan and strategy for scaling- up towards to effective interventions in collaboration with other programmes, OWER universal access paying attention to reducing gender inequality and health inequities, providing a continuum of care 4.1. throughout the life-course, integrating service delivery across different levels of the health system and strengthening coordination with civil society and the private sector.

To achieve OWER 4.1, the WHO Region of the Americas will undertake the following actions:

• mobilize the political will to establish legal and regulatory frameworks to support regional, subregional, national and local policies and plans of action on: women’s health and sexual and reproductive health, involve- ment of men and reduction of maternal, perinatal and neonatal mortality (MDGs 3, 4, 5 and 6);

• as part of an approach that emphasizes intercultural relations, human rights and gender equality, lobby Mem- ber States: to allocate human and financial resources; to prioritize initiatives that guarantee universal access to reinforced and skilled sexual, reproductive, maternal and neonatal health care; and to collaborate in tackling the inequalities that contribute to high levels of disease and mortality among disadvantaged populations; and

• strengthen interagency cooperation and develop alliances and networks at the global, regional and country levels to promote and support progress in policies and programmes relating to sexual, reproductive, maternal and newborn health, by promoting the participation of those directly responsible and exchanging experi- ences.

National research capacity strengthened as necessary and new evidence, products, technologies, interven- OWER tions and delivery approaches of global and/or national relevance available to improve maternal, newborn, child 4.2. and adolescent health, to promote active and healthy ageing, and to improve sexual and reproductive health.

To achieve OWER 4.2, the WHO Region of the Americas will undertake the following actions:

• strengthen systems for monitoring, surveillance and assessment of progress towards the MDGs relating to sexual, reproductive, maternal, perinatal and newborn health at the regional and country levels. Strengthen the implementation and development of local capacity to utilize and exploit the Perinatal Information System (PIS) and incorporate it into surveillance systems at the country level. Promote and provide training in the use of audit techniques for severe maternal morbidity and maternal mortality;

• promote and undertake operational research on problems identified as priorities in order to provide informa- tion that may be of use in developing interventions for improving sexual, reproductive, maternal, perinatal and newborn health; and

61 WHO Sexual and Reproductive Health Revised Budget 2008–2009

• propose comprehensive human-resources training models and innovative intervention strategies to foster improvement in the quality of sexual, reproductive, maternal, perinatal and newborn health services.

Support guidelines, approaches and tools for improving maternal care in use at the country level, with OWER technical support provided to Member States to reinforce actions that ensure skilled care for 4.3. every pregnant woman and every newborn, through childbirth and the postpartum and post- natal periods, particularly for poor and disadvantaged populations, with progress monitored.

To achieve OWER 4.3, the WHO Region of the Americas will undertake the following action:

• formulate, develop and adapt appropriate evidence-based techniques, standards and guidelines, in line with the primary health care strategy, to strengthen national capacity in the fields of maternal, perinatal and new- born health, in coordination with other units and areas of PAHO (MDGs 4 and 5).

Guidelines, approaches and tools made available, with provision of technical support to Member States for accelerated action towards implementing the strategy to accelerate progress towards the attainment OWER of international development goals and targets related to reproductive health, with particular emphasis 4.7. on ensuring equitable access to good-quality sexual and reproductive health services, particularly in areas of unmet need, and with respect for human rights as they relate to sexual and repro- ductive health.

To achieve OWER 4.7, the WHO Region of the Americas will undertake the following actions:

• formulate, develop and adapt appropriate evidence-based techniques, standards and guidelines, in line with the primary health care strategy, to strengthen national capacity in the field of sexual and reproductive health, including family planning, cervical cancer and gender violence, in coordination with other units and areas of PAHO (MDGs 3, 4 and 6);

• strengthen and refocus sexual and reproductive health services by promoting the empowerment of women, men, families and communities in the continuum of mother-and-child care as an effective method of reducing maternal, perinatal and neonatal mortality and morbidity and promoting sexual and reproductive healthcare services; and

• through a cross-sectoral approach, manage the planned delivery of technical cooperation, providing train- ing for the introduction of appropriate evidence-based techniques, guidelines and standards for sexual and reproductive health care and reduction of maternal mortality, including through the prevention of teenage pregnancies, care of newborns, elimination of congenital syphilis and reduction of vertical transmission of HIV/AIDS.

62 WHO Sexual and Reproductive Health Revised Budget 2008–2009

REGIONAL OFFICE FOR SOUTH-EAST ASIA

Issues and challenges The South-East Asia Region, with its 11 Member States, is home to approximately one-third of the world’s popula- tion. Sexual and reproductive health is one of the major challenges in the Region; although significant progress has been made during the past few decades, much more remains to be achieved.

The Region showed a marked decline in the total fertility rate during the period 1975–2005, except in Timor-Leste, where a significant increase occurred during the past five years, to 7.8 in 2005. Although the global total fertility rate declined from an average of 4.5 births per woman in 1970–1975 to 2.6 births in 2000–2005, the rates in Ban- gladesh, Bhutan, India, Maldives and Nepal are still between 3.1–4.4. The adolescent fertility rate was high in Ban- gladesh, India, Nepal and Timor-Leste in 2005, ranging from 80 to 182 per 1000 girls aged 15–19 years. Although access to modern contraceptive methods has improved in most countries of the Region, with a contraceptive prevalence rate of 24–70% (except in Timor-Leste, at 9%) in 2005, the rate is tending to stagnate in some countries, and a large proportion of births are unplanned, mistimed or unwanted. The unmet need for contraception is high, from 8.6% in Indonesia in 2003 to 37% in Maldives in 2004.

Maternal and newborn health, the quality of family planning services and unsafe abortion continue to be major issues for the Region. There are 170 000 maternal and 1.4 million neonatal deaths every year, representing 33% and 35% of the 2005 and 2000 global figures, respectively, with, in addition, 1 million stillbirths. South-East Asia, together with Sub-Saharan Africa account for 86% of all maternal deaths. Unsafe abortion is responsible for about 13% of all pregnancy-related deaths, and half of the unsafe abortions in the world occur in Asia.

There are limited data on STIs and RTIs in most countries of the Region in comparison with the data on HIV infec- tion, indicating that more attention should be paid to STIs and RTIs. In the 2007 UNAIDS report on the global AIDS epidemic55, it was estimated that there are about 4.9 million people living with HIV infection in South-East Asia. Women accounted for 29% of adults for HIV in 2007 compared to 26% in 2001. About 2.5 million cases are in India alone. Although the prevalence of HIV infection among pregnant women remains relatively low in many countries of the Region, it has been increasing. In 2004, an estimated 155 400 pregnant women in Asia were infected with HIV; 46 900 children became infected with HIV through vertical transmission of the virus from their mother, and about 31 000 children developed AIDS. Promotion of healthy sexual behaviour and practices is crucial in prevent- ing STIs and HIV/AIDS. A framework for linking services for STIs and HIV/AIDS with those for maternal and new- born health and sexual and reproductive health is being finalized in collaboration with the WHO Regional Office for the Western Pacific, UNICEF, UNFPA and UNAIDS. It will be used to help countries to strengthen the prevention and control of STIs and HIV infection through the widest range of sexual and reproductive health services.

The global reproductive health strategy endorsed by the World Health Assembly in 2004 and its framework for implementation provide guidance for improving sexual and reproductive health and programme approaches for addressing sexual and reproductive health problems in countries. A regional adaptation of the framework is being used to help each country to address key sexual and reproductive health priorities.

The role of WHO in promoting evidence-based guidelines, standards and tools in sexual and reproductive health has been undertaken in collaboration with UNFPA, other development partners and international nongovern- mental organizations, such as Ipas, the Johns Hopkins Program for International Education in Gynecology and Obstetrics, Family Health International and the Program for Appropriate Technology in Health. These collabora- tions have addressed a wide range of sexual and reproductive health issues, including the prevention of unsafe abortion, maternal and newborn health, use of the human rights tool for maternal and newborn health and prevention of cervical cancer, among others. These initiatives will be extended in 2008–2009 to ensure wider implementation of the guidelines, standards and tools.

63 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Goal

To contribute to improvement of sexual and reproductive health status, including achievement of MDGs and other international development goals, in the South-East Asia Region.

WHO’s work in sexual and reproductive health in the South-East Asia Region The work of the WHO Regional Office for South-East Asia in sexual and reproductive health in 2008–2009 is reflected in its approach to the following Organization-wide expected results, including those related to maternal and newborn health and making pregnancy safer.

Policy and technical support provided to countries towards expanded gender-sensitive delivery of pre- vention, treatment and care interventions for HIV/AIDS, tuberculosis and malaria, including integrated training OWER and service delivery; wider service-provider networks; and strengthened laboratory capacities and better linkages 2.2. with other health services, such as those for sexual and reproductive health, maternal, newborn and child health, sexually transmitted infections, nutrition, drug dependence treatment services, respiratory care, neglected diseases and environmental health.

The Regional Office will provide technical support to countries to extend and decentralize prevention, treat- ment and care services for STIs, including HIV infection, and integration of the framework for prevention and management of STIs and HIV infection and other endemic diseases into maternal, newborn and sexual and reproductive health services.

