Regional consultation on the development of the European action plan for sexual and reproductive health and rights (SRHR) 2017–2021: Copenhagen, Denmark, 14–15 December 2015

Regional consultation on the development of the European action plan for sexual and reproductive health and rights (SRHR) 2017–2021 Copenhagen, Denmark, 14–15 December 2015 ABSTRACT A regional consultation on the development of the European action plan for sexual and reproductive health and rights (SRHR) was held in Copenhagen, Denmark, on 13–14 December 2015. This report presents the main points of the plenary presentations and a brief thematic summary of participants’ comments on Draft 1 of the action plan. Keywords SEXUAL HEALTH REPRODUCTIVE HEALTH HUMAN RIGHTS WHO EUROPEAN REGION POLICIES Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). © World Health Organization 2016 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. 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However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. Regional consultation on the development of the European action plan for sexual and reproductive health and rights page iii CONTENTS Page Acronyms and abbreviations …………………………………………………………………………………………… . iv 1. Background and rationale ................................................................................................ 1 1.1 Participants, objectives and outcomes of the meeting .............................................. 2 2. Plenary sessions ............................................................................................................. 2 2.1 Opening .............................................................................................................. 2 2.2 Challenges of SRHR in the Region .......................................................................... 3 2.3 Global and regional strategic priorities related to SRHR ............................................ 5 2.4 The draft action plan for SRHR, 2017-2021 ............................................................. 7 2.5 The vision of WHO collaborating centres and partners ............................................. 9 3. Country feedback on the draft action plan: summary ....................................................... 10 3.1 Human rights ..................................................................................................... 10 3.2 Men’s involvement and gender issues .................................................................. 11 3.3 Unsafe abortion and infertility .............................................................................. 12 3.4 Prevention, promotion, education and social determinants ..................................... 12 3.5 Menopause ........................................................................................................ 13 3.6 Links with other initiatives and non-health sectors ................................................. 13 4. Next steps and closing .................................................................................................. 14 Annex 1 ...................................................................................................................... 15 Programme ............................................................................................................. 15 Annex 2 ...................................................................................................................... 18 Participants ............................................................................................................. 18 Regional consultation on the development of the European action plan for sexual and reproductive health and rights page iv Acronyms and abbreviations EBCOG European Board and College of Obstetrics and Gynaecology EU European Union ICD–11 International Classification of Diseases 11th edition IPPF EN International Planned Parenthood Federation, European Network LGBTI lesbian, gay, bisexual, transgender and intersex HBSC Health Behaviour in School-aged Children (survey) HPV human papillomavirus MDGs Millennium Development Goals NGO nongovernmental organization SDGs Sustainable Development Goals SRH sexual and reproductive health SRHR sexual and reproductive health and rights STIs sexually transmitted infections UN United Nations UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 1 1. Background and rationale The WHO European regional strategy on sexual and reproductive health (SRH) was developed in 2001 and has been used by many countries in the WHO European Region in developing their national policy documents. Progress has been made over the last 15 years in improving maternal and perinatal health, family planning, prevention of sexually transmitted infections (STIs) and unsafe abortion, and improving sexual health. Inequalities nevertheless remain between and within countries. For instance: • maternal mortality ratios differ 40 times across countries in the Region; • indirect causes of maternal deaths, especially chronic cardiovascular and mental health, are increasing; • communicable diseases like tuberculosis and influenza are increasing in some population groups and are causing maternal deaths ; • unmet need for family planning in countries in the Region for which data are available ranges from 5% to nearly 23%; • STIs are often neglected until serious complications occur, such as miscarriage, premature delivery, infertility and