HRP annual report 2020

HRP ANNUAL REPORT 2020 UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), based in the WHO Department of Sexual and Reproductive Health and Research (SRH)

HRP ANNUAL REPORT 2020 UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), based in the WHO Department of Sexual and Reproductive Health and Research (SRH) HRP annual report 2020 ISBN 978-92-4-003560-7 (electronic version) ISBN 978-92-4-003561-4 (print version) © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. 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The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. About us Why sexual and reproductive health and rights? Changes at HRP during 2020 WHO transformation and HRP HRP Theory of Change Helping people to realize their desired family size Selected 2020 achievement in family planning and contraception Selected 2020 achievements in fertility care Ensuring the health of pregnant women and girls and their newborn infants Selected 2020 achievements in maternal and perinatal health Preventing unsafe abortion Selected 2020 achievements in preventing unsafe abortion Promoting sexual health and well-being Selected 2020 achievements in preventing and managing STIs Selected 2020 achievements in preventing cervical cancer SRHR during the global COVID-19 pandemic and other health emergencies Selected 2020 achievements in sexual and reproductive health during the COVID-19 pandemic Selected 2020 achievements in SRHR in other disease outbreaks Selected 2020 achievement in SRHR in humanitarian settings Healthy adolescence for a healthy future Selected 2020 achievements in adolescent sexual and reproductive health Preventing and responding to violence against women and girls Selected 2020 achievements in violence against women and girls Selected 2020 achievement in female genital mutilation (FGM) Protecting and securing sexual and reproductive health with human rights Selected 2020 achievements in human rights for sexual and reproductive health and rights Supporting and strengthening national health systems for achieving Universal Health Coverage Selected 2020 achievements in integrating sexual and reproductive health services into UHC strategies Selected 2020 achievements in self-care interventions for sexual and reproductive health Selected 2020 achievements in digital health 01 02 03 04 05 06 07 08 09 10 11 12 1 2 4 4 6 8 9 10 12 14 18 19 20 21 23 24 26 29 30 32 34 36 37 38 40 42 44 45 46 47 CONTENTS HRP ANNUAL REPORT 2020 iii CONTENTS Strengthening research capacity and leading research development in SRHR Selected 2020 achievements by the HRP Alliance Selected 2020 achievement in research management Partnering to achieve impact: HRP partnerships in 2020 Selected 2020 achievements and key partnerships Donors Photographer Credits 13 14 15 16 48 49 50 52 53 56 57 HRP ANNUAL REPORT 2020iv

HRP ANNUAL REPORT 2020vi 1HRP ANNUAL REPORT 2020 The UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) has been providing leadership on sexual and reproductive health and rights (SRHR) for over 45 years. 01 ABOUT US Founded in 1972, we have a unique mandate within the United Nations (UN) system to lead research and to build research capacity for improving SRHR through generating and enabling use of high-quality evidence. HRP is based at the World Health Organization (WHO) headquarters in Geneva, Switzerland, within the Department of Sexual and Reproductive Health and Research (SRH). We work collaboratively with partners across the world to shape global thinking on SRHR by providing new evidence-based ideas and insights. We support high-impact research, inform WHO norms and standards, support research capacity strengthening in low- and middle-income settings, and facilitate the uptake of new information and innovations – including clinical and behavioural interventions, digital technologies, and the research and development of new medicines and devices. An ethical, human rights-based approach that aims to reduce gender inequalities and structural inequities in access is integrated throughout our work. HRP shares the WHO vision of the right for every single person across the globe to attain the highest possible standard of sexual and reproductive health. We strive for a world where human rights that enable sexual and reproductive health are safeguarded, and where all people have access to quality and affordable sexual and reproductive health information and services. HRP ANNUAL REPORT 20202 02 WHY SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS? The right to sexual and reproductive health for the well-being of individuals, families and communities, and for sustainable development is internationally recognized. The Sustainable Development Goals (SDGs); the UN Secretary-General’s Global Strategy for Women’s, Children’s and Adolescents’ Health; the WHO Reproductive Health Strategy; and the Programme of Action of the 1994 International Conference on Population and Development all reflect a collective vision that underlines the importance of protecting all people’s human rights to access information and services that will enable them to achieve the highest standards of sexual and reproductive health. While great progress has been made since HRP was established in 1972, huge challenges remain. A substantial proportion of women and couples are unable to plan whether and when to have children and how many to have. Too many women and newborns continue to die before, during and after childbirth. Violence against women and girls – including harmful traditional practices – is widespread and a human rights violation. Many individuals and couples are still unable to access information and services to ensure their sexual, reproductive, maternal and perinatal health, putting their health, well-being and lives at risk. Humanitarian crises and disease outbreaks threaten lives, livelihoods, health, and access to services for millions. And there are now more adolescents than at any time in history, greatly increasing demand for high-quality services that meet their needs. Better data are key. Accurate service statistics through robust health management information systems help front-line health workers to provide better services and care and enable managers to plan for equitable implementation; rigorously and ethically collected evidence improves estimates of health conditions and strategic planning to address priority needs; and information from intervention and implementation research informs policy, budgeting and programming at scale. Without continuing investments in research, as well as in improving the capacity of countries to conduct and use research, it is unlikely that national primary health systems will be able to effectively implement globally agreed norms and standards of care, or to achieve the goal of universal health coverage (UHC). For over 45 years, HRP has been conducting research with international and national partners to improve sexual and reproductive health and to safeguard the human rights of all people everywhere. We invite you to join us in our efforts – with your help, we can continue to improve lives worldwide. HRP ANNUAL REPORT 2020 3 HRP ANNUAL REPORT 20204 WHO transformation and HRP 03 CHANGES AT HRP DURING 2020 The major areas of work in the WHO Transformation Agenda reflect three strategic objectives: to focus WHO work on driving impact at country level and embed its mission and strategy in the day-to-day work and organizational culture; to establish a fit- for-purpose organization to deliver the mission and strategy, anchored in new ways of working that are enabled by effective processes and put into practice through an aligned, three-level operating model; and to leverage WHO partners and the global community to drive health outcomes, including new partnership and resource mobilization initiatives. For HRP, the transformation has resulted in three significant organizational changes. First, the Department of Sexual and Reproductive Health and Research (SRH; formerly called the Reproductive Health and Research Department [RHR]), within which HRP is based, is now located in the Universal Health Coverage across the Life Course Division to reflect the centrality of SRHR issues in both UHC and a life- course approach to health care. Second, while HRP is based within SRH, it has also joined the other special research programmes at WHO to become a part of the WHO Science Division. This affiliation facilitates HRP’s engagement in and contribution to the global leadership of WHO in setting the agenda for research and producing normative guidance on research methodologies. Third, through the Transformation process, all WHO departments were given the opportunity to review and revise their internal structures so they can be organized to better fulfil their functions of global leadership, production of global public health goods (especially normative guidance), country support and research. Through a widely consultative process, SRH, including HRP, has been restructured into eight units (see Fig. 1). The department, including HRP, has been operating through this structure since January 2020, with each unit responsible for the following technical areas: • The Addressing Needs of Vulnerable Populations (AVP) unit seeks to overcome discrimination and inequalities in sexual and reproductive health that contribute to risks and vulnerability. It does this through leadership in research and development; innovation; evidence synthesis; development of guidelines and recommendations; provision of specialized technical support; and the dissemination of information on evidence- based practices on issues such as adolescence, gender-based violence and traditional and harmful practices, health emergencies and migration, disability, and sexual orientation and gender identity. • The Contraception and Fertility Care (CFC) unit develops guidelines and recommendations; coordinates research, evidence synthesis, development and innovation; provides specialized technical support; and disseminates information on evidence-based practices in contraception and fertility care, including infertility management and treatment of associated conditions. HRP ANNUAL REPORT 2020 5 Maternal and Perinatal Health (MPH) Prevention of Unsafe Abortion (PUA) Contraception and Fertility Care (CFC) Sexual Health and Reproductive Cancers (SRC) SRH Integration in Health Systems (SHS) Addressing needs of Vulnerable Populations (AVP) Research Leadership and Capacity Strengthening (RLC) Department of Sexual and Reproductive Health and Research (SRH), including HRPHRP Secretariat (SRT) FIG. 1 SRH Structure • The Maternal and Perinatal Health (MPH) unit is responsible for research and development, innovation, evidence