Support provided to Member States to formulate a comprehensive policy, plan and strategy for scaling-up towards to effective interventions in collaboration with other programmes, paying attention to OWER universal access reducing gender inequality and health inequities, providing a continuum of care throughout the life-course, inte- 4.1. grating service delivery across different levels of the health system and strengthening coordination with civil society and the private sector.

Member States will be supported in implementing policies and strategies to achieve universal access to maternal and newborn health and other sexual and reproductive health services by promoting effective interventions. This will involve provision of technical support for planning, implementing and monitoring the strengthening of human resources to achieve skilled care at every birth and universal access to other sexual and reproductive health services; and strengthening collaboration within WHO and with civil society, the private sector and sectors other than health in promoting universal access to maternal and newborn health and other sexual and reproductive health services in the context of a continuum of care.

National research capacity strengthened as necessary and new evidence, products, technologies, interven- OWER tions and delivery approaches of global and/or national relevance available to improve maternal, newborn, child 4.2. and adolescent health, to promote active and healthy ageing, and to improve sexual and reproductive health.

To achieve this Organization-wide expected result, collaboration with national institutions will be strength- ened for training, research and use of research findings to promote evidence-based norms, standards, guide- lines and tools for improving health outcomes in all areas of sexual and reproductive health.

64 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Guidelines, approaches and tools made available, with provision of technical support to Member States for accelerated action towards implementing the strategy to accelerate progress towards the attainment OWER of international development goals and targets related to reproductive health, with particular emphasis 4.7. on ensuring equitable access to good-quality sexual and reproductive health services, particularly in areas of unmet need, and with respect for human rights as they relate to sexual and repro- ductive health.

Technical support will be provided to countries for: regular updating of norms, standards and guidelines for improving sexual and reproductive health services; designing programmes to improve access to and the quality of sexual and reproductive health services, with special attention to poor and disadvantaged popula- tions; and strengthening integration of sexual and reproductive health services into relevant programmes with development partners. This will involve providing technical support for promotion of evidence-based practices promotion and implementation of comprehensive sexual and reproductive health services and integration of sexual and reproductive health services into other programmes, such as those for HIV/AIDS.

Evidence-based and ethical policies, strategies, interventions, recommendations, standards and guidelines OWER developed and technical support provided to Member States to promote safer sex and strengthen institu- 6.6. tions in order to tackle and manage the social and individual consequences of unsafe sex.

The Regional Office will work to strengthen the capacity of Member States to manage the social and individ- ual consequences of unsafe sex, including the promotion of healthy sexual and reproductive behaviours.

OWER Ethics- and rights-based approaches to health promoted within WHO and at national and global levels. 7.4.

The Regional Office will work to increase awareness and use of ethics- and rights-based approaches to health by implementation of the WHO human rights tools for maternal and newborn health and other sexual and reproductive health issues.

65 WHO Sexual and Reproductive Health Revised Budget 2008–2009

REGIONAL OFFICE FOR EUROPE

Issues and challenges There are large discrepancies in maternal and perinatal health outcomes among and within the 53 Member States of the WHO European Region. Maternal mortality provides stark evidence: in 2005, maternal mortality was four times higher in the Central Asian Republics and Kazakhstan than in the countries of the European Union (EURO Health for All Database, 2007).

The discrepancy in outcomes is related to discrepancies in health services: up to 40% of deliveries in Tajikistan take place at home without medical assistance, while almost all births in the countries of the European Union take place in the presence of a skilled attendant.

The rate of abortions in Europe has decreased over the past 10 years, but the rate varies from 300 per 1000 live births in countries that were members of the European Union before 2004 to 700 per 1000 live births in countries in the Commonwealth of Independent States. Termination of pregnancy is not available in only a few Member States; however, in some countries up to 20% of all cases of maternal mortality are still due to unsafe abortions. The rate of abortion is high in vulnerable groups of the population, including adolescents and young adults.

The mean age at the start of sexual activity in Europe is decreasing, but surveys in many western European coun- tries, such as Finland and Sweden, have shown a decrease in the use of condoms by young people during the past five years. There is a lack of comparative, age-disaggregated data on the sexual and reproductive health of young people in the Region.

Up to 15% of the populations of many countries in the Region are migrants (including illegal migrants), refugees and asylum seekers, and their access to sexual and reproductive health services is a challenge for the Regional Office and the Member States. There are no standards on sexual education in multicultural Europe and no stan- dards for youth-friendly sexual and reproductive health services.

More than 50% (29 of 53) of the Member States have a total fertility rate of 1.5 or less, which in some cases has led to the adoption of policies to decrease access to sexual and reproductive health information and services. Furthermore, the average age of mothers is increasing, with often negative consequences.

Despite reasonably well-organized health systems and means for detecting precancerous lesions in the cervix before its progression to invasive cancer, more than 60 000 new cases of cervical cancer are diagnosed annually in the Region, many in advanced stages, resulting in more than 30 000 deaths. Immunization with the HPV vaccine, if affordable, could be used by Member States and communities in combating this public health problem.

There are two main groups of challenges. At the policy level, there is inequity and lack of access to services, leg- islative constraints, lack of decentralization and integration of networks of providers and levels of care and no multidisciplinary approach to perinatal care. At the level of services, there are problems of over-medicalization, inappropriate use of technology, inappropriate use of drugs and use of abortion instead of family planning. The Regional Office for Europe is striving to address these issues in a focused manner.

WHO’s work in sexual and reproductive health in the European Region The goals and targets for sexual and reproductive health in the European Region are defined by the WHO Euro- pean regional strategy on sexual and reproductive health56 and the WHO global reproductive health strategy47.

The current situation of sexual and reproductive health has been analysed regularly and the results presented at the meeting of the European Regional Advisory Panel on Research and Training in Reproductive Health, which assists the Regional Office in defining priorities. During the meeting of the Regional Advisory Panel in 2007, the following priorities were confirmed: 66 WHO Sexual and Reproductive Health Revised Budget 2008–2009

• maternal and perinatal mortality and morbidity;

• prevention of unwanted pregnancy and ensuring safe abortion;

• improving the sexual and reproductive health and rights of young people, for instance by providing youth- friendly health services, and emphasizing the needs of vulnerable and underserved groups;

• promoting the role of the health sector in addressing gender-based violence;

• family planning in the new Europe; and

• prevention of cervical cancer.

In order to address these priorities, the Regional Office’s work is focused on the following activities, which con- tribute to achievement of the following four Organization-wide expected results.

Support provided to Member States to formulate a comprehensive policy, plan and strategy for scaling- up towards to effective interventions in collaboration with other programmes, OWER universal access paying attention to reducing gender inequality and health inequities, providing a continuum of care 4.1. throughout the life-course, integrating service delivery across different levels of the health system and strengthening coordination with civil society and the private sector.

To achieve this expected result, the Regional Office will support Member States in developing comprehen- sive policies, plans and strategies, in line with strategies adopted at the European regional level and at the global level, for achieving universal access to sexual and reproductive health services. Effective interventions will be developed and implemented in collaboration with other sectors and programmes, paying attention to gender inequality and gaps in health equity, integrating service delivery into different levels of the health system and strengthening coordination with civil society and the private sector.

Building capacity in Member States to draw up comprehensive, gender-sensitive policies, plans and strate- gies by inter-country development of tools, materials and guidance will involve:

• in 2008, a regional meeting on progress in implementing the global reproductive health strategy (2004) and the Regional strategy on sexual and reproductive health (2001);

• in 2008–2009, assisting Azerbaijan, Ireland, Kyrgyzstan, Moldova and Ukraine in formulating and imple- menting national sexual and reproductive health strategies;

• in 2009, a subregional meeting on monitoring and evaluating implementation of the MDGs and national sexual and reproductive health strategies in Azerbaijan, Kyrgyzstan, Moldova, Romania, Tajiki- stan, Turkmenistan and Uzbekistan;

• in 2008 and 2009, an annual meeting of the Regional Advisory Panel on Research and Training in Repro- ductive Health; and

• in 2008, a regional Family and Community Health focal points’ meeting.

67 WHO Sexual and Reproductive Health Revised Budget 2008–2009

National research capacity strengthened as necessary and new evidence, products, technologies, interven- OWER tions and delivery approaches of global and/or national relevance available to improve maternal, newborn, child 4.2. and adolescent health, to promote active and healthy ageing, and to improve sexual and reproductive health.

The work of the Regional Office on this expected result will focus on capacity-building for operations research and generation of evidence of regional and national relevance. The intercountry programmes will address the following activities:

• in 2008, building institutional capacity to organize operations research training;

• in 2008, providing training in operational research in sexual and reproductive health for Russian-speak- ing participants;

• in 2008-2009, supporting operations research projects in sexual education, the effectiveness of youth- friendly activities and the results of implementation of WHO family planning and STI guidelines; and

• in 2009, a meeting of WHO Collaborating Centres.

Guidelines, approaches and tools made available, with provision of technical support to Member States for accel- erated action towards implementing the strategy to accelerate progress towards the attainment of international OWER development goals and targets related to reproductive health, with particular emphasis on ensuring equitable 4.7. access to good-quality sexual and reproductive health services, particularly in areas of unmet need, and with respect for human rights as they relate to sexual and reproductive health.