chronic pain; • access to safe abortion is still a challenge for many due to legal restrictions and lack of access to quality services; and • one in four women in the Region has experienced physical and/or sexual violence by an intimate partner. New evidence and recently approved global and regional strategic documents require revision of SRH policies in the Region. Technical briefings organized during the 64th and 65th sessions of the WHO Regional Committee for Europe triggered the process of development of the European action plan for sexual and reproductive health and rights (SRHR). The Health 2020 strategic framework, approved by all 53 Member States of the Region, recognized that improvement in health can be attained only if the whole of government is involved to achieve two linked objectives: 1. improving health for all and reducing health inequalities 2. improving leadership and participatory governance for health. The proposed action plan will be based on the principles of the life-course approach, equity, human rights, intersectoral action, participation and evidence-based action. It will set overarching concrete steps consistent with Health 2020, global and regional strategies and policy documents, including the United Nations (UN) Sustainable Development Goals (SDGs) and the renewed UN Global strategy on women’s, children’s and adolescents’ health 2016–2030. The intention is that the action plan will provide a framework to guide and inform development of country-specific policy responses, action plans and programmes for improving SRHR. It will reflect differences in demographic, cultural and socioeconomic profiles between countries of the Region. Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 2 1.1 Participants, objectives and outcomes of the meeting The consultation meeting (the agenda is shown at Annex 1) brought together country representatives from 37 Member States of the Region and experts in SRH and related areas, such as health systems, nutrition and physical activity, mental health, tobacco and alcohol, and the life-course approach (see Annex 2). The main objectives were to: 1. review the draft action plan for SRHR 2. propose optimal monitoring of achievements 3. identify neglected areas to be included in the action plan. It was anticipated that outcomes of the meeting would include consensus on the new European action plan for SRHR and recommendations on further involvement of Member States and other stakeholders in its finalization. 2. Plenary sessions 2.1 Opening The meeting was opened by Zsuzsanna Jakab, WHO Regional Director for Europe, who remarked that 2015 had been a very important year. It was the year in which the Global strategy for women’s, children’s and adolescents’ health (2016–2030) was published and achievements against the Millennium Development Goals (MDGs) were evaluated, including MDG 5a on reducing maternal mortality and 5b on achieving universal access to SRH services. The analysis of progress on achieving the MDGs has revealed unfinished business that has been reflected in the new SDGs to 2030. The adoption of the SDGs by Member States of the European Region reflects their commitment to ensuring universal access to SRH services, including for family planning, information and education, and the integration of SRH into national strategies and programmes. Dr Jakab noted that SDG 5 on gender equality includes a target that links SRH and human rights. “It is therefore time”, she stated, “for Europe to agree the main actions necessary to promote SRHR.” Gauden Galea, Director of the Division of Noncommunicable Diseases and Promoting Health through the Life-course in the WHO Regional Office for Europe, then described the schedule for the action plan. He explained that the action plan would be redrafted to reflect outputs from the meeting and be presented for review to the Standing Committee of the WHO Regional Committee for Europe at the end of January 2016. Gunta Lazdane, Sexual and Reproductive Health Programme Manager of the Regional Office, defined the agenda for the meeting, its main objectives and intended outcomes (see section 1 above). She emphasized the importance of participants prioritizing areas of content for the action plan to ensure that it did not become an encumbrance for countries and to ensure the most important issues were addressed. She reviewed the main objectives of the 2001 WHO European strategy on SRH, suggesting that it influenced around 15 or more national strategies. It was never presented for approval to the Regional Committee, however, which means that Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 3 monitoring of implementation was not as strong as it could have been. The Regional strategy was followed by the global reproductive health strategy adopted by the Fifty-seventh World Health Assembly in 2004. Dr Lazdane stressed that all efforts have been made to link the draft action plan to other Regional Committee-approved strategic documents, including Health 2020, the child and adolescent health strategy and documents on issues such as older people’s health, mental health and noncommunicable diseases. It was important, however, that the action plan did not duplicate what was already in these documents or, indeed, contradict any approved policy. She also explained the rationale for keeping the SRHR action plan separate from the women’s health strategy for the Region, which is currently under