synthesis, development of guidelines and recommendations, provision of specialized technical support, and dissemination of information on evidence-based practices in maternal and perinatal health, including antenatal, intrapartum and postnatal health care. • The Prevention of Unsafe Abortion (PUA) unit is responsible for research and development, innovation, evidence synthesis, development of guidelines and recommendations, provision of specialized technical support, and dissemination of information on evidence-based practices on prevention of unsafe abortion, including safe abortion services and post-abortion care. • The Research Leadership and Capacity Strengthening (RLC) unit coordinates HRP’s work on research agenda setting, research methodology development, research capacity strengthening, scientific and ethical review processes, study design, statistical and data management and analysis support, and research partner engagement. • The Sexual and Reproductive Health Integration into Health Systems (SHS) unit is responsible for research and development, innovation, evidence synthesis, development of guidelines and recommendations, provision of specialized technical support, and dissemination of information on evidence-based practices for the integration of sexual and reproductive health services in primary health care for achieving UHC. This includes in fragile settings and with a focus on self-care and digital health, health data systems, innovative financing, and monitoring of global health indicators. • The Sexual Health and Reproductive Cancers (SRC) unit is responsible for research and development, innovation, evidence synthesis, development of guidelines and recommendations, provision of specialized technical support, and dissemination of information on evidence-based practices on sexual health. This includes for sexually transmitted infections (STIs), reproductive cancers, sexual functioning, well-being and pleasure, and sexuality counselling. • The HRP Secretariat (SRT) is responsible for HRP governing and advisory bodies, strategic and operational planning, finance and administration, communications, global advocacy, fundraising and partner engagement. HRP ANNUAL REPORT 20206 HRP Theory of Change In 2019 HRP developed a new “theory of change”. The theory of change defines HRP’s overall goals, its work, outputs and outcomes, and the impact that the special programme aims to see in countries. At the highest level, the goal of HRP is to contribute to the achievement of sexual and reproductive health and rights for all, with particular emphasis on meeting the needs of low- and middle-income countries. This is achieved through HRP’s continuing contribution to changes in international and national policies and laws, as integral elements of national health systems and programmes. This subsequently has an impact on health-care practices and provision, and addresses harmful social norms with a human rights-based approach to health. HRP creates new knowledge through different types of research and synthesizes available research evidence. This evidence is then used, particularly by WHO and other co-sponsors with HRP support, to develop evidence-based guidelines, implementation tools and policy statements, which are subsequently used both internationally and nationally to inform strengthening of health systems and service delivery. HRP works with its international partnerships and networks, including with co-sponsors, research partners, professional associations and civil society, to accelerate uptake of research-based evidence and to contribute to enhancing national capacity to generate and use evidence. The theory of change is at the core of HRP’s impact measurement, and a detailed results framework has been developed that will enable HRP and our partners to monitor our progress. HRP Theory of Change Actions across key thematic areas of sexual and reproductive health and rights Appropriate research agenda is set International partnerships and networks engaged New knowledge created Enhanced national level capacity to generate and use evidence Partners engaged to stimulate and support country level action Evidence is used/applied nationallyEvidence is used/applied internationally Policies, practices, laws and fulfilment of rights Policies, practices, laws and fulfilment of rights Norms, attitudes, beliefs and behaviours Improved and more visible global evidence base on SRHR Evidence-based normative guidelines, implementation tools and policy statements Norms, attitudes, beliefs and behaviours Sexual and reproductive health and rights for all Health systems, programmes and services Research evidence synthesised National changes in:International changes in: HRP ANNUAL REPORT 2020 7 HRP ANNUAL REPORT 20208 Access to safe, quality and affordable contraceptive information and services, together with the prevention and treatment of infertility, allows people to have the number and timing of children they would like. 04 HELPING PEOPLE TO REALIZE THEIR DESIRED FAMILY SIZE Ensuring access to preferred contraceptive methods for women and couples is essential to securing their well-being and autonomy, while supporting the health and development of communities. Evidence shows that in 2019, amongst the 1.9 billion women of reproductive age (15–49 years) worldwide, 270 million have an unmet need for contraception. Some women and girls face particular challenges – less than half of the need for family planning was met in Middle and Western Africa. Reasons for this include: fear or experience of side effects, limited access and choice, cultural or religious opposition, and poor quality of available services. Satisfying the demand for contraception would significantly reduce unintended pregnancies, unplanned births and induced abortions, as well as maternal morbidity and mortality; some forms of contraception can also help prevent transmission of STIs, including HIV. Infertility affects millions of people globally, the vast majority of whom cannot access the essential interventions they need for various reasons. Despite the scale of infertility and its negative consequences for individuals, couples, families and communities, it is a neglected area of policy, programming and research. HRP is in a unique position to provide global leadership on infertility, helping people to fulfil their right to procreate. HRP ANNUAL REPORT 2020 9 The results of the recent “Evidence for Contraceptive Options and HIV Outcomes Study” or “ECHO Trial” showed that the incidence of HIV infection and other STIs remains high among adolescent girls and women in parts of East and Southern Africa. Despite this, contraceptive services in these and other regions do not provide sufficient choices for girls and women when it comes to the prevention of both unplanned pregnancies and the transmission of STIs, including HIV. In recognition of the action required to invest in and expand contraceptive choices, alongside HIV prevention and STI services – as part of a broader provision of human rights-based SRHR services – HRP joined with WHO, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Global HIV Prevention Coalition to publish a new policy brief, Actions for improved clinical and prevention services and choices preventing HIV and other sexually transmitted infections among women and girls using contraceptive services in contexts with high HIV incidence. SELECTED 2020 ACHIEVEMENT IN FAMILY PLANNING AND CONTRACEPTION HRP ANNUAL REPORT 202010 WHO fact sheets are the most accessed resources on the WHO website, and are also translated into all WHO official languages. In 2020, HRP wrote a new WHO infertility fact sheet, published in September. This fact sheet includes key information and figures; definitions of infertility, including primary and secondary infertility; the causes of infertility; the scale of the issue worldwide; and information on its impact on people and societies. It is an important communications and advocacy material, highlighting that around 48 million couples and 186 million individuals live with infertility globally. The fact sheet will be re-printed in a journal article and has informed policy development by the Ministry of Health in Argentina on the provision of infertility and fertility care during the coronavirus disease (COVID-19) pandemic. Research on the returns on governmental investments in assisted reproduction technology in South Africa was published. The analysis was conducted from a public investment perspective and showed that investing in assisted reproductive technology would result in economic benefits for the government, emanating from future net tax contributions. This research provides a further advocacy tool to ministries of health and finance to increase investments in infertility care. Access the article here: https://www.sciencedirect. com/science/article/pii/S2405661820300125 1 2 SELECTED 2020 ACHIEVEMENTS IN FERTILITY CARE HRP ANNUAL REPORT 2020 11 HRP ANNUAL REPORT 202012 Each day, about 800 women across the world die from complications related to pregnancy or childbirth, most of which are preventable or treatable. The vast majority of maternal deaths – around 99% – occur in low- and middle- income countries, and the risk of maternal death is highest for adolescent girls under 15 years old. 05 ENSURING THE HEALTH OF PREGNANT WOMEN AND GIRLS AND THEIR NEWBORN INFANTS The major complications that account for nearly 75% of all maternal deaths are severe bleeding, infections, high blood pressure during pregnancy (pre-eclampsia and eclampsia), complications during delivery, and unsafe abortion. Other maternal deaths are caused by or associated with diseases such as malaria and HIV. In addition, many more women experience morbidities due to complications of pregnancy and childbirth that include many immediate and longer-term debilitating conditions. Ensuring access to affordable and good-quality care throughout pregnancy and the perinatal period is essential to reducing the rates of complications and deaths related to pregnancy and childbirth. HRP’s research continues to address priority challenges faced by health systems, informing countries of best practices to reduce maternal mortality and morbidity. HRP ANNUAL REPORT 2020 13 14 The results of the HRP-led WHO ACTION-I trial showed that dexamethasone – a glucocorticoid used to treat many conditions, including rheumatic problems and severe COVID-19 – can boost survival of premature babies when given to pregnant women at risk of preterm birth in low-resource settings. The results, which were published in the New England Journal of Medicine, resolve an ongoing controversy about the efficacy of antenatal steroids for improving preterm newborn survival in low-income