This expected result will be achieved by improving the availability of tools, standards and guidelines to assist Member States in implementing the global and regional reproductive health strategies, thus increasing access to high-quality sexual and reproductive health services, and with respect for human rights. The inter- country programme activities should lead to rigorous analysis of unmet needs in sexual and reproductive health and, on the basis of the results, to gender-sensitive tools and guidelines. The activities include:

• in 2008-2009, providing assistance to Member States in implementing WHO guidelines;

• in 2008-2009, publication of the European magazine on sexual and reproductive health, Entre Nous (three issues per year);

• strategic assessment of prevention of unwanted pregnancy and unsafe abortion in the Russian Federa- tion, Tajikistan and Ukraine;

• annual subregional workshops in countries to intensify focus and assistance to Member States involved in the WHO/UNFPA Strategic Partnership Programme; and

• dissemination of WHO guidelines at international and national meetings and congresses of professional associations.

68 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Evidence-based and ethical policies, strategies, interventions, recommendations, standards and guidelines devel- OWER oped and technical support provided to Member States to promote safer sex and strengthen institutions in order 6.6. to tackle and manage the social and individual consequences of unsafe sex.

To achieve this Organization-wide expected result, the Regional Office will support the development or updating of national programmes and reinforce multisectoral mechanisms for the prevention of unsafe sex and management of its consequences. This work includes control of STIs in most Member States, sup- ported by international tools, such as adapted global strategies, documentation of existing experience and providing options for national policies and approaches, while reinforcing national networks. The activities include:

• in 2008, a regional meeting of countries most in need, in order to share experiences and discuss barriers to promoting safe sex; and

• in 2009, setting up a centre of excellence for capacity-building and sharing of experience on safe abor- tion.

69 WHO Sexual and Reproductive Health Revised Budget 2008–2009

REGIONAL OFFICE FOR THE EASTERN MEDITERRANEAN

Issues and challenges Sexual and reproductive health problems present a disproportionately high disease burden among individuals, families and communities in the Eastern Mediterranean Region. Over and above the individual suffering it causes, sexual and reproductive ill-health has a broader impact on social and economic development. Investments in sexual and reproductive health are essential to breaking the cycle of poverty and freeing national and household resources. Unmet family planning needs, pregnancy- and childbirth-related conditions and sexually transmitted infections including HIV, directly affect the potentially most economically active segments of the population in the Region, including women who die during pregnancy in the prime of life. Nonetheless, the adoption of a holistic approach to sexual and reproductive health care is only partially realized in countries of the Region and the attainment of sexual and reproductive health for all still faces challenges also because information on major determinants of sexual and reproductive health morbidity throughout the life-span is still inadequate to enable evidence-based programme development and implementation. It is estimated that 53,000 women still die every year of pregnancy-related complications in the Region. Furthermore, around 610,000 newborns die every year in the first month of life in countries of the Region, and the contraceptive prevalence rate is still below 40% with total fertility rate as high as 4 children per woman.

WHO’s work in sexual and reproductive health in the Eastern Mediterranean Region The work of the Region in 2008-2009 will include increased attention to upgrade the technical know-how of sexual and reproductive health-care workers, and hence improve the quality and management of the delivered services in countries of the Region. Complementary efforts to disseminate, and promote the adaptation and adoption of, evidence-based guidance will support this effort. Areas of particular focus will include:

• continued support to safe motherhood, including antenatal, delivery, postpartum and neonatal health care and family planning, as priority component of sexual and reproductive health in all countries of the Region;

• work on sexual and reproductive health across the entire life-course and during adolescence and postmeno- pausal age in particular;

• practices harmful to sexual and reproductive health, reproductive tract infections, reproductive system can- cers, premarital and pre-conception counselling, genetic counselling and neonatal screening for inherited disorders; and

• generation and dissemination of information on major determinants of sexual and reproductive morbid- ity throughout the life-span, thus enabling evidence-based programme development and implementation throughout the Region.

Guidelines, approaches and tools made available, with provision of technical support to Member States for accel- erated action towards implementing the strategy to accelerate progress towards the attainment of international OWER development goals and targets related to reproductive health, with particular emphasis on ensuring equitable 4.7. access to good-quality sexual and reproductive health services, particularly in areas of unmet need, and with respect for human rights as they relate to sexual and reproductive health.

The work of the Regional Office will fall under a regional expected result that aims to provide technical sup- port to countries to build national capacities for developing gender-responsive policies and strategies and implementing and monitoring programmes for improving sexual and reproductive health and achieving health-related MDGs.

70 WHO Sexual and Reproductive Health Revised Budget 2008–2009

In order to support the national efforts during revision and adaptation of already introduced technical and managerial guidelines, the Regional Office will support the adaptation and use of a number of WHO’s cor- nerstones for evidence-based guidance for family planning, namely: the Medical eligibility criteria for con- traceptive use, which provides guidance regarding who can use contraceptive methods safely; the Selected practice recommendations for contraceptive use, which provides guidance on how to safely and effectively use a contraceptive method once it is deemed to be medically appropriate; and the Decision-making tool for family planning clients and providers. Close collaboration and technical backstopping activities will be maintained throughout the biennium to help the implementation of the country work plans in close coor- dination with headquarters, the UNFPA Country Technical Services Team for Arab States, and WHO offices in the participating countries.

Emphasizing an evidence-based approach for strategic planning for promoting sexual and reproductive health, the Regional Office has set up a “Reproductive Health Research Directory”. In 2008-2009, the Regional Office will continue to support this important resource for research in the Region.

The WHO/UNFPA Strategic Partnership Programme is expected to continue in 2008-2009. This programme is a joint WHO-UNFPA initiative to support country programmes with the dissemination, adaptation and adop- tion of newly developed or updated evidence-based practice guidelines through UNFPA Country Support Teams and country offices, WHO regional and country offices and intercountry collaborating agencies. In the Eastern Mediterranean Region, the Strategic Partnership Programme activities in sexual and reproductive health will focus on maternal and neonatal health, family planning and control and management of sexually transmitted infections, including HIV/AIDS.

71 WHO Sexual and Reproductive Health Revised Budget 2008–2009

REGIONAL OFFICE FOR THE WESTERN PACIFIC

Issues and challenges The Western Pacific Region, with 27 Member States and one Associated Member (from 37 countries and areas) is characterized by a diversity that transcends size (both geographical and demographic), climatic conditions, economic development and sociocultural norms, all of which significantly influence health, including sexual and reproductive health.

Reproductive health has undergone tremendous changes in its conception, definition, scope and importance in the past several years, especially in terms of its link to sexual health, the social determinants of gender, and human rights. Several international declarations have stressed the importance of sexual and reproductive health, and all the MDGs, especially those related to maternal health and child survival, HIV/AIDS, and gender equity, will require strong inputs from sexual and reproductive health for their achievement. The global reproductive health strategy adopted by the World Health Assembly in May 2004 underscores these concepts and identifies five core elements of sexual and reproductive health and five actions for countries to take in order to strengthen sexual and reproductive health.

Five core elements of reproductive health

1. improving antenatal, delivery, postpartum and newborn care; 2. providing high-quality services for family planning, including infertility services; 3. eliminating unsafe abortion; 4. combating STIs, including HIV infection, RTIs, cervical cancer and other gynaecological conditions; and 5. promoting sexual health.

Five areas of action for implementing the reproductive health strategy

1. strengthening health system capacity; 2. improving information for priority setting; 3. mobilizing political will; 4. creating a supportive legislative and regulatory framework; and 5. strengthening monitoring, evaluation and accountability.

Virtually all the countries of the Region face issues and challenges with respect to all five core elements. The rates of maternal and newborn mortality are still unacceptably high in some countries, and seven have been identi- fied as priorities for making pregnancy safer and for newborn health (Cambodia, China, Lao People’s Democratic Republic, Mongolia, Papua New Guinea, Philippines and Viet Nam). The maternal mortality ratio in Cambodia, Lao People’s Democratic Republic and Papua New Guinea exceeds 300 maternal deaths per 100 000 live births. Addressing maternal, newborn and child health, often the backbone of primary health care, offers opportunities for addressing the other components of sexual and reproductive health.

In some countries, contraceptive use is low, leading to large numbers of unintended pregnancies and to abortion; every year, more than 10 million abortions are performed in the Region9, hundreds of thousands of which are unsafe, contributing to maternal mortality.

72 WHO Sexual and Reproductive Health Revised Budget 2008–2009

In the Region, 17–24% of the population is aged 10–19 years, and they are at risk for the consequences of unpro- tected sex, including not only maternal death but also STIs and HIV/AIDS. STIs require an urgent response, as there is resurgence, especially of chlamydial infections and congenital syphilis, in China, Mongolia and some Pacific island countries. In Fiji, 29% of pregnant women had a chlamydial infection in a survey in 2005. Countries in the Region differ significantly in the prevalence of AIDS: most are classified as having low prevalence, although there are pockets of high prevalence. Intravenous drug use is a major concern in some countries, and, overall, heterosexual spread of HIV is on the rise. Sexual health as a critical element of the broader concept of sexual and reproductive health is still relatively neglected in most countries of the Region.

