Ensuring timely access to essential supplies: Sexual and reproductive health.
In recent decades, governments, international agencies, international and national nongovernmental organizations, cooperation agencies and civil society have undertaken technical and political reflections on the challenges involved in providing adequate sexual and reproductive healthcare services for women and men and meeting the multiple demands of these users, which vary widely according to socioeconomic status, cultural and personal interests. At the same time, the implications of sexual and reproductive rights as human rights have been explored and re-conceptualized in light of the serious obstacles that still exist to their full recognition and effective incorporation into government plans, regulations and programs and in public policy in general.
Indeed, most countries still do not have legislation that reflects the commitments to the right to health that gradually have been incorporated into the international system of human rights. This signals a serious legal gap that limits citizens' ability to demand their rights, thus hindering the full exercise of the right to health and especially sexual rights and reproductive rights.
This serious situation is complicated by the stubborn presence of cultural, political and religious fundamentalisms that intertwine and reinforce one another to resist significant progress in this realm by imposing a single acceptable form of behavior and attitudes on the private and intimate realm of sexuality and reproduction. The fundamentalism of the market also has added its own generous contribution of ideological intolerance and narrow-mindedness.
Nonetheless, it is increasingly evident that the enjoyment of optimal sexual and reproductive health is essential for the comprehensive health of women and men throughout their life, as well as for their well-being and development. Especially in the case of women, deficient sexual or reproductive health care can result in serious consequences and can affect their quality of life and life expectancy. In fact, one of the clearest indicators of women's inequitable access to health is evident in maternal mortality, which has a disproportional impact on women in developing countries: their risk of becoming ill or dying due to pregnancy or childbirth is several times higher than that of women from industrialized countries.
These deaths are, for the most part, preventable: they can be avoided through the allocation of sufficient resources and the implementation of basic public health measures that continue to be postponed. Maternal mortality and morbidity also are related to cultural gender bias, which is evident every time that women face difficulties in protecting themselves in situations of risk, such as non-consensual sexual relations, sexual violence, exposure to sexually transmitted infections, unwanted or mistimed pregnancy, unsafe and clandestine abortions and coercion in use of contraception or denial of access to contraceptive methods.
The Cairo Paradigm
To promote and protect human sexuality and reproduction, a series of international agreements and initiatives have been established. These include the programs and platforms for action from the UN international conferences, especially the International Conference on Population and Development (Cairo, 1994) and the Fourth World Conference on Women (Beijing, 1995); the "safe motherhood" initiatives led by the Pan American Health Organization and the World Health Organizations as well as various non-governmental organizations; and the establishment of special programs to confront the HIV/AIDS epidemic. At the same time, activism campaigns on health issues have been developed over several decades by international and regional women's networks demanding the right to safe abortion services, prevention of adolescent pregnancy, prevention of HIV/AIDS, quality healthcare, as well as monitoring initiatives or watchdog groups on public health policy and the development of health indicators with a gender perspective, to name only a few.
The International Conference on Population and Development, ICPD--held in Cairo, Egypt, in 1994--was crucial for the development of a new paradigm of sexual and reproductive health and reproductive rights. Not only did the ICPD define reproductive health and reproductive rights, but it also established the basis for the later recognition of sexual rights, which meant a tremendous conceptual transformation, a veritable revolution that continues in full swing.
Overcoming the primarily demographic focuses of earlier conferences, the ICPD addressed the issue of population in tandem with human development; women's status; gender equity; comprehensive health; individual and collective well-being; and respect for individual rights, especially reproductive rights. Population policies--which historically have been linked to processes that violate rights through coercion and the imposition of demographic goals, especially among women of limited resources--are now integrated into development policies "with a human face." Thus, the Programme of Action marked the beginning of a new perspective on the triad of population, women and development, reinforcing the concept of health as a process and as a civil right.
Equally important was the ICPD emphasis on the empowerment of women as a necessary condition for the protection of reproductive health, understanding empowerment as women's ability for autonomy and for making responsible and informed choices in their own lives and with their decision to become involved in the political, social and economic life of their countries.