countries. Dexamethasone and similar drugs have long been shown to be effective in saving the lives of preterm babies in high-income countries, where high- quality newborn care is more accessible. This is the first time a clinical trial has proven that the drugs are also effective in low-income settings. Read more: https://www.who.int/news/item/23- 10-2020-steroids-boost-survival-of-preterm- babies-in-low-resource-settings-new-study-finds 1 Evidence from HRP research was used to develop the WHO labour care guide, a new tool that puts the WHO recommendations on intrapartum care into practice. It helps skilled health personnel to provide woman-centred, safe and effective care, and to optimize the outcome and experience of childbirth for every woman and baby. Launched alongside the WHO labour care guide user’s manual, the tool promotes a person-centred approach to monitoring the health of a woman and the health and well-being of her baby from active first stage of labour to end of second stage of labour. Read more: https://www.who.int/news/item/15- 12-2020-monitoring-childbirth-in-a-new-era-for- maternal-health 2 SELECTED 2020 ACHIEVEMENTS IN MATERNAL AND PERINATAL HEALTH HRP undertook a qualitative systematic review to pay long-overdue respect to the authority of women’s experiences during the postnatal period – defined by WHO as the first six weeks after childbirth. Published in PLOS ONE, the review examines first-hand data from 15 countries and 36 studies published after the year 2000 relating to women’s beliefs, expectations and values at this significant time of life. This review will help to inform new WHO guidelines on a positive experience of postnatal care, which are due to be published in 2021. Read more: https://www.who.int/news/item/22- 04-2020-what-matters-to-women-in-the- postnatal-period 3 HRP ANNUAL REPORT 2020 15 An HRP study showed that substandard and falsified medicines (also known as “out of specification” drugs) could contribute to the persistence of the high numbers of severe complications and deaths of women caused by postpartum haemorrhage, eclampsia and sepsis, particularly in low- and middle-income countries. Nearly half (48.9%) of all uterotonic drugs sampled failed quality assessments. One in seven injectable antibiotic samples (13%) and one in 29 magnesium sulfate samples (3.4%) were of low quality. Nearly half of the samples assessed were collected after 2011, indicating that this is currently an issue of global concern. The research included studies that looked at the quality of medicines at different points in the health system supply chain – including in both the public and private sectors – such as providers; wholesalers; central/regional medical stores; health centres, clinics, and drug shops or pharmacies; and community health workers. In general, higher failure rates were found in private sector outlets than in public sector outlets. The findings underline the crucial need for national procurement bodies and private providers to procure medications that adhere to WHO prequalification, or similar stringent requirements. Read more: https://www.who.int/news/item/10- 07-2020-poor-quality-medicines-putting-lives-of- pregnant-women-at-risk https://www.who.int/docs/default-source/ reproductive-health/maternal-health/ quality-medicines-pregnancy-complications. pdf?sfvrsn=5b904907_2 4 An HRP study highlighted the unacceptable mistreatment of women during childbirth in four countries: Ghana, Guinea, Myanmar and Nigeria. In 2020, less than two months after the publication of the study, and with support from HRP, the collaborating centre in Guinea, CERREGUI, brought ministry officials together with maternity hospital directors, nongovernmental organizations, professional associations and international agencies to develop a set of recommendations to reduce mistreatment of women during childbirth. These include practical steps such as allowing chosen birth companions and accepting the birth position desired by the woman, as well as health system changes, including scaling up training in respectful maternity care and strengthening governance and oversight. Accepted by the Ministry of Health of Guinea, these recommendations are incorporated into the national Reproductive, Maternal, Newborn, Infant, Adolescent Health and Nutrition (SRMNIA-N 2020– 2024) Strategic Plan. They have also informed the Regional MUSKOKA Action Plan of 2021. Read more: https://www.who.int/news/item/15- 05-2020-research-leads-to-actions-improving- childbirth-in-guinea 5 HRP ANNUAL REPORT 2020 When a woman has access to trusted emotional, psychological and practical support during labour and childbirth, evidence shows that both her experience of childbirth and her health outcomes can improve. In the new Evidence-to-action brief, Companion of choice during labour and childbirth for improved quality of care, HRP and WHO present updated information on the benefits of labour companionship for women and their newborns, and how it can be implemented as part of efforts to improve the quality of maternity care. Read more: https://www.who.int/news/item/09- 09-2020-every-woman-s-right-to-a-companion- of-choice-during-childbirth 6 New research from the Global Maternal Sepsis Study (GLOSS) – a major HRP and WHO initiative – shows that infection has a much larger impact on global maternal mortality and morbidity than previously thought. The results from GLOSS, published in The Lancet Global Health, are the first to provide data on frequency of maternal infections and sepsis across the pregnancy and post- pregnancy period, in a number of health facilities around the world. Around 11 women per 1000 live births had an infection which resulted in or contributed to what is known as a severe maternal outcome – either they died or nearly died – during their hospitalization. This research highlights how urgent improvement is needed to manage this life- threatening risk faced by all pregnant and recently pregnant women, wherever they are in the world. The results of the study were incorporated into the 2020 WHO Global report on the epidemiology and burden of sepsis: current evidence, identifying gaps and future directions. 7 HRP ANNUAL REPORT 202016 Respectful intrapartum care maintains women’s dignity, privacy and confidentiality; ensures freedom from harm and mistreatment; and enables informed choice during labour and childbirth. The WHO model of intrapartum care provides a basis for empowering all women to access and demand the type of care that they want and need. In 2020, HRP edited the special supplement, Optimal intrapartum care, to highlight how quality of care is fundamental to the WHO approach to maternity care. The 11 manuscripts in the supplement cover existing WHO intrapartum care recommendations and new evidence on progression of labour, use of the partograph, fetal monitoring, management of labour and respectful maternity care. Read more: https://www.who.int/news/item/20- 08-2020-meeting-women-s-emotional- psychological-and-clinical-needs-during- childbirth Governments can help to save lives and improve every woman’s and adolescent girl’s experience of pregnancy by updating their national guidelines with the WHO recommendations on antenatal care. For WHO recommendations to be effective, however, they must be adapted to local contexts and monitored in a consistent way. That is why, in 2020, using evidence generated by HRP, WHO released the Antenatal care recommendations adaptation toolkit, in collaboration with ministries of health, WHO regional and country offices, implementation experts and country stakeholders. The toolkit sets out practical steps for governments wishing to introduce WHO recommendations at national and subnational levels. In addition, an antenatal care monitoring framework has been developed to help countries and health facilities track their progress and impact. Access the toolkit: https://www.srhr.org/ antenatalcare/#Tools 8 9 HRP ANNUAL REPORT 2020 17 HRP ANNUAL REPORT 202018 Unsafe abortion occurs when a pregnancy is terminated either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both. Safe abortions are those performed in accordance with WHO guidelines and standards, thus ensuring that the risk of severe complications is minimal. The rate of unsafe abortions is higher where access to effective contraception and safe abortion care is limited or unavailable. 06 PREVENTING UNSAFE ABORTION Life-threatening complications that may result from unsafe abortion include haemorrhage, infection, and injury to the genital tract and internal organs. In addition to the deaths and disabilities caused by unsafe abortion, there are major social and financial costs to women, families, communities and health systems. Almost every abortion-related death and disability could be prevented through sexuality education, use of effective contraception, provision of safe and legal induced abortion, and timely care for complications. 19 SELECTED 2020 ACHIEVEMENTS IN PREVENTING UNSAFE ABORTION New estimates, published in The Lancet Global Health, and jointly authored by the Guttmacher Institute and HRP, looked at the incidence of unintended pregnancy and abortion by income, region, and the legal status of abortion from 1990 to 2019. The results show a worldwide decline in unintended pregnancies since 1990–1994. Over the same period, the proportion of unintended pregnancies ending in abortion has increased. These findings suggest that over the past 30 years, more women and individuals than ever before have been able to limit or space their pregnancies. This is possible thanks to improved access to a choice of contraception, in addition to, and as part of, comprehensive sexual and reproductive health services, including safe abortion care to the full extent of the law. Despite progress, however, between 2015 and 2019, almost half of all pregnancies were unintended. Furthermore, women living in the poorest regions were nearly three times as likely to experience unintended pregnancies than those in the wealthiest regions. Abortion rates were highest in low-income countries that have the most legal restrictions to abortion care. Read more: https://www.who.int/news/item/23- 07-2020-new-estimates-show-worldwide-fall-in- unintended-pregnancies-since-1990-1994 1 The HRP initiative “Supporting Country Strategies to Reduce Maternal Mortality and Achieve SDG Targets through a Health Systems Approach” was expanded in 2020 to include three more countries – Lao People’s Democratic Republic, Myanmar and Sierra Leone. The initiative now spans 10 countries across four WHO regions and six departments at WHO headquarters, supporting approximately 25 staff members within the country and regional offices dedicated to its implementation. The initiative focuses on changes that support an enabling environment for expanding access to services in countries. The work in countries is supplemented by regional and global efforts to develop, document, monitor and share best practices, and to provide strategic leadership in efforts to reduce unsafe abortion. HRP coordinates the work through a Technical Working Group that brings together all three levels of WHO. The initiative is already seeing significant successes in countries. To name a few of many examples, these include: strengthened training on sexual and reproductive health in training institutions and for health professionals in Benin; a new country collaboration strategy in Rwanda to help guide WHO programme alignment; and an update and dissemination of national policy and guidelines on sexual and reproductive health in South Africa. 