development. She closed her presentation by recapping on the main outcomes from the expert meeting on the action plan held in Trieste, Italy on 28–29 April 2015, which were to: • confirm the importance of the new action plan • suggest a focus on the positive aspects of SRH through a comprehensive approach • suggest the inclusion of actions to decrease SRHR inequalities. The last point was strengthened recently in the Minsk Declaration, signed by Member States during the European Ministerial Conference on the Life-course Approach in the Context of Health 2020. Vicky Claeys, Regional Director of the International Planned Parenthood Federation, European Network, presented on SRHR and the SDGs. She explained that SRHR cut across all areas of sustainable development and are critical to the overall success of the SDGs. Many of the goals and targets relate directly to SRHR, while others are essential for creating an environment in which SRHR can be realized. Human rights, she explained, are considered so important that they are foundational to the SDG agenda. A human rights framework is essential to promoting equality and ensuring people get access to what they need, she said. She reminded participants of the need to include civil society in deliberations about the action plan, promoting the benefits of joint efforts. 2.2 Challenges of SRHR in the Region Petr Velebil, Institute for the Care of Mother and Child, Prague, Czech Republic, spoke on maternal and perinatal health in the Region. He reported that according to the European Perinatal Health Report 2010 (published in 2013), maternal mortality in the European Union (EU) was low in most countries (<10 per 100 000 live births), but these figures are gross underestimates: some countries are now using more reliable reporting systems. The European Perinatal Health Report suggests that preterm babies born before 28 weeks constitute over one third of all deaths, but data are not comparable between countries. He called for enhanced information and improved evidence with disaggregated data, comparable data across many areas to enable priorities to be set, and strengthening of health services to ensure effective delivery of high- impact, evidence-based interventions. Helle Karro, University of Tartu, Estonia presented on family planning and infertility. She said that family planning and infertility were two sides of the same coin: on the one side is the right to avoid unintended pregnancies, and on the other side- making pregnancies possible. Both Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 4 are strongly related to SRHR. A systematic review of national, regional and global trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015 found that the situation has improved worldwide, with increases in contraceptive prevalence and decreases in unmet need. There are nevertheless large differences across regions and between countries in the European Region. Standardized data about contraceptive use are not collected routinely in Member States and the quality of available data is often problematic. Analyses of contraceptive trends and derivation of reliable estimates in the Region is challenging because of methodological differences between data sources and lack of frequent and timeous surveys. Challenges in relation to fertility can be categorized broadly under two headings, she said: prevention (incidence of STIs and tubal infertility, the roles of sexuality education and SRH services, and public awareness); and equality of access to services (restrictions to treatment within countries leading to the rise of cross-border reproductive care and the creation of further barriers and social injustice, and the safety, cost–effectiveness and ethics of new reproductive technologies). Gunta Lazdane, presenting on behalf of Lali Khotenashvili, Medical Officer in the Joint Tuberculosis, HIV/AIDS & Hepatitis Programme of the Regional Office, discussed STIs. Dr Lazdane reported on achievements and progress in the Region, which include congenital syphilis elimination, support for evidence-informed and human-rights-based STI policies, and optimization of STI service delivery, with an emphasis on at-risk and vulnerable populations: the last of these is very strongly linked to the third goal of the draft action plan. Challenges nevertheless exist, she said, including STIs having low priority in the national health agendas of many Member States, weak STI surveillance and lack of data. Stigma and discrimination associated with STI persists, combined with a limited or absent role for civil society in STI control and prevention. Issues that require an immediate response include lack of condom promotion and utilization, the emergence of gonococcal antimicrobial resistance and interrupted supply of penicillin. A global health-sector strategy on STIs will be presented for approval to the World Health Assembly in 2016, with specific targets set for achievement by 2030. Annette Aronsson, WHO Collaborating Centre on Community Safety Promotion, Karolinska Institute, Sweden, addressed participants on unsafe abortion. WHO has defined unsafe abortions as procedures for terminating an unwanted pregnancy either by persons lacking the necessary skills, or in an environment lacking the minimal medical standard, or both. They constitute a serious public health hazard in many countries, leading to mortality and morbidity. There are particular risks associated