Indeed, for the first time at a world summit, reproductive rights were conceptualized as human rights, based on the basic right of all individuals and couples to decide freely and responsibly the number of children they wish to have and when to have them, or to decide not have children at all, and to have access to the information and means with which to exercise these options. This definition was a significant advance over the World Conference of Teheran, which in 1968 identified these rights as belonging to "the parents." "With regard to sexual and reproductive healthcare services, the ICPD Programme of Action:
* Applies basic human rights principles explicitly to population policies and programs; rejects coercion (including incentives or disincentives), violence, and discrimination; and re-asserts that all people have the right to good quality health care;
* Calls for and defines reproductive and sexual health care that provides good quality, comprehensive information and services for all, including adolescents;
* Recognizes unsafe abortion as a major public health issue and urges governments to reduce the incidence of unsafe abortion, ensure that services are safe when they are not against the law, offer reliable and compassionate counseling for all women who have unwanted pregnancies and provide humane care for all women who suffer the consequences of unsafe abortion." (Adrienne Germain and Rachel Kyte, The Cairo Consensus: The Right Agenda for the Right Time. New York: International Women's Health Coalition, 1995, http://www.iwhc.org/resources/cairoconsensus.cfm).
In Article 7.23, this ground-breaking agreement also recognized that "appropriate methods for couples and individuals vary according to their age, parity, family-size preference and other factors" and that governments therefore must "ensure that women and men have information and access to the widest possible range of safe and effective family planning methods in order to enable them to exercise free and informed choice." This article also adds that governments must strive for services that are "safer, affordable, more convenient and accessible for clients and ensure, through strengthened logistical systems, a sufficient and continuous supply of essential high-quality contraceptives." Further on, article 7.45 emphasizes that "countries must ensure that the programmes and attitudes of health-care providers do not restrict the access of adolescents to appropriate services and the information they need, including on sexually transmitted diseases and sexual abuse. In doing so, and in order to, inter alia, address sexual abuse, these services must safeguard the rights of adolescents to privacy, confidentiality, respect and informed consent, respecting cultural values and religious beliefs. In this context, countries should, where appropriate, remove legal, regulatory and social barriers to reproductive health information and care for adolescents."
Twelve Years Later
However, the transcendental ideological change implied in the Cairo consensus is somehow stalled today. The issue of resources is one of the factors that explains this phenomenon. Indeed, the ICPD Programme of Action noted that by the year 2000, the total budgetary allocations for population policies should have tripled if universal access to reproductive health services is to be achieved by the year 2015, along with the provision of sufficient human resources and reproductive health supplies so that these services function in an optimal fashion. In other words, the ICPD agreement proposed to increase the existing global spending on reproductive health from today's US$5 billion to US$17 billion; donor countries theoretically contribute a third of the resources, and developing countries the remaining two-thirds. But the expected resources never arrived, which has produced a tremendous shortfall since the agreements of 1994. Not even the Millennium Summit, which established the Millennium Development Goals in 2000, managed to encourage the contribution of resources for women's health. In other words, the promises on paper have still not become concrete commitments in terms of funding.
At the same time, there continues to be ideological resistance to the conceptual advances from Cairo, especially due to the growing conservativism encouraged by the Bush administration, which has persistently cut U.S. funding for activities of the United Nations Population Fund (UNFPA), the world's leading agency in the provision of aid for sexual and reproductive health and family planning. At the same time, the Bush administration has promoted abstinence and monogamy campaigns with the steadfast support of the Catholic Church, especially in Latin America and the Caribbean. Indeed, such a stance was evident from the very start of his presidency when Bush reinstated the Global Gag Rule, with the dreadful and well-known consequences to reproductive health education, services and supplies in developing countries.
Due to increasing demand by a growing world population of reproductive age, the rising cost of high-quality contraceptives and increased transmission of HIV/AIDS, among other factors, the need for reproductive health supplies is urgent. According to the UNFPA, there is a clear rationale for investing in reproductive health supplies:
* Poverty: Falling fertility rates in low-income countries correlate with a decline in poverty.