2 HRP ANNUAL REPORT 2020 HRP ANNUAL REPORT 202020 WHO defines sexual health as “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” 07 PROMOTING SEXUAL HEALTH AND WELL-BEING Based on this definition, and drawing from the WHO Operational framework for sexual health and its linkages with reproductive health, and from the Guttmacher- Lancet Commission’s report on sexual and reproductive health and rights, HRP’s work on sexual health and well-being spans the continuum from well-being to disease and dysfunction: prevention and control of sexually transmissible infections, including HIV; prevention and management of cancers of the reproductive system; education, counselling and care related to sexuality, sexual identity and sexual relationships; and sexual function and psychosexual counselling. 21 SELECTED 2020 ACHIEVEMENTS IN PREVENTING AND MANAGING STIs Point-of-care tests allow people to be screened, tested, diagnosed and treated for STIs in a single visit to a health worker, and can help to dramatically reduce the burden of disease. These tests help to reduce the burden on health workers and systems and can reduce expensive laboratory costs. Crucially, they help to make testing, diagnosis and treatment of STIs easier for people to access. With more timely diagnosis, people can receive the right counselling, treatment and care. They are also less likely to pass the infection onto their sexual partner or partners, helping to stop the further spread of STIs, thereby also preventing the related negative consequences for health and well-being. In 2020, HRP published a “call to action” for health systems to integrate point-of-care testing to mitigate the transmission and burden of STIs. The call to action underlines how the complexity of health systems – including context, institutions, adoption systems and problem perception – must be recognized and mapped, in order to better ensure effective point-of-care testing policy design and programme implementation for better outcomes and impact. Data show that an estimated 87 million new gonococcal infections occurred worldwide in 2016, causing gonorrhoea – with often grave results for health. The infection can cause a number of negative health outcomes, including pelvic inflammatory disease, infertility, adverse pregnancy outcomes, elevated risk for HIV acquisition and transmission, and neonatal conjunctivitis. Furthermore, increasing antimicrobial resistance has made treating gonorrhoea more challenging, which poses a significant threat to people’s health worldwide. A vaccine against gonococcal infections is therefore greatly needed. In recognition of this, HRP generated the evidence to inform a WHO document to describe the preferred product characteristics (PPC) for gonococcal vaccines. WHO PPC documents provide guidance on WHO preferences for new vaccines in priority disease areas, including from the perspective of low- and middle-income countries. Defining the attributes of vaccine products that meet the needs of low- and middle-income countries, while also addressing concerns of high-income countries, can advance development of vaccines that are suitable for global use. The new PPC for gonococcal vaccines describes what is necessary to achieve global health goals and defines key populations, as well as considerations to take into account when working to refine specific target ages for vaccination among young people in higher-risk populations in different countries. Read more: https://www.who.int/immunization/ research/ppc-tpp/Gonococcal_vaccine_PPCs_for- public-comment.pdf 1 2 HRP ANNUAL REPORT 2020 There is no cure for herpes. At present, antiviral medications can help to reduce the severity and frequency of symptoms but cannot cure the infection. Beyond the potential pain and discomfort experienced by people living with herpes simplex virus (HSV) infection, the associated consequences can have a profound effect on their psychological and social well-being, as well as their sexual and reproductive health. Evidence shows that people with herpes simplex virus type 2 (HSV-2) infection are at least three times more likely to become infected with HIV, if exposed. In addition, people with both HIV and HSV-2 infection are more likely to spread HIV to others. In order to better highlight the scale of the problem, HRP and WHO published new estimates on the global infection prevalence and incidence of HSV-1 and HSV-2 in 2016, as well as estimates on the global and regional burden of genital ulcer disease due to HSV. The estimates showed that an estimated 491.5 million people were living with HSV-2 infection in 2016, equivalent to 13.2% of the world’s population aged 15 to 49 years. An estimated 3.7 billion people had HSV- 1 infection during the same year, amounting to about 66.6% of the world’s population aged 0 to 49. The results of both studies highlight the global need for increased awareness of HSV infection and its symptoms, improved access to antiviral medications, and heightened HIV prevention efforts for those with genital HSV symptoms. In addition, development of better treatment and prevention interventions is needed, particularly for HSV vaccines. 3 HRP ANNUAL REPORT 202022 SELECTED 2020 ACHIEVEMENTS IN PREVENTING CERVICAL CANCER Cervical cancer is a disease that can be eliminated. The world already has the necessary tools, but these need to be made accessible. In recognition of this – and greatly thanks to years of hard work by HRP staff – in August 2020, the World Health Assembly passed a resolution calling for elimination of cervical cancer and adopting a strategy to make it happen. The strategy aims that by the year 2030, all countries can achieve 90% human papillomavirus (HPV) vaccination coverage, 70% screening coverage, and 90% access to treatment for cervical pre-cancer and cancer, including access to palliative care. It is a testament to the enthusiasm for this important goal that, even in the context of the COVID-19 pandemic, 194 countries from around the world collectively resolved to end the needless suffering from a cancer that is both preventable and curable. Comprehensive cervical cancer control includes primary prevention (vaccination against HPV), secondary prevention (screening and treatment of pre-cancerous lesions), tertiary prevention (diagnosis and treatment of invasive cervical cancer) and palliative care. In order to help programme managers introduce HPV virological testing as part of screening in their national cervical cancer prevention and control programmes, WHO launched a new tool that draws from HRP research, Introducing and scaling up testing for human papillomavirus as part of a comprehensive programme for prevention and control of cervical cancer. This practical guidance will help countries achieve the global strategy goal of 70% screening coverage by 2030. 1 2 HRP ANNUAL REPORT 2020 23 HRP ANNUAL REPORT 202024 WHO defines health emergencies as sudden-onset events due to naturally occurring or man-made hazards, or gradually deteriorating situations where the risk to public health steadily increases over time. Countries around the world are under constant threat from infectious diseases and conflict, and also increasingly face threats related to natural disasters. 08 SRHR DURING THE GLOBAL COVID-19 PANDEMIC AND OTHER HEALTH EMERGENCIES Throughout the COVID-19 pandemic, countries have had to make difficult decisions on how best to balance the demands of responding directly to the virus, and maintaining the delivery of essential health services, while safeguarding the human rights and well-being of all people. All areas of SRHR are affected by the pandemic. Research is ongoing to examine risks faced by pregnant women – upholding women’s rights to a positive pregnancy, intrapartum and postnatal experience is crucial, while observing protocol to avoid infection with COVID-19. People across the world are facing challenges in accessing contraceptive and abortion information and services, including fertility care services, and pre-existing services and supply chains have in many cases been severely disrupted. Access to sexual health care is being challenged in many settings, including for managing the complications of female genital mutilation (FGM), accessing cervical cancer screening and treatment services, and vaccinating against HPV. With restrictions on movement, as well as greater stress and challenges to employment and finances, women and their children are at increased risk of violence, often finding themselves locked-in with their abusers and unable to reach out to resources for help, or finding that pre-existing resources are no longer available. While COVID-19 is posing challenges for the sexual and reproductive health of all people everywhere, it is particularly difficult for those living in emergency situations, and for refugee and migrant populations who are often unable to access health systems. WHO estimates that every year more than 172 million people are affected by conflict and, as of December 2017, an estimated 135 million people required humanitarian assistance. Moreover, on average 100 epidemic-prone events occur each year. An estimated 32 million women and girls of reproductive age live in emergency situations, all of whom require sexual and reproductive health information and services. The critical importance of scientific evidence to guide planning and action to meet the sexual and reproductive health needs of women and girls, as well as men and boys, living in health emergencies cannot be overstated. HRP ANNUAL REPORT 2020 25 26 Unity Studies is a global sero-epidemiological standardization initiative that aims to increase evidence-based knowledge to inform actions to improve health. HRP published a study protocol on the Unity Studies website investigating maternal, pregnancy and neonatal outcomes for women and neonates infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) – the virus which causes COVID-19. The study aims to determine whether SARS-CoV-2 infection during pregnancy increases the risk of adverse pregnancy, postpartum or neonatal outcomes. Additionally, the study will characterize the clinical spectrum of COVID-19 in pregnant women; quantify the rate of transmission (if any) happening during pregnancy, birth and after birth; determine the incidence of detectable SARS-CoV-2 RNA in pregnancy-related fluids (i.e. amniotic fluid), breast milk and tissues; and follow clinical outcomes of women and their newborns up to six weeks after childbirth. 