with second-trimester abortions. Abortion is illegal in some countries of the Region (it is not available on any grounds). Access to safe abortion is challenged by a number of factors, Dr Aronsson suggested, including legal barriers, lack of gynaecologists, outdated abortion methods, inadequate infection control and pain management, and anti-abortion movements. The current political situation in Europe may also mean that women’s ability to move across borders to access safe abortion is restricted. Marilys Corbex, Technical Office on Cancer of the Noncommunicable Disease Programme of the Regional Office, spoke about cervical cancer prevention. Incidence in countries across the Region varies widely, ranging from <3.5 new cases per 100 000 females per year to 30. Mortality is highly related to incidence, with variations mainly due to differences in prevention and control programmes in countries. Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 5 There are many opportunities across the life-course to prevent cervical cancer, Dr Corbex said. WHO has adopted a comprehensive approach involving primary prevention for girls of 13–19 years (vaccination), secondary prevention for women over 30 (screening), and tertiary prevention for all as needed (treatment). Primary prevention primarily involves human papillomavirus (HPV) vaccination, which has been introduced to 28 countries of the Region. Challenges have been encountered, however, including the high price of the HPV vaccine (particularly for low- and middle-income countries) and problems achieving high coverage. Screening coverage reach the recommended 70% in only 12 countries out of 53 while seven countries have no screening programme at all or have coverage of <10%. Population-based screening programs have been shown to achieve better coverage and to be more cost–effective than opportunistic screening however only 32 countries in the region have chosen to implement population-based screening programs. Monitoring and evaluation of screening is suboptimal in many countries, coverage remains unknown, false negatives due to poor quality of testing can be high but remain unnoticed. The absence of cancer registries do not allow to measure the incidence of the disease. Generally, Dr Corbex called for increased political commitment to address cervical cancer, higher public awareness about the benefits of prevention, and increased focus on the quality of screening programmes and treatments. Sóley Bender of the University of Iceland concluded the session by discussing adolescent SRH. Significant issues include gender inequality (such as traditional sexual roles for males and females being linked to risk-taking behaviours), health problems (rising STI rates (particularly in relation to Chlamydia, the highest rates for which are reported in young women aged 15–19), early sexual debut and unwanted pregnancies), and unhappiness (related to sexual abuse in childhood, alcohol and drug abuse, and abuse through social media). Professor Bender said that adolescents were vulnerable through issues that make them less able to protect themselves, such as low self-esteem, poverty, peer pressure and limited parental connectedness. Inability to self-protect places young people at risk from harm from risky sexual behaviours and sexual violence, which may be compounded by alcohol or drug use. They may also be unable to discriminate normal sexual behaviours from abnormal when viewing pornography. To move forward from a state of vulnerability to one of empowerment, protective factors (such as self-esteem and supportive parents and peers) need to be strengthened. A multifactorial ecological approach is required, addressing intrapersonal, interpersonal and environmental issues. Important activities include actions to reduce gender inequalities, promote healthy attitudes to sex in society, strengthen the positive health focus (as opposed to scaring people with ill-health messages), provide good role models (in schools, at home, in communities and through the media) and promote male responsibility by debunking traditional ideas about masculine power and authority. 2.3 Global and regional strategic priorities related to SRHR Valentina Baltag, Scientist in the Department of Maternal, Newborn, Child and Adolescent Health of WHO headquarters, described the Global strategy for women’s, children’s and adolescents’ health (2016–2030). The themes of the strategy, she said, were Survive (ending Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 6 preventable deaths), Thrive (ensuring health and well-being) and Transform (expanding enabling environments). It has some new features from its predecessor strategy, which include: • having equity not only as a principle, but also as a prominent feature of all actions; • being universal, applying not only to the 49 countries with the highest levels of mortality and morbidity that were the focus of the previous strategy; • having a prominent focus on adolescents; • prioritizing the life-course approach; and • adopting a multisectoral approach: while the previous strategy focused on health systems, the new one looks more in depth at the wider social determinants of health. SRHR features prominently in the strategy’s vison, principles and objectives, with four specific SRHR targets identified and a range of evidence-based, high-impact interventions defined. Implementing the strategy with increased and sustained