The countries of the Region face difficulties in carrying out the five actions for accelerating reproductive health. Strengthening the capacity of health systems remains a challenge in many countries, the coverage by skilled birth attendants at delivery in the Lao People’s Democratic Republic and Papua New Guinea is still very low, and the integration of services for STIs and HIV/AIDS into sexual and reproductive health services, and vice versa, is not fully implemented in many countries.

Improving information for policy-making is a long-standing problem as, for example, gender-disaggregated data are still not readily available, and the prevalence of STIs in pregnancy and the extent of STI testing of pregnant women are unknown. Mobilizing political will is especially challenging for sexual and reproductive health: it is not high on the political agenda, and sensitive issues such as family planning, adolescent sexuality and prevent- ing unsafe abortion make it even more difficult to address. The regulatory and legislative frameworks in many countries of the Region are often not supportive of sexual and reproductive health issues, such as access to contraceptives for those in greatest need, like unmarried young people, and safe abortion services. Monitoring and evaluation should be strengthened, especially for assessing health sector reforms that have implications for sexual and reproductive health.

The long-term goal of the sexual and reproductive health work of the Organization is influenced by many players, sectors and stakeholders. The activities of the Regional Office in 2008–2009 will contribute directly to achieve- ment of this goal. The aim of the Regional Office is to improve the sexual and reproductive health of the people of the Region, including meeting international development goals, such as those of the International Conference on Population and Development and the MDGs.

WHO’s work in sexual and reproductive health in the Western Pacific Region In the WHO medium-term strategic plan for 2008–2013, much of the work in sexual and reproductive health falls under strategic objective 4—to reduce morbidity and mortality and improve health during key stages of life, including pregnancy, childbirth, the neonatal period, childhood and adolescence, and to improve sexual and reproductive health and promote active and healthy ageing for all individuals. Goals in sexual and reproductive health will also be met by activities to address several other strategic objectives, especially:

• strategic objective 2—to combat HIV/AIDS, tuberculosis and malaria—and specifically Organization-wide expected result 2.2;

• strategic objective 5—to reduce the health consequences of emergencies, disasters, crises and conflicts and minimize the social and economic impacts;

• strategic objective 6—to reduce risk factors for health—specifically Organization-wide expected result 6.6 on unsafe sex; and

• strategic objective 7—to address social and economic determinants of health—specifically Organization-wide expected result 7.5 on gender analysis and responsive actions.

73 WHO Sexual and Reproductive Health Revised Budget 2008–2009

The scope of work in sexual and reproductive health and related areas expands continually in response to new needs, opportunities and challenges. The strategic objectives and expected results of WHO as a whole and those of the Regional Office for the Western Pacific and its country offices should contribute to achievement of the sexual and reproductive health goals.

National research capacity strengthened as necessary and new evidence, products, technologies, interven- OWER tions and delivery approaches of global and/or national relevance available to improve maternal, newborn, child 4.2. and adolescent health, to promote active and healthy ageing, and to improve sexual and reproductive health.

Guidelines, approaches and tools made available, with provision of technical support to Member States for accel- erated action towards implementing the strategy to accelerate progress towards the attainment of international OWER development goals and targets related to reproductive health, with particular emphasis on ensuring equitable 4.7. access to good-quality sexual and reproductive health services, particularly in areas of unmet need, and with respect for human rights as they relate to sexual and reproductive health.

The main activities for achieving these two Organization-wide expected results in the Region will include integrating the prevention and management of STIs and HIV/AIDS into sexual and reproductive, including maternal and newborn health, services, and vice versa. This will require identification and removal of the barriers to achieving integration and will provide an opportunity for integration of previously ‘vertical’ pro- grammes.

Support will be provided for implementation of a framework for accelerating action for the sexual and repro- ductive health of young people, to reinforce the importance to national development of investing in young people.

Many countries in the Region have initiated programmes for secondary prevention of cervical cancer, mainly by cervical cytology screening. Few of these programmes have been successful, largely because of the many difficulties inherent in this strategy. The licensing of HPV vaccines offers an opportunity for primary preven- tion (as most cervical cancer cases are linked to infections with the oncogenic types of HPV targeted by the vaccines), and countries will be advised on their use and will be supported in formulating national plans.

OWER Gender analysis and responsive actions incorporated into WHO’s normative work and support provided to 7.5. Member States for formulation of gender-sensitive policies and programmes.

The activities for achieving this Organization-wide expected result include training of trainers. As a follow-up to the WHO course on training of trainers for gender awareness in 2007, this activity will be integrated into national programmes and projects in order to introduce concepts and provide some basic skills to enable participants to introduce gender and rights into their sexual and reproductive health programmes. The tar- get audiences are health managers, policy-makers and others with responsibilities to increase awareness about gender equality in sexual and reproductive health.

74 STRENGTHENING Linkages BETWEEN 8 SEXUAL AND REPRODUCTIVE HEALTH AND HIV

Issues and Challenges

In 2007, some 33.2 million people were living with HIV infection, half of whom were under the age of 25, and a growing number are women. In addition, for every person who knows his or her HIV-positive status, it is estimated that nine others do not know or prefer not to know.15 HIV is essentially sexually transmitted or transmitted dur- ing pregnancy, childbirth and breastfeeding, so that HIV infection is intimately linked to sexual and reproductive health. Strengthening linkages between sexual and reproductive health and HIV infection therefore provides an opportunity to reduce unsafe sexual behaviour, reduce STIs, including HIV infection, reduce maternal and newborn mortality and morbidity, and ensure that the sexual and reproductive health and rights of people living with HIV infection are respected.

Sexual and reproductive health services provide a platform on which interventions for the prevention, care and treatment of HIV infection can be built, such as counselling and testing, condom promotion, management of STIs, contraceptive services and dual protection from unintended pregnancy and STIs (including HIV infection). Services for HIV/AIDS also offer access to sexual and reproductive health services for people at risk of or liv- ing with HIV infection. Use of contraceptives to prevent unintended pregnancy among HIV-positive women is a cost-effective means of preventing mother-to-child transmission of HIV infection. Integrating services can help decrease the stigma associated with HIV infection and AIDS, while simultaneously addressing the need for both types of service and care in all sectors of the population. Creating opportunities in environments where there is no stigma encourages access and increases the effectiveness of services. Training providers to address both sexual and reproductive ill-health and HIV infection would enhance the quality of services. Establishing stronger linkages between these two programmes can contribute to achieving universal access to services for both.

During the past decade, the international community has reiterated calls for integrating and strengthening link- ages between sexual and reproductive health services and strategies and services for the prevention and treat- ment of HIV/AIDS. The potential benefits of the linkages have not been fully realized, however, due in part to the absence of policies and programmes and normative guidance on effective linkages.

The Fifty-seventh World Health Assembly adopted WHO’s first global reproductive health strategy (WHA Resolu- tion 57.12), which lists five priorities, each of which can contribute to strengthening advocacy, research, policy and programmes in linkages between sexual and reproductive health and HIV.

75 WHO Sexual and Reproductive Health Revised Budget 2008–2009

International commitments

Universal access to sexual and reproductive health information and services would have far-reaching effects for both the maternal health and child health MDGs and for virtually every other Goal, including those for HIV/AIDS, gender and education, environment, and poverty and hunger.

Task Force on Child Health and Maternal Health of the United Nations Millennium Project, Who’s got the power: transforming health systems for women and children (2005)

The most effective way of reducing the proportion of infants infected by HIV is by preventing pri- mary HIV infection in women and by preventing unintended pregnancy among women infected by HIV. These two measures have intrinsic benefits to women and can decrease the proportion of infants infected by HIV by 35–45% in some countries, with a significant contribution from the provi- sion of family planning information, services and counselling.

The Glion Call to Action on Family Planning and HIV/AIDS in Women and Children (2004)

“…emphasizing the global emergency created by HIV/AIDS and sexual and reproductive ill-health; the urgent need for much stronger links between sexual and reproductive health and HIV/AIDS policies, programmes and services; and the centrality of these intersecting efforts towards the achievement of the Millennium Development Goals.”

United Nations General Assembly (2006)

Emphasized “the need to strengthen policy and programme linkages and coordination between HIV/AIDS and sexual and reproductive health”.

Goal

“Promote and strengthen reproductive and sexual health services as the basis of the prevention and treat- ment of HIV/AIDS, particularly through family planning; antenatal, childbirth and postpartum care; con- trol of sexually transmitted infections; the promotion of safer sex; and the prevention of mother-to-child transmission of HIV.”

Reproductive health strategy to accelerate progress towards the attainment of international development goals and targets, paragraph 64 (3)

Challenges to ensuring effective linkages or integration to provide adequate health services include a paucity of evidence to support effectiveness, cost-efficiency, acceptability needs and feasibility; targeted or disease-specific donor funding; verticalization of institutions at national, programmatic, and service delivery levels, as well as within international organizations, and inadequate training and incentives for health care providers to provide for more comprehensive services.