1 SELECTED 2020 ACHIEVEMENTS IN SEXUAL AND REPRODUCTIVE HEALTH DURING THE COVID-19 PANDEMIC To better support identification of safe and effective treatment options for pregnant women with COVID-19, it is crucial that they are included in clinical trials of therapeutic medicines. In recognition of the need for this type of evidence, HRP published an article in The Lancet Global Health which assessed the extent to which pregnant women are included in clinical treatment trials on COVID-19. The study found that, of COVID-19 treatment studies that were identified from high-volume clinical trial registries, a large proportion specifically excluded pregnant women. This exclusion was not well justified as many of the treatments being evaluated had no or low safety concerns for women and fetuses during pregnancy. Included in the paper was a call to action, with the authors concluding that, “Considering the scale of this global epidemic and future epidemics, a public health obligation exists to include pregnant women in treatment and vaccine trials to adequately identify and implement appropriate prevention and care.” 3 HRP continues to assist the WHO Health Emergencies Programme with global response to the COVID-19 pandemic. This includes through the collection of standardized clinical data on people who have been hospitalized with COVID-19. It was recognized early in the pandemic that case report forms (CRF) – the tool used in clinical trials to collect data on participating patients – would need to be collected to inform evidence-based research. In April, HRP and WHO launched a web-based data platform for three types of CRFs: “core-CRF” for general population hospitalized with COVID-19, “CRF-P” for pregnant women hospitalized with COVID, and “MIS-C” for children and adolescents hospitalized with multisystem inflammatory syndrome. The platform is currently being used by 36 countries, with 80 000 records uploaded. Data are being analysed for reporting at the country level. 2 HRP ANNUAL REPORT 2020 27 Following the announcement of the COVID-19 pandemic, it became quickly clear that the world was also facing a so-called “infodemic” – a deluge of information, much of it not based on evidence or from verified sources. At the same time, reports from countries and in the media have brought to light many concerning issues in relation to SRHR exacerbated by the pandemic. The need for clear communication on these issues therefore became urgent. HRP worked quickly with technical colleagues and communications colleagues in WHO to share key messages and evidence-based information. These messages have been shared through HRP and WHO channels, including social media such as Twitter, Instagram and Facebook; key messages on SRHR issues have also been included in the Director-General’s regular COVID-19 media briefings. Such messaging has covered sexual and reproductive health services included in the Maintaining essential health services: operational guidance for the COVID-19 context interim guidance, the interim guidance on the clinical management of COVID-19; Addressing human rights as key to the COVID-19 response; self-care interventions during COVID-19; COVID-19 and violence against women: what the health sector/ system can do; and sexual and reproductive health of adolescents and youth. 5 The WHO “Family Planning Accelerator Project” aims to improve access to quality and human rights-based family planning services. In 2020, staff in the project countries reported several pandemic-related issues which were disrupting access to contraception. These included: a shortage of health staff at family planning clinics; reduced capacity of health facilities to provide family planning; contraceptive supply stockouts; reduced demand for contraceptive services; and disrupted community outreach programmes. HRP leveraged the Accelerator Project to provide support to all project countries through sharing global evidence-based guidance and best practices, as well as experiences between countries; reviewing country-specific guidance materials; and convening regular consultations to plan strategies to address service disruptions and continue essential services. Thanks to HRP’s support, countries have: developed national policies on continuity of family planning services; developed training materials and job aids for managing COVID-19 among family planning clients; trained health-care providers on one or more aspects of identifying COVID-19 symptoms, reporting COVID-19 cases, practising personal hygiene, and using personal protective equipment kits; and shared experiences, practices and lessons learned to enable a better response. HRP is also collaborating with the WHO Department of Maternal, Newborn, Child and Adolescent Health to provide technical support to approximately 20 countries on the delivery of contraceptive services as part of its project to mitigate the indirect effects of the health systems disruption. 4 HRP ANNUAL REPORT 2020 28 HRP ANNUAL REPORT 2020 6 HRP has also developed a number of communications materials, including a series of Q&As published on the WHO website covering the impact of COVID-19 on contraception and family planning, violence against women, pregnancy and childbirth, breastfeeding, and adolescents and youth. HRP staff liaised with collaborators in WHO regions and countries to ensure wider access to the communications. In addition, all COVID-19 Q&As were translated into the official UN languages, and information resources on pregnancy, childbirth and breastfeeding were also translated into Farsi and Italian. The Special Programme worked closely with WHO Communications to develop infographics on key issues such as COVID-19 and violence against women, and antenatal, intrapartum and postpartum health care. An additional set of infographics on violence against women during the pandemic was developed with the Partnership for Maternal, Newborn and Child Health (PMNCH). HRP also partnered with FIFA, WHO and the European Commission to launch the #SafeHome campaign – a worldwide campaign featuring well- known footballers from around the world with the aim to support those at risk from domestic violence. 29 1 SELECTED 2020 ACHIEVEMENTS IN SRHR IN OTHER DISEASE OUTBREAKS Clear and coherent guidance is needed to meet the combined needs of women requiring treatment for Ebola virus disease, including pregnancy care and management of complications. Information on how to protect breastfeeding children and other members in the community from transmission of the disease is also critical. Limited scientific evidence on how to best manage these needs has previously been a challenge for affected countries. In addition, misconceptions that pregnant women have a higher mortality rate than other populations with the disease may in some contexts have put pregnant women at risk of not receiving standard care. In recognition of this, HRP supported the evidence synthesis used to inform development of the WHO Guideline on the management of pregnant and breastfeeding women in the context of Ebola virus disease. This guideline reviews existing evidence and provides a single set of recommendations on the care continuum for women exposed to, diagnosed with, or who have recovered from Ebola. This guideline will enable health-care providers, emergency response teams and health policy-makers to improve prevention and treatment measures in an Ebola outbreak. Since the publication by WHO of interim guidelines on the prevention of sexual transmission of Zika virus in September 2016, the body of evidence has grown considerably. Following expert advice, HRP updated the database that was then used to revise the WHO guideline on the prevention of sexual transmission of Zika virus. This guideline includes recommendations to inform national and subnational policy- makers, health-care providers, other health-care stakeholders and the general public. 2 HRP ANNUAL REPORT 2020 Accountability is crucial to safeguard the SRHR of the 35 million women and girls aged 15–49 who require humanitarian assistance. In recognition of this, HRP published a paper to examine evidence on existing accountability strategies for sexual and reproductive health in humanitarian settings in a range of different places and contexts. The review largely uncovered the fact that most existing evidence focuses on accountability mechanisms within humanitarian work rather than on how to best support affected people to understand their rights and entitlements or to access justice. SELECTED 2020 ACHIEVEMENT IN SRHR IN HUMANITARIAN SETTINGS HRP ANNUAL REPORT 202030 HRP ANNUAL REPORT 2020 31 HRP ANNUAL REPORT 202032 Adolescence is the period of life that encompasses the transition from childhood to adulthood. WHO defines adolescents as people aged between 10 and 19 years, while recognizing that age is only one characteristic defining this critical period of rapid human development. An individual’s behaviour and the choices they make during this time can determine their future health and well-being. 