Reaffirm the values that underlie reproductive health - as agreed upon in Cairo

Has the "paradigm shift" from population control to reproductive health and rights been adopted at the level of international policy, by international organisations and by different countries?

In general, there is a widespread acceptance of the need for such a paradigm shift and, in many settings, the language has indeed changed. Multilateral agencies such as WHO have restructured their activities, bringing together different aspects of reproductive health into more coordinated programme structures. The research mandate of the WHO Department of Reproductive Health and Research has been broadened beyond fertility regulation to include other key areas of reproductive health, and more attention will be given to working with national and district-level health authorities to meet people’s reproductive health needs.

At country level especially, the International Conference on Population and Development ICPD gave legitimacy to the language of health and rights. In China, for example, which has had the world’s most directive population control programme, the State Family Planning Commission has adopted the language of reproductive health and acknowledges women’s demands for a higher quality of care.

What are the current points of controversy in the debate relative to the demographic question, to population development and to "reproductive health"?

There are differences of opinion on how to address them. For example, whereas there is agreement that population policies should not be seen solely as efforts to reduce population growth, there are concerns that this does not mean that unsustainable population growth is no longer important. There is no consensus on how to integrate issues such as population growth, consumption, economic development and environmental concerns. Within the reproductive health area specifically, there are concerns about the most appropriate ways of addressing sexual and reproductive health needs of different groups, for example, young people. What is the appropriate balance between the roles and responsibilities of family members and other actors such as schools? These are complex issues that need to be worked out in each country setting.

As the lead international technical agency in the field of public health, WHO is concerned with the health aspects of sexuality and reproduction. WHO establishes and disseminates norms and standards and provides, on request, information and technical advice to Member States. It is they who have the responsibility to decide what position to take with regard to their implementation.

WHO’s support to governments and our normative work and technical advice are the outcome of systematic biomedical, epidemiological, health systems and operations research, reviews of the evidence and analysis of best practices. This involves inputs not only from biomedical and epidemiological experts but also from users, women’s groups and social scientists. We believe that the involvement of all stakeholders helps to ensure that sensitive or controversial issues can be addressed on the basis of sound and objective knowledge.

Has the Cairo Plan of Action already produced tangible results?

Yes, several. In some places, new partnerships between governments and NGOs have been formed, albeit with ups and downs as groups earn each others’ trust, prove that their motivations are decent, and learn that they have some mutual benefit from collaboration. The needs of neglected groups are increasingly being addressed. In the past, in many countries, reproductive health services were available only to married people, and the sexual and reproductive health of young people remained a neglected area of public health. That is beginning to change. For example, WHO’s work on adolescent health has had, as a central aspect, the development of culturally-sensitive methods to elicit from young people their perspectives on their health needs and the solutions to their problems. Such information was for example used in drafting the national youth policy and Guinea’s reproductive health programme.

WHO has sponsored research on adolescent reproductive health. Studies undertaken in Africa, Asia and Latin America have highlighted a lack of basic knowledge among adolescents about their body’s reproductive functioning and about contraception. There is evidence of increasing sexual activity among adolescents at younger ages coupled with little use of contraceptives among sexually active adolescents. The detrimental effects of single motherhood and unsafe abortion and the growing problem of sexually transmitted infections are known.

The emphasis on controlling women’s fertility in the past three decades rendered men almost invisible in reproduction. To understand better how to promote and enable male responsibility in reproductive health, WHO is supporting research on male sexual behaviour, adolescent male sexuality and contraception, male contraceptive practice and men’s roles in decisions about fertility and family size. Studies are ongoing in twelve countries of Africa, Asia and Latin America. A study in Thailand, for example, found that, while 79 per cent of husbands report having sex with a sex worker at least once in their life.

Evidence is being generated on neglected issues. For instance, WHO is supporting a seven-country study on the prevalence, risk and protective factors and health consequences of violence against women. Another issue for which new evidence has been generated, is unsafe abortion. Over the past several years, WHO has undertaken a major research initiative on practices, beliefs and experiences with induced abortion in countries with different legal contexts. The studies carried out show that abortion clearly emerges as a prevalent and persistent threat to health for many women of reproductive age in all countries. The research highlights the need to focus more directly on the needs and preferences of the women who seek abortion, as well as on the attitudes and skills of providers of abortion services. The quality of abortion care needs to be addressed. The information generated by these studies have been widely used to stimulate public debate in all the countries involved, and in some countries it has brought about policy changes, and improvements in the quality of care.

What is the most worrying problem in the field of reproductive health, and what can one / should one do to solve it?

The most worrying problem is the failure of governments and donor agencies to allocate sufficient resources to the changing paradigm. All the evidence shows that funding has fallen far short of the needs estimated in Cairo.

Related to this is the problem of donor co-ordination. Country case studies conducted by many organisations as part of the ICPD+5 review suggest that donors and technical agencies do not always co-ordinate well their support for programming for reproductive health at the country level. Innovative approaches to planning and financing reproductive health in sector-wide approaches may hold some lessons. If progress is to be made, co-ordination is vital.

Another problem is the failure to translate words into action in terms of the actual functioning of health systems. Health sector reform presents an opportunity to redirect services to meet more effectively the needs of people in sexuality and reproduction. On the other hand, the economic crisis affecting some countries and the economic restructuring affecting others place substantial constraints on the public sector whose mandate it is to ensure the accessibility of reproductive health services. Women experiencing an obstetric emergency will always need a functioning health system. We will not make motherhood safe until we invest in appropriate health care systems.

Another issue relates to the need to translate rights in sexuality and reproduction into laws. Much more can be done to strengthen laws that directly affect reproductive health, and those that create an environment that enables reproductive health.

Which objectives with respect to reproductive health should be reached in the course of the next five to ten years? And what will be the contribution of your organisation?

WHO will work with the public health community to reaffirm the values that underlie reproductive health as agreed upon at ICPD, and that are the basis of Health for All: Equity and solidarity.

WHO will take on its particular responsibilities with respect to the roles of health providers, policy-makers, and the public health community at large. If we have learned anything from the experience of Primary Health Care it is that scientists and health providers do not often believe primary health Care is the best use of their training, and they are understandably uncertain about what is their best role, in advocating non-health interventions. We can and should say in public: "No woman should die of preventable causes in pregnancy — maternal health services must be adequately funded". At the level of the individual provider, perhaps it is simply recognising that a problem exists and knowing where to go for the right kind of help. Take the issue of violence related to sexuality and reproduction. In any case, a concrete division of labour — deciding which sectors, institutions, professions, persons do what — needs to be worked out in an agenda based on rights, equity and dignity.

WHO will undertake additional work to clarify the conceptual framework for reproductive health. Cost-effectiveness is clearly a critical issue everywhere. An important consideration in this context is not to focus on short-term gains at the expense of long-term benefits.

WHO will work with countries to define the programmatic response to reproductive health that is appropriate given the epidemiological, social, political and economic realities that they face. As a concrete step, country strategies for reproductive health might be defined through participatory priority-setting exercises, as they provide a powerful opportunity for learning and for consensus-building.

WHO will pay more attention to education and training. The curricula of academic institutions, such as medical, nursing, midwifery, and public health schools have not caught up with the concept of sexual and reproductive health, as a condition, as an approach, or in terms of comprehensive approaches to services. Our future experts and specialists are leaving their educational institutions with prestigious degrees ill-equipped to lead in the world changed by ICPD.

Paul F.A. Van Look (Director) and, Carla Abou Zahr, Department of Reproductive Health and Research at the World Health Organization WHO