76 WHO Sexual and Reproductive Health Revised Budget 2008–2009

WHO’s work in strengthening linkages between sexual and reproductive health and HIV infection

In order to provide a comprehensive approach to sexual and reproductive health and HIV infection, WHO will focus on the following advocacy, research, policy and programmatic activities. The Department of Reproductive Health and Research has a web link listing activities on linkages undertaken by the Department and its partners: http://www.who.int/reproductive-health/hiv/index.html. This will be updated regularly to reflect activities and will serve as an advocacy and communication tool. The overall goal of the activities is to improve access to and accelerate progress on the prevention, treatment, care and support of persons with HIV infection and on sexual and reproductive health by fostering linkages or integration. The work, involving a wide range of cross-cutting issues, is reflected in a large number of Organization-wide expected results.

The activities listed in this section are cross-cutting across the Department. Many other activities specifically addressing SRH/HIV linkages are listed and described under the work of individual teams. This includes, but is not limited to, work related to the provision of family planning for people living with HIV, advocacy initiatives through the ‘Art for Health’ project on young people living with HIV, introducing screening and treatment of congenital syphilis, generating evidence on ARVs for PMTCT programmes, guidance on safe male circumcision services, and policy and programmatic support for health sector reforms on SRH/HIV linkages.

OWER Guidelines, policy, strategy and other tools developed for prevention of, and treatment and care for patients with, HIV/AIDS, tuberculosis and malaria, including innovative approaches for increasing coverage of the 2.1. interventions among poor people, and hard-to-reach and vulnerable populations.

Policy and technical support provided to countries towards expanded gender-sensitive delivery of pre- vention, treatment and care interventions for HIV/AIDS, tuberculosis and malaria, including integrated training OWER and service delivery; wider service-provider networks; and strengthened laboratory capacities and better linkages 2.2. with other health services, such as those for sexual and reproductive health, maternal, newborn and child health, sexually transmitted infections, nutrition, drug dependence treatment services, respiratory care, neglected diseases and environmental health.

To achieve these result, WHO will maintain and promote an evidence-based approach to comprehensive prevention for women, men, young people and vulnerable populations, and will set up research initiatives, policies and programmes for women, men and young people living in vulnerable situations and at risk for HIV infection and other STIs.

The comprehensive approach to the prevention of mother-to-child transmission of HIV (PMTCT) recom- mended by WHO and UN partners strategy comprises the following elements: Primary prevention of HIV infection; Preventing unintended pregnancies among HIV-infected women; Preventing HIV transmission from HIV-infected women to their children, and Providing care, treatment and support to HIV-infected moth- ers, their children and families. However, despite endorsement of this approach at all levels, the focus to date has been on the third and fourth elements.

Specific activities to improve and strengthen PMTCT within existing sexual and reproductive health services needs to be carried out by supporting activities related to primary prevention for women and their partners and the prevention of unintended pregnancy in women living with HIV:

. Strengthening capacity at country level policy and technical support for the provision of HIV prevention and management services within existing sexual and reproductive health programmes.

. Coordinating advocacy and policy support for increased uptake of PMTCT services through better link- ages with condom promotion and procurement and family planning services.

77 WHO Sexual and Reproductive Health Revised Budget 2008–2009

New knowledge, intervention tools and strategies developed and validated to meet priority needs for the preven- OWER tion and control of HIV/AIDS, tuberculosis and malaria, with scientists from developing countries increasingly 2.6. taking the lead in this research.

National research capacity strengthened as necessary and new evidence, products, technologies, interven- OWER tions and delivery approaches of global and/or national relevance available to improve maternal, newborn, child 4.2. and adolescent health, to promote active and healthy ageing, and to improve sexual and reproductive health.

The aim of these Organization-wide expected results is to improve the quality of methods for preventing infection with HIV and other STIs and ensuring better health for people living with HIV infection; develop- ment of new preventive methods, such as male circumcision, microbicides and vaccines; providing cervical cancer screening for women living with HIV infection; addressing the sexual and reproductive needs of men; and extending effective, evidence-based adolescent sexual and reproductive health programmes to include prevention, care, treatment and support for HIV infection. The activities include:

. assessing the process and impact of integration and linkages between health-care programmes at country, community and provider levels;

. maintaining and promoting an evidence-based approach to comprehensive prevention for women, men, young people and vulnerable populations; and

. establishing evidence of linkages with related fields, such as tuberculosis and malaria.

Guidelines, approaches and tools made available, with provision of technical support to Member States for accel- erated action towards implementing the strategy to accelerate progress towards the attainment of international OWER development goals and targets related to reproductive health, with particular emphasis on ensuring equitable 4.7. access to good-quality sexual and reproductive health services, particularly in areas of unmet need, and with respect for human rights as they relate to sexual and reproductive health.

With respect to HIV infection, the aim of this Organization-wide expected result is to improve existing sexual and reproductive health services to better deliver HIV infection-related care, treatment and support, such as improving contraceptive choice and access for people living with HIV infection and providing referral to treatment and care for opportunistic infections and AIDS. The work will include:

. formulating policy and programmatic guidance for ensuring the sexual and reproductive health needs and rights of people living with HIV;

. formulating policies and programmes for women, men and young people living in vulnerable situations and at risk for HIV infection and other STIs;

. formulating policy and normative guidance and tools for effective linkages between sexual and repro- ductive health and the prevention, care and treatment of HIV;

. positioning sexual and reproductive health issues as a key element of HIV prevention within broader objectives, including the WHO Director-General's strategic project of promoting integrated primary health care;

. supporting countries, civil society and donors in including sexual and reproductive health components within proposals to the Global Fund to Fight AIDS, Tuberculosis and Malaria;

. developing guidance regarding counselling on fertility intentions for women living with HIV;

. promoting dual protection and condom promotion;

78 WHO Sexual and Reproductive Health Revised Budget 2008–2009

. strengthening family planning service delivery and commodities within HIV/AIDS programmes;

. developing policy and programmatic guidance for primary prevention of HIV among women and pre- vention of unintended pregnancies in women living with HIV; and

In order to increase dialogue between WHO and its partners to address sexual and reproductive health and prevention of HIV infection jointly, the following activities will be undertaken:

. fostering an enabling environment to strengthen linkages by extensive dialogue, both within WHO and with other partners;

. coordinating communication and advocacy on HIV prevention, care, treatment and support;

. supporting countries in setting priorities to strengthen linkages between sexual and reproductive health and HIV infection and measuring the effectiveness of programmes;

. establishing indicators for linkages and promoting their adoption;

. translating and disseminating existing and new materials to centres, Member States, partners and col- laborators; and

. participating in research reviews and collection of evidence on linkages between sexual and reproduc- tive health and HIV infection.

Evidence-based and ethical policies, strategies, interventions, recommendations, standards and guidelines OWER developed and technical support provided to Member States to promote safer sex and strengthen institu- 6.6. tions in order to tackle and manage the social and individual consequences of unsafe sex.

Unsafe sex is currently the second most significant risk factor to health globally and accounts for consider- able burden of disease including:

. 80 million estimated unwanted pregnancies . 500,000 infants are infected with HIV . 700,000 infants born with congenital syphilis . 340 million curable sexually transmitted infections (STIs) . 2.5 million people newly infected by HIV . 68,000 deaths from unsafe abortion . 2.1 million deaths from an AIDS related illness

A reduction in morbidity and mortality associated with unsafe sex requires that we deal with the issues of sexual and reproductive health and HIV jointly through the following activities:

. Providing technical support and guidance for the prevention of unintended pregnancy in women living with HIV.

. Developing policy and programmatic recommendations for health care workers to create a more sup- portive, less discriminatory environment so that people may have access to adequate non-judgemental information, counselling, and care.

. Elaborating policies and strategies to improve the overall performance of the health system with a com- prehensive package of interventions that includes the provision of and/or either referral to sexual and reproductive health services in HIV/AIDS centres.

79 WHO Sexual and Reproductive Health Revised Budget 2008–2009

OWER Ethics- and rights-based approaches to health promoted within WHO and at national and global levels. 7.4.

Ensuring that women, men and young people living with HIV infection have access to sexual and reproduc- tive health services will help them realize their sexual and reproductive goals with assurance of the respect, protection and fulfilment of their human rights. In order to attain this, strong linkages and synergies are needed between programmes that address health systems, law and policy and the underlying social deter- minants of the sexual and reproductive needs of HIV-positive people. Further, governments and donors will require technical support to formulate policies and plans for sexual and reproductive health, HIV infection and AIDS in the health sector. If the needs of people living with HIV infection are addressed and the provision of rights-based services is broadened, large numbers of people who do not know their serological status and those at risk of acquiring HIV infection can be assured that their sexual and reproductive health needs will be met.