09 HEALTHY ADOLESCENCE FOR A HEALTHY FUTURE Adolescents across the world face considerable challenges to their SRHR. These include: sexual coercion and intimate partner violence; lack of education and information; high rates of early and unwanted pregnancy; lack of access to health services, especially for contraception and safe abortion; gender inequalities and harmful traditional practices, such as female genital mutilation (FGM), and child, early and forced marriage; and risk of STIs (including HIV). HRP ANNUAL REPORT 2020 33 HRP ANNUAL REPORT 202034 1 SELECTED 2020 ACHIEVEMENTS IN ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH Many children and young people are not able to access comprehensive sexuality education through school, yet their needs for information on SRHR remain. In recognition of this, HRP joined the United Nations Population Fund (UNFPA) and collaborating partners WHO, UNAIDS, United Nations Children’s Fund (UNICEF) and United Nations Educational, Scientific and Cultural Organization (UNESCO) to publish a guidance on out-of-school comprehensive sexuality education. The publication gives in-depth guidance on how to develop comprehensive sexuality education programmes that are appropriate and safe for different groups of children and young people, especially those who are unlikely to be reached through in-school programmes for children. It includes guidance tailored to the specific needs of young people from specific populations that have been left behind, and is aimed primarily to support the work of anyone designing and/or implementing comprehensive sexuality education in out-of- school settings, especially in low- and middle- income countries. Despite the increased recognition of child, early and forced marriage as a harmful practice, and the progress made in a number of countries to address it, rates globally have not declined over the past decade. There is little evidence on the trends, reasons for, and approaches to ending child marriage – with a particular lack of understanding on what is needed to achieve results on a large scale. In recognition of this knowledge gap, HRP published a commentary to summarize the outcomes of an expert group meeting organized by HRP and WHO to discuss research priorities for ending child marriage and supporting married girls. The paper presents research gaps and recommends priorities for research in five key areas; (i) prevalence and trends of child marriage; (ii) causes of child marriage; (iii) consequences of child marriage; (iv) efforts to prevent child marriage; and (v) efforts to support married girls. 2 35 Leveraging a 10-year partnership with the Geneva Foundation for Medical Education and Research, HRP conducted a blended learning certificate course (e-learning with mentor and peer support) in conjunction with UNFPA and Family Planning 2020 (FP2020). In recognition of the particular challenges posed by the global pandemic, the course content was adapted to include COVID-19 and adolescents’ sexual and reproductive health; approaches to ensuring continuity of sexual and reproductive health information and services for adolescents in the context of the pandemic; and case examples for eight sexual and reproductive health interventions described in the Guttmacher-Lancet Commission Report. Over 300 participants from more than 50 countries undertook the course. 3 HRP ANNUAL REPORT 2020 HRP ANNUAL REPORT 202036 Violence against women and girls constitutes a major public health concern and is a grave violation of human rights. Estimates by WHO indicate that, worldwide, about one woman in every three has experienced physical and/or sexual intimate partner violence or non-partner sexual violence in their lifetime. 10 PREVENTING AND RESPONDING TO VIOLENCE AGAINST WOMEN AND GIRLS Violence against women and girls takes multiple forms, including intimate partner violence, sexual violence, forced marriage, femicide and trafficking. FGM and child and early marriage constitute harmful practices that share some of the same risk factors as violence against women, such as unequal gender norms. Violence against women and girls can lead to a range of adverse physical, mental and psychosocial health outcomes, including negative impacts on sexual and reproductive health. Intimate partner violence and non-partner sexual violence can lead to unintended pregnancies, induced abortions, gynaecological problems and STIs, including HIV. Intimate partner violence during pregnancy also increases the likelihood of miscarriage, stillbirth, preterm delivery and low-birthweight infants. Conflict and post-conflict situations, including displacement, can exacerbate violence against women and girls, and may present the risk of additional forms of violence. 37 1 2 SELECTED 2020 ACHIEVEMENTS IN VIOLENCE AGAINST WOMEN AND GIRLS RESPECT women: preventing violence against women, launched in 2019, is a framework that outlines a set of action-oriented steps that enables policy-makers and health implementers to design, plan, implement, monitor and evaluate interventions and programmes using seven strategies to prevent violence against women. The strategies are summarized in the acronym R.E.S.P.E.C.T, with each letter representing one strategy. In 2020, HRP joined with UN Women and WHO to publish the RESPECT women implementation package. This package aims to help policy-makers and practitioners to design and implement evidence-based, ethical and effective national and subnational policies, programmes and interventions for preventing violence against women based on each of the seven strategies of the 2019 framework. The Generation Equality Forum, a global gathering for gender equality, announced the leaders of the Generation Equality Action Coalitions, to achieve gender equality and human rights for all women and girls. WHO – together with the United Nations Entity for Gender Equality and the Empowerment of Women (UN Women) – was invited to co- lead the Action Coalition focusing on ending gender-based violence. This honour for WHO is in great part thanks to the continuing efforts of HRP to undertake research and inform WHO guidelines on violence against women and girls. The Action Coalitions aim to deliver concrete and transformative change for women and girls around the world in the coming five years. Gender-based violence is one of six themes which the Generation Equality Forum will focus on that are critical for achieving gender equality. HRP ANNUAL REPORT 2020 SELECTED 2020 ACHIEVEMENT IN FEMALE GENITAL MUTILATION (FGM) Female genital mutilation (FGM) exacts a crippling economic as well as human cost, as revealed by HRP and WHO. New HRP modelling reveals that the total costs of treating the health impacts of FGM would amount to US$ 1.4 billion globally per year, if all resulting medical needs were addressed. For individual countries, these costs would near 10% of their entire yearly expenditure on health on average; in some countries, this figure rises to as much as 30%. The new interactive modelling tool that generated these data, known as the FGM Cost Calculator, was launched on the International Day of Zero Tolerance for Female Genital Mutilation. Using data from 27 high-prevalence countries, the Cost Calculator demonstrates clear economic benefits from ending FGM – if FGM were abandoned now, the associated savings in health costs would exceed 60% by 2050. In contrast, if no action is taken, it is estimated that these costs will soar by 50% over the same time period, as populations grow and as more girls undergo the procedure. Access Q&A on the Cost Calculator: https:// www.who.int/news-room/q-a-detail/fgm-cost- calculator HRP ANNUAL REPORT 202038 HRP ANNUAL REPORT 2020 39 HRP ANNUAL REPORT 202040 Human rights are fundamental to the health of individuals, couples and families, and to the social and economic development of communities and nations. 11 PROTECTING AND SECURING SEXUAL AND REPRODUCTIVE HEALTH WITH HUMAN RIGHTS As explained in the 2017 Report of the high-level working group on the health and human rights of women, children and adolescents, everyone has the right to health and through health, because the “right to health does not stand alone but is indivisible from other human rights. Good health not only depends on but is also a prerequisite for pursuing other rights. Human rights cannot be fully enjoyed without health; likewise, health cannot be fully enjoyed without the dignity that is upheld by all other human rights”. Discrimination, abuse and violence, however, continue to prevent women and girls everywhere from fulfilling their human right to the highest standard of sexual and reproductive health. HRP ANNUAL REPORT 2019 41 42 The relationship between power and accountability is a critical concern in realizing SRHR through policies and programmes. In recognition of this, HRP published a paper in the BMC International Journal of Equity in Health that examines accountability strategies for SRHR through the lens of power. The paper provides a nuanced approach to understanding how power shapes accountability as well as a global health assessment of them. It also invites further thinking about elements of policy that address and recognize the role of power that may need to be built into accountability strategies for health, and in particular for sexual and reproductive health. 3 SELECTED 2020 ACHIEVEMENTS IN HUMAN RIGHTS FOR SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS 1 A number of global health organizations advocate for gender-transformative programming with men and boys to improve sexual and reproductive health for all. In 2020, HRP published a systematic review looking at the evidence of this approach, and in particular at the characteristics of successful gender-transformative interventions for engaging men and boys in the context of SRHR. The findings demonstrate that the value of including men and boys in SRHR interventions is no longer contested, but rather that the evidence gaps are around how best to do this in ways that promote gender equality and health for all, and which are based on the best available scientific evidence. The 1995 Beijing Declaration and Platform for Action on Women affirmed that women’s rights are human rights and that gender equality is an essential building block for health, well-being, development and peace. Progress on gender equality has been made in all 12 key areas identified in the Declaration, but for millions of girls and women around the world today, this visionary agenda is still far from reality. To mark the 25th anniversary of the Beijing Declaration, HRP joined WHO and the United Nations University International Institute for Global Health (UNU- IIGH) to publish a special series of papers in the British Medical Journal (BMJ). This series asks what has been learned and what still needs to change in order to achieve the priorities articulated 25 years ago. In the context of the COVID-19 pandemic, the series underlines how investing in the health, well-being and needs of women is both a moral imperative and crucial for safeguarding lives, reducing poverty, and stimulating economic growth with up to a nine-fold return on investment. Read more: https://www.who.int/news/item/27- 10-2020-beijing-25-where-are-we-now-and- where-do-we-go-next 2 HRP ANNUAL REPORT 2020 43 There is little evidence on SRHR for persons with disabilities, and particularly on evaluations of service interventions. In recognition of this significant evidence gap, HRP and partners published a systematic review to assess interventions to promote SRHR for persons with disabilities in low- and middle- income countries. The review further highlighted how little evidence exists. The researchers were unable to identify a single intervention promoting access to maternal health, family planning and contraception, or safe abortion for people with disabilities