* Family planning: Multiple studies demonstrate that family planning programs produce tangible savings. In Mexico, the equivalent of a dollar invested saved nine dollars in other expenses; in Thailand, a dollar invested saved 16 dollars; in Egypt, a dollar invested saved 31 dollars.
* Maternal mortality rate: Life-saving obstetric equipment and drugs are essential to ensure safe motherhood. Also, using contraceptives to avoid too early and unwanted pregnancies and to "space" births is crucial to efforts to reduce MMR.
* Gender equality and education: It is estimated that if modern contraceptive services were available to all 201 million women with unmet need for contraceptives in the developing world, the number of unplanned births would be reduced by 72%.
* HIV/AIDS: Condoms are currently the only product able to prevent sexually transmitted HIV. In addition, the risk of contracting HIV is 2-9 times greater when other STIs are present--a good reason to ensure the reliable provision of supplies for testing and drugs for the treatment of STIs.
* Adolescents and young people: the largest ever number of young people [>1.3 billion] are beginning their reproductive and sexual lives.
In light of the financing crisis that keeps women's and men's reproductive health care demands from being met and the ideological resistance to providing sexual and reproductive health care to certain sectors of the population (such as adolescents), a number of international and national organizations that work in this area have joined in alliances to resolve these problems. For example, the Reproductive Health Supplies Coalition includes John Snow Inc., Population Action International (PAI), PATH (Program for Appropriate Technology in Health) and the International Planned Parenthood Federation (IPPF). At the same time, other organizations monitor and denounce the worldwide impact of the Global Gag Rule. Meanwhile, the United Nations Population Fund (UNFPA) has started its own initiative, the Global Programme to Enhance Reproductive Health Commodity Security to find a way to satisfy an increasing demand (see sidebar, p. 31). All these groups and organizations agree: people's sexual and reproductive healthcare needs must be met efficiently and in a timely fashion with high quality of care and the highest ethical standards.
A Shopping List that Saves Lives
* Contraceptives that allow couples to plan for pregnancy;
* Condoms for dual protection against unwanted pregnancy and sexually transmitted infections, including HIV/AIDS;
* Drugs, midwifery kits and medical equipment to provide skilled care at birth;
* Soap, plastic sheets and razor blades to cut umbilical cords and make deliveries safer. US$1 million of commodities can prevent any one of the following:
* 800 maternal deaths;
* 11,000 infant deaths;
* 14,000 additional deaths of children under age five;
* 150,000 induced abortions;
* 360,000 unwanted pregnancies.
Source: UNFPA, "Securing the Supplies that People Rely On," brochure available online at http://www.unfpa.org/upload/lib_pub_file/ 335_filename_rchs-brochure-english.pdf.
RELATED ARTICLE: Global programme to enhance reproductive health commodity security.
Reproductive Health Commodity Security (RHCS) is achieved when all individuals can obtain and use affordable, quality reproductive health commodities of their choice whenever they need them. Reproductive health commodities, in this discussion, are comprised of equipment, pharmaceuticals and supplies for: obstetric and maternal health care; the prevention, diagnosis and management of reproductive tract infections and sexually transmitted infections; and contraceptive supplies including male and female condoms. RHCS is essential to meeting the target of universal access to reproductive health by 2015, as called for by the International Conference on Population and Development (ICPD) and reiterated at the 2005 World Summit. It is also critical in the fight against HIV/AIDS.
The UNFPA's new Global Programme to Enhance Reproductive Health Commodity Security provides a structure for moving beyond ad hoc responses to shortages towards more predictable, planned and sustainable country-driven approaches for securing essential supplies and ensuring their use.
Focused at country level, the Global Programme creates a process that will galvanize, institutionalize and coordinate national efforts. Three separate funding streams offer flexibility to assist countries based on their specific needs and current capacity.
In addition, the Global Programme will forge stronger links with regional institutions in the areas of capacity enhancement and training, research and development, data collection and project monitoring. By encouraging plans of action that emphasize linkages between HIV/AIDS and reproductive health care, it also will seek to harmonize multilateral efforts in the areas of sexual, reproductive and maternal health.