PRODUCT LISTING

Funding source Product and Organization- Product title Product description identification wide expected result

073 Strengthening linkages Coordinate communication and advocacy PDRH, between sexual and activities related to prevention, care, treatment Organization-wide reproductive health services and support of HIV infections expected result 4.7 and HIV infection services and programmes through advocacy

Activities 1. Developing technical briefs and advocacy materials for fostering linkages between sexual and reproductive health and HIV services, coordinating and maintaining donor support 2. Identifying and establishing opportunities for dissemination of technical and scientific information on linkages between sexual and reproductive health and HIV infection 3. Convene meeting of the interagency working group on SRH/HIV linkages 4. Developing and updating the Department’s web site on technical and scientific developments in linkages between sexual and reproductive health and HIV infection

074 Strengthening linkages Coordinate research on prevention, care, HRP, Organization- between sexual and treatment and support for HIV infection wide expected reproductive health and result 4.2 HIV infection services and programmes through research

Activities 1. Identifying research needs and fostering research on strengthening linkages between prevention, care and support for HIV infection and sexual and reproductive health, including research for improving the sexual and reproductive health of women, men and young people living in vulnerable situations and at risk for HIV infection and other STIs 2. Maintaining and promoting an evidence-based approach to strengthening services and programmes to promote prevention of HIV infection and improve sexual and reproductive health 3. Participating in research reviews and establishment of evidence on linkages between sexual and reproductive health and HIV infection 4. Assessing the process and impact of integration and linkages in health-care programmes at country, community and provider levels

Continued on next page

80 WHO Sexual and Reproductive Health Revised Budget 2008–2009

075 Strengthening linkages Coordinate policy and programme activities PDRH, between sexual and related to prevention, care, treatment and Organization-wide reproductive health and HIV support for HIV infection expected result 4.7 infection services through policy and programmatic activities

Activities 1. Supporting the development of policies and programmes to ensure a rights-based approach in the provision of sexual and reproductive health services for people living with HIV 2. Strengthening training and support to health-care providers to ensure provision of appropriate sexual and reproductive health and HIV services 3. Developing policies, guidelines and strategies to support countries to achieve universal access to sexual and reproductive health and services for HIV and AIDS 4. Developing guidance on key interventions to strengthen effective linkages between sexual and reproductive health and prevention, care and treatment of HIV 5. Convene an international consultation to develop normative guidance on linkages

076 External collaboration with Strengthening policy environment, collaboration PDRH, and provision of advice to and partnerships for improving SRH/HIV linkages Organization-wide partners and collaborators on expected result 4.7 linkages between sexual and reproductive health and HIV infection

Activities 1. Strengthening collaboration and dialogue between WHO and other United Nations agencies, networks of people living with HIV infection and other partners to address issues of linkages 2. Convening meetings as and when needed to address issues in sexual and reproductive health and HIV infection

077 Translation, update and Disseminating existing and new materials HRP, Organization- dissemination of existing to centres, Member States, partners and wide expected HRP scientific and technical collaborators result 4.2 materials

Activities 1. Disseminating existing and new materials to centres, Member States, partners and collaborators 2. Reprinting existing standards, guidelines and technical materials 3. Updating existing WHO documents to strengthen the components of linkages between sexual and reproductive health and HIV infection

078 Support to countries in setting Capacity strengthening at country-level to PDRH, priorities to strengthen support SRH/HIV linkages Organization-wide linkages between sexual expected result 2.1 and reproductive health and HIV infection and measuring effectiveness of programmes

Activities 1. Developing indicators and promoting their adoption to monitor progress in reaching universal access to SRH and HIV 2. Providing technical support to Member States for setting priorities to scale up effective programmes 3. Implementing comprehensive PMTCT programmes in ten countries 4. Implementing the SRH/HIV assessment tool in three countries 5. Develop an action plan linking HIV and reproductive health programmes in one country 6. Evaluating programmes on strengthening linkages between: 1) VCT/PITC and FP services, 2) VCT/PITC and STI services, 3) PMTCT/HIV and FP services; to access high-impact or wide-reaching initiatives

Continued on next page

81 WHO Sexual and Reproductive Health Revised Budget 2008–2009

Funding source Product and Organization- Product title Product description identification wide expected result

079 Guidance on integrated Guidance to health systems on providing PDRH, services for people living with integrated sexual and reproductive health Organization-wide HIV infection services for people living with HIV infection expected result 2.2 which ensure that their reproductive rights are protected and respected

Activities 1. Developing, through a broad consultative process, a guidance on the sexual and reproductive health for people living with HIV

82 9 RESEARCH COORDINATION AND SUPPORT

Building on its traditional strength, HRP will continue to ensure the scientific rigour of its research through a series of scientific review activities. Specialist panels undertake independent scientific, technical and financial reviews of research activities in their field of expertise—social science and operations research, basic and bio- medical research, epidemiological research and research on country programmes—ensuring that each project proposed for support is scientifically and financially sound. The Scientific and Ethical Review Group reviews the ethical aspects of all clinical and animal research proposed for HRP support. The Group also advises HRP on ethical aspects of new scientific developments in sexual and reproductive health. The Toxicology Panel assesses the adequacy of toxicological data on new drugs or devices, or new applications of existing drugs and devices, proposed for clinical research.

Goal

To ensure that research carried out and supported by HRP is rigorously reviewed and assessed in order to achieve the highest possible ethical and scientific standards.

Improvement and maintenance of ethical standards in research will continue to be promoted at regional and national workshops. In order to enhance the impact of its research, HRP will continue to promote research and disseminate findings at national and international meetings. HRP is in a unique position to coordinate research activities in some areas globally.

The statistical and methodological rigour of supported research projects, including adherence to guidelines for good clinical practice, remains critical for WHO. The Statistics and Informatics Services team adds value to the research supported by HRP by providing biostatistical and data processing services and technical advice on the design, management, analysis and interpretation of findings to all multinational clinical trials and epidemiological studies conducted or sponsored by HRP and to other research projects not requiring centralized data coordina- tion. It also provides support in the formulation, review and execution of activities for strengthening research capability in biostatistics and data processing, including training statisticians and data managers in collaborating institutions.

83 WHO Sexual and Reproductive Health Revised Budget 2008–2009

PRODUCT LISTING

Funding source Product and Organization- Product title Product description identification wide expected result

080 Scientific and ethical rigour of Meetings of scientific and ethical review bodies HRP, Organization- HRP research assured organized wide expected result 4.2

Activities 1. Convening specialist panel meetings on social science and operations research, basic and biomedical research, epidemiological research and country programme development in sexual and reproductive health 2. Convening Scientific and Ethical Review Group meetings

081 Strengthening the capacity Workshops to strengthen the capacity of HRP, Organization- of collaborating centres collaborating institutions and scientists to wide expected to communicate and disseminate the findings of their research result 4.2 disseminate information on sexual and reproductive health research

Activities 1. Supporting workshops to train trainers in dissemination of research findings

082 Informatics support for HRP Computer equipment upgraded as necessary, HRP, Organization- clinical research supplies made available, licenses for software wide expected renewed, other support services result 4.2

Activities 1. Providing support for clinical trials 2. Providing informatics support for HRP research

083 Informatics support for the Computer equipment upgraded as necessary, PDRH, Department supplies made available, licenses for software Organization-wide renewed, other support services expected result 4.7

Activities 1. Providing informatics support to the Department

84 10 GENERAL TECHNICAL ACTIVITIES

In addition to the work described in the preceding pages, the Department of Reproductive Health and Research at headquarters undertakes general technical activities, which include the convening of strategic and technical advisory bodies, provision of advice to Member States on issues in sexual and reproductive health, disseminating information, advocacy, communication and fundraising, as well as contingency funding of unanticipated research needs through the Director’s Initiative Fund.

Scientific advisory bodies

The overall strategic direction for the Department’s work is given by the Scientific and Technical Advisory Group and by the Gender and Rights Advisory Panel, both of which meet annually and advise the Policy and Coordina- tion Committee of HRP and the Department’s Director. The Scientific and Technical Advisory Group provides stra- tegic guidance on all activities, recommends priorities, reviews plans of action and budgets and continuously and independently evaluates implementation and impact of the Department’s work. The role of the Gender and Rights Advisory Panel is to ensure that considerations of gender equality and reproductive rights are brought into all the Department’s work.

Goal

To ensure that the work of the Department is of the highest scientific quality, gender-sensitive, ethically sound and responsive to the sexual and reproductive health needs of people everywhere, but particularly those living in poverty in developing countries.

Communications, advocacy and information

A primary function of the Department is to generate, disseminate and facilitate the application of knowledge on sexual and reproductive health. Knowledge is transmitted in the form of information by various media and instruments and is managed at three levels: at the point of entry (journals, newsletters, press releases of other institutions), when it is shared within the Department and when it is designed and packaged for outside con- sumption.

Goal

To communicate, proactively and cost-effectively, the entire spectrum of issues in sexual and reproductive health to the intended target audiences and stakeholders; to facilitate the transfer of knowledge on sexual and reproductive health by appropriate strategies and media; and to implement advocacy, fundraising and external relations interventions.

85 WHO Sexual and Reproductive Health Revised Budget 2008–2009

The potential users of the disseminated information are scientists, policy-makers, programme managers and other health-care providers, donors, journalists and the general public. These target audiences need materials of different levels of technical complexity in different languages. In order to reach these diverse audiences, the Department works with its collaborating institutions and other partners, including the WHO regional and country offices, sister United Nations agencies, governments and nongovernmental organizations. The capacity of col- laborating institutions to disseminate information often needs strengthening. The last step is to show that the disseminated information is reaching the target audiences, is being used in the intended manner and is having the desired impact.