in low- and middle-income countries. Right to a Better World is a documentary video series produced by HRP and WHO in partnership with the Office of the High Commissioner for Human Rights (OHCHR) and the Oxford Human Rights Hub (OxHRH). It explores how tactics developed by the human rights movement can be used to achieve sexual and reproductive health rights and drive meaningful progress towards the fulfilment of the 2030 Agenda for Sustainable Development. There are four 20-minute thematic episodes in this series, all free to access: contraception, comprehensive sexuality education, maternal mortality and morbidity, and violence against women. The episodes may be watched at home, in groups and in classroom settings. Viewers are encouraged to learn from the experiences shared and consider how these tactics could be adapted to their own contexts. According to HRP Director, Ian Askew, “human rights are the key to ensuring every person has access to comprehensive sexual and reproductive health care, and WHO and HRP are committed to mainstreaming human rights into health policies and programmes. Our partnership with UN Human Rights and OxHRH affirms that in the changing landscape of sexual and reproductive health, human rights must be heard as loudly as clinical and scientific research.” Read more: https://www.who.int/news/item/18-11- 2020-your-right-to-a-better-world 4 5 HRP ANNUAL REPORT 2020 HRP ANNUAL REPORT 202044 Much of HRP’s research is directly focused on strengthening various elements of national health systems in order to achieve universal health coverage (UHC), including access to sexual and reproductive health services for all. UHC – including for sexual and reproductive health – means that all people have access to the health services they need, when and where they need them, without suffering financial hardship. 12 SUPPORTING AND STRENGTHENING NATIONAL HEALTH SYSTEMS FOR ACHIEVING UNIVERSAL HEALTH COVERAGE For this to become a reality, it must be based on strong, people-centred primary health care. In recognition of this, HRP works to ensure an evidence base for integrating, implementing and financing sexual and reproductive health within WHO guidance and tools on implementing UHC in national health systems. We coordinate with WHO colleagues and partners across the world to produce guidance on digital health – to aid decision-makers across sectors to make decisions based on evidence and informed by best practices – so as to help ensure sustainable and well-integrated outcomes that recognize local contexts and existing digital architecture, with the overall aim to improve health for all. In addition, our innovative digital tools aim to connect decision- makers with health systems, and health workers with high-quality evidence-based WHO guidance. HRP also conducts research on self-care innovations, in recognition of how – as part of broader strategies for health – self-care can help individuals and communities to access high-quality health services and to take care of their own health and the health of their families. 45 One of the three strategic goals of WHO is to ensure that an additional 1 billion people in the world are protected by UHC by 2023 – that they are able to access the services they need to keep healthy and without falling into poverty as a result. A key step in making this a reality is for countries to be able to work out what services their people need and how to provide them. In 2020, WHO launched its new Universal health coverage (UHC) compendium to help people do just this. Thanks to HRP, a comprehensive range of sexual and reproductive health interventions were included in the new compendium. 1 SELECTED 2020 ACHIEVEMENTS IN INTEGRATING SEXUAL AND REPRODUCTIVE HEALTH SERVICES INTO UHC STRATEGIES HRP ANNUAL REPORT 2020 Universal access to sexual and reproductive health services and the promotion and protection of human rights, dignity and empowerment of all people are globally agreed commitments underlying UHC, and the WHO UHC compendium includes many interventions that reflect these priorities. Pregnancy and birth, sexual well-being, reproductive choice, reproductive cancers, violence against women, and sexually transmissible infections are key areas for health interventions recognized in the WHO Reproductive Health Strategy and Sexual health and its linkages to reproductive health: an operational approach. A new HRP-authored special supplement, Universal health coverage: sexual and reproductive rights in focus, published in Sexual and Reproductive Health Matters, shows that when it comes to this global commitment, countries are at different stages of progress, both towards UHC generally, and towards comprehensive, rights-based sexual and reproductive health services in particular. 2 SELECTED 2020 ACHIEVEMENT IN SELF-CARE INTERVENTIONS FOR SEXUAL AND REPRODUCTIVE HEALTH People-centred self-care interventions for sexual and reproductive health that help improve autonomy in accessing health care can help countries make progress towards achieving UHC. Such interventions can do this by improving access to affordable, quality health services and products, supported by rapid advancements in medical and digital technologies. Since the publication of the first WHO Consolidated guideline on self-care interventions for health: sexual and reproductive health and rights in 2019, the global COVID-19 pandemic has shone a spotlight on the importance of self-care interventions. In recognition of the need for further research to support WHO guidance on self-care interventions, HRP published protocols for nine systematic reviews: over-the- counter emergency contraception; lubricant use for sexual health; gender-affirming hormone use; over-the-counter pre-exposure prophylaxis (PrEP) initiation and continuation; micronutrient supplementation during pre-pregnancy, pregnancy and postpartum periods; self-monitoring of blood glucose for gestational diabetes; self-monitoring of blood pressure among women with hypertensive disorders of pregnancy; pregnancy self-test; and self-testing for proteinuria during pregnancy. HRP ANNUAL REPORT 202046 1 2 SELECTED 2020 ACHIEVEMENTS IN DIGITAL HEALTH With the right approach and effective investment, digital health interventions can be successful long- term solutions that help to improve the health and well-being of the people they were designed to reach. HRP, in collaboration with WHO and partners UNICEF, UNFPA and PATH, launched a new guide, Digital implementation investment guide (DIIG): integrating digital interventions into health systems, to help ensure that digital health investments are effective, sustainable and equitable, and that they are implemented in a coordinated way and are appropriate for the local context. This guidance will be particularly useful for donors and ministries of health that make decisions on digital investments for health whether in government, technical bodies, national health and/or digital systems. Digital tools are an increasingly popular approach to improving the health of adolescents and young people, who are accessing the Internet at earlier stages of life. In 2020, HRP, along with WHO, UNESCO, UNICEF and UNFPA, launched a new framework – Youth-centred digital health interventions – to provide guidance on effective planning, development and implementation of digital solutions with and for young people to address the many health challenges they may face as they grow into adulthood. The next generation of digital health designers, developers, researchers and funders can use the framework to learn from the experiences of experts in the field – including missteps, course corrections and successes – to better meet young people’s diverse health needs. 47HRP ANNUAL REPORT 2020 48 Many countries across the world lack the necessary human resources and infrastructure to undertake crucial research in SRHR. 13 STRENGTHENING RESEARCH CAPACITY AND LEADING RESEARCH DEVELOPMENT IN SRHR HRP ANNUAL REPORT 2020 As the only body within the UN system with a global mandate to work on strengthening research capacity in SRHR, the HRP Alliance promotes and funds relevant research, training, institutional development and networking to increase the research capacity of low- and middle-income countries. Rigorous scientific methods are essential to develop valid and credible evidence that informs norms and standards guiding the provision of safe, effective, equitable and acceptable sexual and reproductive health services. HRP ANNUAL REPORT 2020 49 The HRP Alliance brings together national and regional government and nongovernmental institutions conducting research in SRHR in collaboration with WHO regional and country offices, WHO country collaborators and other HRP research partners. The Alliance currently has seven regional hubs serving the following regions: Africa (francophone and anglophone), Americas, Eastern Mediterranean, South-East Asia and the Western Pacific. In 2020, the Alliance saw six hubs offer 13 short courses, training a total of 521 participants from all six regions. One third of the short courses were related to research methodology and data analysis, and several were dedicated to building skills in scientific writing and publication procedures. Sixty-two publications specifically related to sexual and reproductive health were published by the seven HRP Alliance hubs in 2020. 1 In recognition of the specific challenges faced by female early career scientists, HRP Alliance launched a year-long mentorship programme for junior female researchers, with the support and advice of HRP’s Gender and Rights Advisory Panel (GAP) and HRP staff experts on gender and rights. 2 SELECTED 2020 ACHIEVEMENTS BY THE HRP ALLIANCE HRP ANNUAL REPORT 202050 SELECTED 2020 ACHIEVEMENT IN RESEARCH MANAGEMENT The HRP Research Project Review Panel (RP2) is a statutory external, independent body of scientific experts that provides in-depth scientific and budget reviews of all HRP research protocols to ensure they are aligned with the highest research standards, to protect the health and rights of individuals in different social and cultural settings, according to World Health Assembly Resolution 41.9. The RP2 Secretariat supports development, review and approval of HRP research protocols and ensures scientific quality assurance through dialogue and collaboration with the responsible officers, study teams and external reviewers. In 2020, 46 new HRP research protocols were managed and submitted for review by the RP2. Of these, 16 were for multi-country studies, seven were generic core protocols to be implemented in multiple sites and 12 were country-specific individual studies. A total of 34 protocols (including five approved exemptions) were reviewed and approved by 2020, with no rejections. The protocols represent 14 studies falling under the HRP definition of Implementation Research. HRP ANNUAL REPORT 2020 51 52 HRP engages with a wide range of partners and stakeholders (see Fig. 2). These partnerships are essential for achieving four strategic objectives: strengthened global diplomacy for promoting SRHR in global political arenas; human rights–based approach to SRHR issues; technical cooperation and support for research; and a coherent approach to SRHR globally. 