Although the specific activities funded through the program will be decided at the country level, the Global Programme sets clear parameters. This ensures that funded activities further UNFPA's mandate and international goals while also addressing the specific, self-defined development priorities of each country. The application and review process ensures that supply-side issues are complemented by an integrated, human rights-based approach that will benefit the end user. It will also focus attention on broader health systems issues of quality of care, the policy environment, access and demand.
For more information, visit the UNFPA website at http://www.unfpa.org/news/news.cfm?ID=881.
RELATED ARTICLE: Sexual and reproductive rights for all!
"Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. In line with the above definition of reproductive health, reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations and not merely counselling and care related to reproduction and sexually transmitted diseases."
Article 7.2 of the Programme of Action from the International Conference on Population and Development, Cairo, 1994.
RELATED ARTICLE: Catholic churches influence over sexuality loosening?
Governments across Latin America are attempting to increase access to emergency contraception (EC)--which can prevent pregnancy if taken within 72 hours of sexual intercourse--despite "stiff resistance" from the Roman Catholic Church.
Chilean President Michelle Bachelet last year announced a policy to distribute EC at public hospitals at no cost to girls as young as age 14; Mexico has required EC to be distributed at all public hospitals; and Peru has offered it at no cost. Public hospitals in Buenos Aires, also offer EC at no cost, and a bill pending in Argentina's Congress would expand the service nationwide. Argentinean Catholic bishops have urged Congress to reject the bill, saying that EC is "an assault on human life" and that the legislation would violate the country's constitution.
EC has gained more acceptance throughout Latin America "as people increasingly ignore traditional Catholic Church teachings on sexuality," said Margarita Berkenwald, coordinator of the sexual and reproductive health program in Buenos Aires, adding: "This is part of an historic process in our region, a process of evolution in which reproductive rights are increasingly seen as people's rights." EC is available without a prescription in about 40 countries worldwide.
Source: Kaiser Network, 09/01/07, published in IPPF NewsNewsNews International News Highlights in Sexual and Reproductive Health & Rights, 10/01/2007, available on-line at http://www.ippf.org/en/News/Intl+news/.
RELATED ARTICLE: Growing interest in contraceptive use.
As more couples wish to delay and limit childbearing, the demand for modern contraceptives is rising. The UN estimates that the proportion of couples using contraceptives will grow 18 percent from 2000 to 2015. The number of contraceptive users over this period is projected to increase more than 40 percent as a consequence of both population growth and an increase in the proportion of people using contraception.
The greatest increases will be in the poorest countries, which currently have high population growth rates and low but growing rates of contraceptive use. A recent analysis of 87 less-developed countries that rely on donor financing for contraceptives predicted that the number of contraceptive users in these countries would rise by 79 percent during the next 15 years. The number of contraceptive users in sub-Saharan Africa is projected to rise by 200 percent by 2015.
The HIV/AIDS pandemic compounds the problem of contraceptive supply shortages in less-developed countries. Of the 40 million people worldwide living with HIV or AIDS, 94 percent are in less-developed countries. Poverty, lack of knowledge and lack of access to reproductive health supplies help fuel the spread of the virus. Health experts recognize the use of condoms as the most effective means of protection for sexually active individuals.
Source: Population Reference Bureau, Securing Future Supplies for Family Planning and HIV/AIDS Prevention, 2002, online at http://www.prb.org/Publications/PolicyBriefs/SecuringFutureSuppliesf or FamilyPlanningandHIVAIDSPrevention.aspx.
RELATED ARTICLE: UN: HIV crisis in Latin America.
In a meeting organized by UNAIDS, health officials from Latin America discussed the accomplishments and challenges in the fight against HIV and urged the international community not to abandon the cause.
According to UNAIDS, more than half of the estimated 1.7 million people living with HIV in Latin America live in the four largest countries: Argentina, Brazil, Colombia and Mexico. But prevalence of the virus is highest in smaller countries such as El Salvador, Guatemala, Panama, Honduras and Belize.