PRODUCT LISTING

Funding source Product and Organization- Product title Product description identification wide expected result

084 External collaboration with Provision of advice to Member States on HRP, Organization- and advice provided to methods, findings and implications of research in wide expected Member States sexual and reproductive health result 4.2

Activities 1. Providing information in response to enquiries from individuals, Member States, United Nations agencies, nongovernmental and other organizations on issues related to sexual and reproductive health research 2. Convening meetings as and when needed to formulate guidance for Member States and other partners on interpretation and operationalisation of findings from research on sexual and reproductive health

085 External collaboration with Provision of advice to Member States on PDRH, and advice provided to standards, guidelines, policies and programme Organization-wide Member States issues in sexual and reproductive health expected result 4.7

Activities 1. Providing information in response to enquiries from individuals, Member States, United Nations agencies, nongovernmental and other organizations on issues related to sexual and reproductive health policies, programmes and services 2. Convening meetings as and when needed to formulate guidance for Member States and other partners on interpretation and operationalization of findings relevant to the implementation of sexual and reproductive health policies and programmes

086 Scientific and Technical Funded in alternate years by HRP and PDRH HRP, Organization- Advisory Group and Gender wide expected and Rights Advisory Panel result 4.2 meetings

Activities 1. Convening Scientific and Technical Advisory Group meeting 2. Convening Gender and Rights Advisory Panel meeting

087 Scientific and Technical Funded in alternate years by HRP and PDRH PDRH, Advisory Group and Gender Organization-wide and Rights Advisory Panel expected result 4.7 meetings

Activities 1. Convening Scientific and Technical Advisory Group meeting 2. Convening Gender and Rights Advisory Panel meeting

Continued on next page

86 WHO Sexual and Reproductive Health Revised Budget 2008–2009

088 Advocacy and promotion of Development of web sites, newsletters, and other HRP, Organization- sexual and reproductive health information and promotional materials wide expected research result 4.2

Activities 1. Maintaining and enhancing HRP web site 2. Producing and disseminating HRP Newsletter Progress in Sexual and Reproductive Health Research 3. Publishing and disseminating Biennial Technical Report 4. Developing promotional materials for HRP 5. Launching HRP resource mobilization initiatives in support of sexual and reproductive health

089 Advocacy and promotion of Development of web sites, newsletters, and PDRH, sexual and reproductive health other information and promotional materials Organization-wide expected result 4.7

Activities 1. Maintaining and enhancing Department of Reproductive Health and Research web site 2. Producing and disseminating Biennial Report 3. Development of promotional materials for sexual and reproductive health 4. Launching resource mobilization initiatives in support of sexual and reproductive health research

090 Translation, reprinting and HRP, Organization- dissemination of existing wide expected HRP scientific and technical result 4.2 materials

Activities 1. Disseminating existing materials to Member States, partners and other collaborators 2. Reprinting articles and other scientific and technical materials

091 Translation, reprinting and PDRH, dissemination of existing Organization-wide PDRH technical materials expected result 4.7

Activities 1. Disseminating existing materials to Member States, partners and other collaborators 2. Reprinting existing standards, guidelines and scientific and technical materials

87 WHO Sexual and Reproductive Health Revised Budget 2008–2009

88 11 PROGRAMME MANAGEMENT

This component is concerned with leadership, direction, external relations, resource mobilization and managerial and administrative support. An important function is organization of the meetings of HRP’s Policy and Coordina- tion Committee, which meets annually in June, and of the Standing Committee of HRP cosponsors, which gener- ally meets three times a year. Other activities in programme management include staff development and training, purchase of office equipment and supplies and other related expenses.

PRODUCT LISTING

Funding source Product and Organization- Product title Product description identification wide expected result

092 HRP programme planning, Governance, planning and evaluation, HRP HRP, Organization- governance, management, programme management , staff development wide expected evaluation and staff result 4.2 development

Activities 1. Convening HRP Standing Committee meetings 2. Convening annual meeting of HRP Policy and Coordination Committee 3. Supporting HRP external evaluation 4. Organizing HRP staff development and training

093 PDRH programme planning, Planning and evaluation of PDRH programme PDRH, governance, management, management Organization-wide evaluation and staff expected result 4.7 development

Activities 1. Supporting Department of Reproductive Health and Research evaluation 2. Organizing staff development and training activities

094 Administrative support for Direct administrative support costs budgeted for HRP, Organization- HRP and incurred by HRP (including budget, finance, wide expected human resources services, office rental and legal result 4.2 services)

095 Stationery, supplies, postage Includes coded articles, stationery, office supplies, HRP, Organization- and communications for HRP telephone and postage wide expected result 4.2

096 Stationery, supplies, postage Includes coded articles, stationery, office supplies, PDRH, and communications for telephone and postage Organization-wide PDRH expected result 4.7

89 WHO Sexual and Reproductive Health Revised Budget 2008–2009

90 12 BUDGET TABLES AND FIGURES 6.0% 5.1% 9.3% 31.8% 12.4% 12.2% 23.2% % 100.0% of total 2,879,000 5,972,000 2,472,000 5,844,000 4,479,000 Full Budget Level US$ 48,064,000 15,264,000 11,154,000 Budget

Table 2. WHO Organization-wide budget for programme development in sexual and reproductive health (excluding HRP) Grand total Headquarters Western Pacific Eastern Mediterranean Europe South-East Asia The Americas Major WHO Office Africa Note: This table consolidates budget figures across major WHO offices for Organization-wide expected result 4.7: 'Guidelines, approaches and tools made available, with provision of technical support to Member States for accelerated action towards implementing the strategy to accelerate progress towards attainment of international development goals and targets related to reproductive health, with particular emphasis on ensuring equitable access good-quality sexual and health services, particularly in areas of unmet need, and with respect for human rights as they relate to sexual reproductive health'

91 WHO Sexual and Reproductive Health Revised Budget 2008–2009 6.4% 1.9% 9.3% 6.6% 8.7% 4.9% 3.8% 33.2% 11.6% 13.6% % 100.0% of total 3,910,000 1,196,000 5,701,000 7,131,000 4,070,000 2,573,000 5,339,000 3,020,000 2,328,000 8,344,000 63,974,000 20,362,000 61,401,000 US$ Budget ure. g Contingency Budget Level

6.4% 1.9% 6.5% 8.1% 4.7% 3.7% 11.0% 33.7% 10.2% 13.7% 100.0% % of total udgetary contributions to RHR, except those HRP. osts, which are not included in this PSC fi p 1,246,000 4,179,000 7,232,000 6,661,000 4,292,000 2,730,000 5,339,000 3,090,000 2,428,000 9,014,000 Full Budget Level 68,288,000 22,077,000 US$ 65,558,000 Budget

ort to WHO administrative pp es, rent, and su g es, infrastructure char g s for administrative costs in the form of direct char y a p Table 3. RHR consolidated budget for 2008-2009, by section Grand total Technical Cooperation with Countries Strengthening Linkages between Sexual and Reproductive Health HIV Budget Section Gender, Reproductive Rights, Sexual Health and Adolescence Total including PSC Research Coordination Controlling Sexually Transmitted and Reproductive Tract Infections Promoting Family Planning Preventing Unsafe Abortion Improving Maternal and Perinatal Health WHO Programme Support Cost (PSC) (see note) Programme Management General Technical Activities Note: In accordance with standard WHO procedures, a programme support cost of 13% is charged on expenditures against all extrab HRP

92 WHO Sexual and Reproductive Health Revised Budget 2008–2009 37.6% 62.4% 49.3% 55.5% 50.7% 44.5% % 100.0% 100.0% 100.0% of total 7,971,000 21,180,000 40,221,000 13,209,000 30,279,000 22,308,000 31,122,000 17,913,000 61,401,000 US$ Budget Contingency Budget Level

roductive health (PDRH). p 41.0% 59.0% 52.5% 58.5% 47.5% 41.5% 100.0% 100.0% 100.0% % ) is part of the Department Reproductive of total ment in re p ramme develo 9,179,000 g Full Budget Level 22,388,000 43,170,000 34,436,000 25,257,000 13,209,000 31,122,000 17,913,000 ro US$ 65,558,000 p Budget

artment devoted to p art of the De p

g t for HRP and the remainin p arate accounts are ke p Table 4. RHR consolidated budget for 2008-2009, detailing staff and product costs Grand total RHR Department Grand total RHR UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) Programme Development in Reproductive Health (PDRH) Products Products Staff Posts Sub-total PDRH Staff Posts Staff Posts Products Sub-total HRP Note: The UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP Health and Research (RHR). Se

93 WHO Sexual and Reproductive Health Revised Budget 2008–2009 4.7% 6.5% 3.8% 95.3% 93.5% 96.2% % of total 2,573,000 2,899,000 1,387,000 1,512,000 63,974,000 21,180,000 40,221,000 58,502,000 19,793,000 38,709,000 61,401,000 US$ Budget ure. g Contingency Budget Level