14 PARTNERING TO ACHIEVE IMPACT: HRP PARTNERSHIPS IN 2020 HRP ANNUAL REPORT 2020 FIG. 2 HRP Partnerships IBP Network Housed at WHO since 2000, the IBP Network is one of the longest-running partnerships dedicated to family planning and reproductive health. With over 85 member organizations, which include international nongovernmental organizations, local civil society organizations, academic institutions and others, IBP uses innovative knowledge management strategies to disseminate HRP’s research, WHO guidelines, and the series of High Impact Practices supported by the United States Agency for International Development (USAID). The IBP Network supports their implementation in countries and facilitates collaboration among members – 2020 saw the launch of the new IBP online platform, which reached 14 000 professionals working on issues related to sexual and reproductive health. IBP hosted 20 webinars, with almost 7500 participants from over 100 countries; 11 of these shared information on HRP research and WHO guidelines. Global Network for the Independent Evaluation of STI Point-of-care Tests This network comprises the ministries of health, national research centres and 27 hospitals from 14 countries, as well as six WHO collaborating centres and four test manufacturers. It seeks to improve access to STI testing among populations in need – including key populations – through developing an evidence-based, scalable model for introducing and implementing STI diagnostics. In 2020, the laboratory capacity to conduct STI testing – including reference testing as well as quality control and external quality assurance – was strengthened across all 14 countries participating in the Network. Technical assistance coordination mechanism for SRHR of adolescents and youth HRP collaborates with several global and regional partners to provide technical support to nine countries in scaling up adolescent sexual and reproductive health programmes with a focus on contraception. In 2020, it responded to technical assistance (TA) requests from nine countries in three WHO regions using a specially designed TA coordination mechanism. This involved working across all three levels of WHO and engaging with partner organizations and initiatives such as FP2020, the Ouagadougou Partnership and the Global Financing Facility to provide TA that was effective, timely and efficient (even in the context of COVID-19). 1 3 4 Network of Infertility Non-state Actors (NSAs) In 2020, HRP partnered with NSAs to deliver a series of educational webinars related to infertility focusing on: impact of COVID-19 on fertility services; prevention of infertility; organizing fertility care in resource-poor settings; and achieving universal access to fertility care, with a particular focus on reaching programme managers and policy-makers in West Africa. HRP also collaborated with the Network to develop, reprint and widely disseminate the updated WHO fact sheet on fertility. 2 SELECTED 2020 ACHIEVEMENTS AND KEY PARTNERSHIPS HRP ANNUAL REPORT 2020 53 HRP ANNUAL REPORT 202054 5 7 National parliaments and parliamentarian associations Within WHO, HRP has pioneered engagement with national parliaments and various parliamentary platforms, including the Inter-Parliamentary Union (IPU) and the European Parliamentary Forum for Sexual and Reproductive Rights (EPF). Among key highlights in 2020, HRP partnered with the IPU, the United Nations Programme to Accelerate an End to Child Marriage and GirlsNotBrides to engage parliamentarians in advocating with their governments and other stakeholders for efforts to address child marriage in the context of COVID-19. It also partnered with EPF to conduct a series of advocacy activities within the Parliamentary Assembly of the Council of Europe, and collaborated in the development of the Global Atlas on Abortion and the Fertility Policies Atlas for Europe. QUALI-DEC project The QUALI-DEC project seeks to improve decision-making in childbirth by health professionals and by women themselves through developing evidence-based tools to guide choices before or during labour, reducing non-medically justified caesarean sections and encouraging natural childbirth. In 2020, countries participating in the study finished the baseline formative research and tailored the interventions, including policy-makers and other stakeholders. Dissemination and knowledge transfer plans were drafted in 2020 targeting members of parliament and policy-makers. Network for Improving Quality of Care for Maternal, Newborn and Child Health This Network is a partnership of governments, implementation partners and funding agencies working with 11 countries to ensure that every pregnant woman, newborn and child receives good-quality care with equity and dignity. HRP led a scoping review to identify measures of experience of facility-based care throughout the continuum of care for pregnant women and newborns, informing and facilitating the country activities across the Network. 6 WHO collaborating centres WHO collaborating centres are research institutes, parts of universities, or academies that carry out activities in support of the WHO’s programmes. HRP continues to engage with 33 of WHO’s collaborating centres, which contribute valuable expertise and resources to enable HRP to carry out its full programme of research, including generating evidence for WHO guidelines on SRHR issues. These collaborating centres are from all six WHO regions – one in the African Region, four in the Region of the Americas, three in the Eastern Mediterranean Region, 10 in the European Region, eight in the South-East Asia Region and seven in the Western Pacific Region. 8 55HRP ANNUAL REPORT 2020 1 2The “Digital Learning Course on Sexual and Reproductive Health and Rights” was launched to sustain access to contraceptive services during the COVID-19 pandemic; it is an interactive course on counselling and prescribing of over-the-counter contraception in pharmacies and drug stores. The first version of the course is available through the Academy’s COVID-19 mobile learning app for health workers. Further self-care modules will be developed and added to the SRHR course, covering topics such as HPV self-sampling; self-collection of STI samples, including self-testing for HIV; and pregnancy self-tests. The Midwifery education toolkit brings together multiple training courses on sexual, reproductive, newborn and mental health interventions for compassionate midwifery care, including during pandemics and for use in fragile and humanitarian settings. It focuses on a midwifery-led model of care, preventing unnecessary interventions yet ensuring life-saving actions, enabling health professionals to work effectively in a multidisciplinary team. One of the first courses under development is the “Essential Postpartum Family Planning Counselling Course”. As part of the WHO Transformation, a new focus on learning to build skills and competencies – as well as to make a greater positive impact worldwide – is being realized through the new WHO Academy, which will become a state-of-the-art training institution for the health sector, seeking to reach 10 million learners around the world by 2023. In 2020, the Academy worked closely with HRP to develop and design competency-based learning programmes to accelerate sexual and reproductive health impact. The Academy has embraced SRHR as one of its first priorities, collaborating with HRP on two ambitious products: HRP ANNUAL REPORT 202056 DONORS United Nations Organizations United Nations Entity for Gender Equality and the Empowerment of Women United Nations Population Fund World Health Organization assessed contribution Governments France Germany Government of Flanders, Belgium Netherlands Norway Russian Federation Sweden Switzerland Thailand United Kingdom Non-state Actors Bill and Melinda Gates Foundation David and Lucile Packard Foundation Elrhe Harvard School of Public Health Sanofi Espoir Foundation The Global Fund to Fight AIDS, TB and Malaria Wellcome Trust 57HRP ANNUAL REPORT 2020 PHOTOGRAPHER CREDITS Cover Page: © UNICEF / Ayene vi: © WHO / Patrick Brown Page 3: UN Women / Lauren Rooney Page 7: © UNICEF / Patricia Willocq, Guatemala Page 8: © UNICEF / Chak, Family in Bangladesh Page 9: © UN Women Page 10: © Jeniffer Araujo Page 11: © Unsplash / Tim Foster Page 12: © WHO / Christine McNab Page 13: ©McNab_HayRIverMidwife Page 14: © UNICEF / Pudlowski © MSF / Severine Sajous © UNICEF / Vishwanathan Page 15: © WHO / Quinn Mattingly © MSF Page 16: © UNICEF / Zehbrauskas © UNICEF / Adriko Page 17: © UNICEF / BhardwaJ Page 18: © PAHO / IWHC__Sarahpabst__arg265 Page 19: © WHO / Paula Bronstein Page 20: © Unsplash / honey-fangs-33iKv_A1E2s Page 21: © UNICEF / Ayene © Oregon State University / Aleksandra Sikora Page 22: © Sofia Moya Page 25: ©UNICEF-Dejongh-Cote d’Ivoire Page 26: © UNICEF / Dejongh-Cote d’Ivoire © WHO / 20210130_CAMBODIA_109 © WHO / Blink Media - Nana Kofi Acquah Page 27: © Public Services International © WHO / Blink Media - Nana Kofi Acquah Page 28: © Secretaria Especial de Saúde Indígena (Sesai) Page 29: © World Bank / Vincent Tremeau Page 30: © WHO / Rada Akbar Page 31: © WHO / Sebastian Meyer Page 32: © Unsplash / Kevin Laminto Page 33: © UNICEF/ Kiron Page 34: © UNFPA © UN Women Page 35: © UNICEF / ECU/2020/Arcos Page 36: © UN Women / Ellie van Baaren Page 37: © UN Women Page 39: © UNICEF/ Bongyereirwe Page 40: © Pixabay / Andrzej Rembowski Page 41: © DFID-Women’s health and rights Page 42: © United Nations / Kosovo Team (UNKT) / Arben Llapashtica © Juan Arredondo © UN Women / Bruno Spada Page 43: © 2019 WHO / NOOR / Arko Datto © OHCHR / Your right to a better world Page 44: © Trakanphurtphon Hospital, Ubon Ratchatani Province, Thailand Page 45: © WHO / Asad Zaidi © Getty Images / Paula Bronstein Page 46: © WHO / Blink Media - Nikolay Doychinov Page 48: © HRP Alliance Page 49: © HRP Alliance Logo © HRP Alliance Page 50: © WHO / Salyna Bashir Page 51: © WHO / 20210210_GUINEA_Cervical_cancer_prevention

World Health Organization Department of Sexual and Reproductive Health and Research Avenue Appia 20 1211 Geneva 27 Switzerland Email: srhhrp@who.int Website: https://www.who.int/teams/sexual-and-reproductive- health-and-research-(srh)/overview