The proliferation of HIV in Latin America has been fueled largely by factors such as poverty, migration, insufficient information about prevention and "rampant homophobia," according to UNAIDS. However, injecting drug users and male homosexuals are the communities with the most recent outbreaks of the epidemic. "Unprotected sex between men remains a significant factor in HIV transmission and accounts for nearly half of the sexually transmitted HIV infections in Brazil," according to a 2006 UNAIDS report, adding that "as HIV spreads from the most-at-risk populations to other lower-risk populations, women are increasingly being infected."
Source: Associated Press, 18/12/2006.
RELATED ARTICLE: Basic reproductive health commodities: Definition and example.
The definition of the term "reproductive health commodities" is not widely known by national organizations that provide health-care services, not even those with considerable experience as providers of reproductive care. In fact, in 2000 Population Action International (PAI) undertook a survey of 64 agencies dedicated to service provision in several countries around the world, and none of the 25 responding organizations had an officially approved definition of reproductive health care and the required commodities. The PAI survey results also indicated that the term "commodities" can be defined in a number of ways and may include: supplies, equipment, pharmaceuticals, over-the-counter drugs, laboratory supplies, materials, consumer goods and medication.
Nonetheless, contraceptives and prophylactics for the prevention of HIV were the most commonly named, essential elements for reproductive health care. But the list of reproductive health commodities undoubtedly is much broader and more diverse than the pill or condoms.
The following table on basic reproductive health commodities draws on information from numerous international organizations working on the subject.
Basic Products for Fertility Regulation
a. Contraceptive methods: male and female condoms, diaphragms, IUDs, oral contraceptives, injectable contraceptives, implants and other hormonal contraceptives, emergency contraception, spermicidal products.
b. Other products for fertility regulation: specula, forceps, scissors, scalpels, suture and other elements for inserting and removing IUDs, performing vasectomy, implanting subcutaneous contraception, and performing minilaparotomy, laparoscopy and tubal ligation.
c. Elements for the termination of pregnancy, such as the instruments used in Manual Vacuum Aspiration (MVA) and drugs used for medical abortion, such as misoprostol and mifepristone.
d. Products for maternal and neonatal care.
Products Related to Sexually Transmitted Infections and HIV/AIDS
a. Commodities for the prevention of sexually transmitted infections, including HIV/AIDS, and for the treatment of all STIs. For example, male and female condoms, equipment for diagnostic exams, specula, syringes, needles, gloves, informational material, drugs.
Standards for Reproductive Health Commodities
Access to reproductive health commodities also implies a series of conditions. It is not enough that the supplies are in stock: they must get to the users in optimal conditions. The United Nations Population Fund (UNFPA) sets relevant standards based on its considerable experience in this area.
The UNFPA approach to reproductive health commodity security can be summarized in a simple statement: the right quantities of the right products in the right condition in the right place at the right time for the right price, which means:
1. The Right Quantities: Needs assessment and forecasting to predict the quantity and type of commodity needed and when it will be needed. Potential shortfalls can often be averted with careful forecasting.
2. Of the Right Products: Needs vary from one country to the next, from one culture to the next, from one individual to the next. Research enables UNFPA and its partners to understand the use of commodities and to identify opportunities to increase demand.
3. In the Right Condition: Quality assurance, storage and warehousing are fundamental aspects of commodity security. People count on reproductive health products to protect their health and plan their families. It is essential that they be of good quality with maximum shelf life.
4. In the Right Place: Distribution systems must be reliable, efficient and able to reach people in distant locations and under difficult conditions.
5. At the Right Time: Lead times, consumption patterns and transportation determine whether supplies are available when they are needed. Long-term planning offers a measure of control by anticipating needs far in advance.
6. For the Right Price: Costs are kept down through good planning and coordination, competitive bidding, innovative attempts to rationalize expenses, tracking, monitoring and accountability. As the largest international public sector procurer of these reproductive health commodities, UNFPA is able to purchase in bulk to keep prices down.
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|Publication:||Women's Health Journal|
|Date:||Jan 1, 2007|
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