4.4% 6.2% 3.5% 95.6% 93.8% 96.5% % of total udgetary contributions to RHR, except those HRP. osts, which are not included in this PSC fi p 2,730,000 2,899,000 1,387,000 1,512,000 Full Budget Level 68,288,000 22,388,000 43,170,000 62,659,000 21,001,000 41,658,000 US$ 65,558,000 Budget

ort to WHO administrative pp es, rent, and su g es, infrastructure char g All sources RHR Voluntary contributions WHO Assessed contributions Voluntary contributions All sources PDRH WHO Assessed contributions Voluntary contributions All sources HRP WHO Assessed contributions s for administrative costs in the form of direct char y a p Table 5. RHR consolidated income requirements and sources of funds for 2008-2009 UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) Grand total RHR Department Programme Development in Reproductive Health (PDRH) Total income requirement, including PSC WHO Programme Support Cost (PSC) (see note) HRP Note: In accordance with standard WHO procedures, a programme support cost of 13% is charged on expenditures against all extrab

94 WHO Sexual and Reproductive Health Revised Budget 2008–2009 1% 0% 9% 10% 25% 16% 37% 85% 10% 17% 5,339,000 4,179,000 3,090,000 7,232,000 2,428,000 4,292,000 6,661,000 9,014,000 22,077,000 65,558,000

- RHR consolidated budget 4,312,450 3,609,780 1,770,000

1,246,000

59% 4,834,410 74% 2,474,300 10% 6,249,500 23% 20,162,570 37% 8,229,990 -14% 4,155,000 32% 55,798,000 - - 726,000 715,000 2,348,000 4,199,000 2,904,000 10,350,000 22,388,000 PDRH

- - - -

100,000 1,046,000

5% 456,000 4% 827,000 0% 8,438,000 0% 0% 2,123,000 85% 24% 3,807,000 32% -34% 1,349,000 11% 17,000,000 742,000 4,613,000 3,464,000 6,661,000 3,033,000 2,328,000 4,292,000 6,110,000 11,727,000 HRP 43,170,000

- 3,328,000 2,442,500 1,125,300 4,378,410 4,312,450 3,609,780 1,770,000 6,106,990 11,724,570 38,798,000 2006-2007 2008-2009 Change 2006-2007 2008-2009 Change 2006-2007 2008-2009 Change

200,000

Table 6. RHR 2008-2009 proposed budget compared with 2006-2007 (full level) Grand total Programme Management Gender, Reproductive Rights, Sexual Health and Adolescence Technical Cooperation with Countries General Technical Activities Controlling Sexually Transmitted and Reproductive Tract Infections Improving Maternal and Perinatal Health Preventing Unsafe Abortion Strengthening Linkages between Sexual and Reproductive Health HIV Research Coordination Promoting Family Planning Budget section

95 WHO Sexual and Reproductive Health Revised Budget 2008–2009 % 100.0% of total 65,558,000 US$ Full Budget Level Budget 408,000 0.6% 962,000 1.5% 963,000 1.5% 148,000 0.2% 441,000 0.7% 150,000 0.2% 40,000 0.1% 50,000 0.1%

42,298,000 64.5% 2,910,000 4.4% 1,924,000 2.9% OWER 2.1 STI/HIV prevention OWER 2.2 STI/HIV technical support OWER 2.4 STI surveillance OWER 4.1 Universal access (health systems) OWER 10.3 Health services capacity strengthening OWER 2.6 HIV/AIDS prevention research OWER 3.3 Violence against women OWER 4.2 Research in sexual and reproductive health OWER 4.7 Programme development in sexual and reproductive health OWER 6.6 Unsafe sex 15,264,000 23.3% OWER 10.1 Health service research OWER 7.4 Reproductive rights Table 7. RHR consolidated budget for 2008-2009, by WHO Organization-wide expected result WHO Organization-wide expected result Grand total

96 WHO Sexual and Reproductive Health Revised Budget 2008–2009

REFERENCES

1 Investing in development: a practical plan to achieve the Millennium Development Goals. New York, United Nations Millennium Project, 2005. http://www.unmillenniumproject.org/reports/fullreport.htm.

2 Resolution adopted by the United Nations General Assembly 60th session. 2005 World Summit outcome [A/RES/6/1]. New York, United Nations, 24 October 2005.

3 Resolution A60/262. Political declaration on HIV/AIDS. New York, United Nations, 2006.

4 Maputo plan of action for the operationalisation of the continental policy framework for sexual and reproductive health and rights 2007–2010. Special Session of the African Union Conference of Ministers of Health. Maputo, Mozambique, 18-22 September 2006.

5 United Nations Population Division. Fertility and marriage database. New York, United Nations, 2007.

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7 United Nations Population Division. Fertility and marriage database. New York, United Nations, 2007.

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13 WHO and UNICEF. Low birth weight: country, regional and global estimates. New York, United Nations Children’s Fund, 2004.

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16 De Cock KM et al. Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice. JAMA, 2000, 283:1175–1182.

17 Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. Guidelines on care, treatment and support for women living with HIV/AIDS and their children in resource-constrained settings. Geneva, World Health Organization, 2004.

18 The European Collaborative Study. HIV-infected pregnant women and vertical transmission in Europe since 1986. AIDS, 2001, 15:761–770.

19 Herpes simplex virus type 2: programmatic and research priorities in developing countries. Report of a WHO/UNAIDS/LSHTM Workshop (London, 14-16 February 2001). Geneva, World Health Organization, 2001.

20 Smith JS, Robinson NJ. Age-specific prevalence of infection with herpes simplex virus types 2 and 1: a global review.Journal of Infectious Diseases, 2002; 186 Suppl 1:S3–S28.

21 Kjaer SK et al. High-risk human papillomavirus is sexually transmitted: evidence from a follow-up study of virgins starting sexual activity (intercourse). Cancer Epidemiology Biomarkers and Prevention, 2001, 10:101–106.

22 Koutsky LA et al. A controlled trial of a human papillomavirus type 16 vaccine. New England Journal of Medicine, 2002, 347:1645– 1651.

23 Parkin DM et al. Global cancer statistics, 2002. CA A Cancer Journal for Clinicians, 2005, 55:74–108.

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27 Unpublished estimates based on Global burden of disease 2002 estimates. Revised as of July 2004.

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31 The priority-setting process: setting priorities in sexual and reproductive health. Geneva, World Health Organization, 2003 (document reference RHR/STAG(20)/2003/8.1).

32 WHO medium-term strategic plan 2008–2013 and proposed programme budget 2008–2009. Geneva, World Health Organization, 2007.

33 UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) external evaluation 1990–2002, executive summary. Geneva, World Health Organization, 2003.

34 Medical eligibility criteria for contraceptive use, 3rd ed. Geneva, World Health Organization, 2004.

35 Selected practice recommendations for contraceptive use. Geneva, World Health Organization, 2002.

36 Decision-making tool for family planning clients and providers. Geneva, World Health Organization, 2005.

37 Global handbook for family planning providers. Geneva, World Health Organization, 2007.

38 WHO child growth standards : length/height-for-age, weight-for-age, weight-for-length, weight-for height and body mass index-for-age: methods and development. Geneva, World Health Organization, 2006.

39 WHO 1995 Expert Committee Report: Physical status: the use and interpretation of anthropometry. Technical Report Series 854. Geneva, World Health Organization, 1995.

40 Advisory Group on maternal nutrition and low birth weight. Geneva, World Health Organization, 2003.

41 Villar J et al. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. The Lancet, 2006, 367: 1819-1829.

42 http://www.prebic.org/

43 Management of birth defects and haemoglobin disorders: report of a joint WHO-March of Dimes Meeting, Geneva 17-19 May 2006. Geneva, World Health Organization and March of Dimes, 2006.

44 WHO Reproductive Health Library. Geneva, World Health Organization, 2007. (http://www.who.int/reproductive-health/rhl/index. html)

45 Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2003, 5th ed. Geneva, World Health Organization, 2007.

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47 Reproductive health strategy to accelerate progress towards the attainment of international development goals and targets. Geneva, World Health Organization, 2004 (WHO Document A57/13).

48 Frequently asked clinical questions about medical abortion. Geneva, World Health Organization, 2006.

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51 Prevention and control of sexually transmitted infections: global strategy. Geneva, World Health Organization, 2006.

52 Jejeebhoy SJ, Bott S. Non-consensual sexual experiences of young people in developing countries: an overview. In Sex without consent: young people in developing countries. Jejeebhoy SJ, Shah IH, Thapa S (eds.). London, Zed Books, 2005.

53 Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2003, 5th ed. Geneva, World Health Organization, 2007.

54 García-Moreno C. et al. WHO multi-country study on women’s health and domestic violence against women: initial results on prevalence, health outcomes and women’s responses. Geneva, World Health Organization, 2005.

55 Report on the global AIDS epidemic 2006. Geneva, Joint United Nations Programme on HIV/AIDS, 2006.

56 WHO regional strategy on sexual and reproductive health. Copenhagen, World Health Organization, 2001 (document EUR/01/5022130).

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