financing over the next 15 years would yield tremendous returns, Dr Baltag claimed. These would include an end to preventable deaths, a 10-fold return on investments from socioeconomic benefits, and a so-called grand convergence in health that would give all women, children and adolescents an equal chance to survive and thrive. Rajat Khosla, Human Rights Adviser in the Department of Reproductive Health and Research of WHO headquarters, presented on new WHO tools related to human rights and SRH. He described how SRHR are reflected in a plethora of international and regional documents, including the Cairo and Beijing declarations. WHO documents have addressed the subject serially, starting with the global reproductive health strategy in 2004, which describes human rights as a key underpinning principle. WHO encourages countries to ensure SRH services address the basic health needs and human rights of their population and support the integration of sexual health programming as appropriate for countries’ key populations. Dr Khosla provided examples of how WHO is implementing this concept through key documents and publications on SRHR, including those addressing international development, HIV, women and health, contraception and safe abortion. A report on sexual health, human rights and the law was launched recently by WHO. Its aim is to support the creation of enabling legal and regulatory frameworks and promote the elimination of barriers to SRH services, assurance of the quality of, and respect for, human rights in SRH services, elimination of discrimination in access to health services (addressing the specific needs of particular populations), assurance of access to information and education, and protection against sexual and sexuality-related violence. He concluded by reminding Member States of their human rights obligations to remove barriers in access to SRH information and services and put in place laws and regulations that aim to support and promote sexual health. Isabel Yordi Aguirre, Gender Technical Officer in the Policy and Governance for Health and Well-being Division of the Regional Office, spoke on the upcoming women’s regional health strategy for Europe. The strategy will have direct relevance to SDGs on good health and well-being, gender equality and reducing inequalities. Women in the European Region have better health than those in most countries of the world, but inequities are increasing within and between countries, she explained. The strategy will seek to look beyond women’s mortality advantage (they tend to have greater life expectancy but it may be offset by fewer additional years lived without disability or activity restriction) to focus on Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 7 issues that affect their ability to live healthily across the life-course. It will also recognize that women’s health is much more than reproductive health. The strategy’s guiding principles are linked to the Global strategy for women’s, children’s and adolescents’ health and Health 2020 and include being equity driven, human-rights based, gender-responsive and intersectoral. Empowerment of women and communities through participation will also be crucial. Proposed key areas of action are eliminating discriminatory values, norms, practices and behaviours, reducing exposure and vulnerability to disease, disability and injuries (including mental health issues), and addressing bias in health systems and health research. The strategy has been preceded by a brief report highlighting key issues in women’s health and will be accompanied by a more comprehensive and detailed evidence-based report. It will be developed and disseminated for consultation between January and May so that it can be presented with the SRHR action plan to the Regional Committee. These presentations were supported by a discussion on regional strategic documents related to SRHR recently approved by the Regional Committee. Brief presentations were made by the following Regional Office staff: • Juan Tello, Health Systems and Public Health • Martin Weber, Child and Adolescent Health • Manfred Huber, Healthy Ageing, Disability, Long-term Care • Dinesh Sethi, Violence and Injury Prevention • Matthijs Muijen, Mental Health • Joao Breda, Nutrition, Physical Activity and Obesity • Lars Møller, Alcohol and Illicit Drugs • Jill Farrington, Noncommunicable Diseases • Osman Niyazi Cakmak, Vaccine-preventable Diseases and Immunization • Irina Eramova, Joint Tuberculosis, HIV/AIDS and Hepatitis Programme. 2.4 The draft action plan for SRHR, 2017-2021 Paul Van Look, WHO consultant, presented the draft European action plan for SRHR and its proposed indicators. He described some milestones on the way to the current stage that represented the development of SRHR within global and regional environments, but emphasized that the time was now right to look again at SRHR in Europe. Dr Van Look said it was important that fundamental terms adopted by the action plan were defined. The definition of sexual health and sexual rights arose from an expert consultation held by WHO in 2002, followed by the publication of the Defining sexual health document in 2006. The definition of reproductive health and reproductive rights are those adopted by the International Conference on Population and Development, Cairo, Egypt, in September 1994. The action plan’s vision is for a European Region in which: all people are enabled and supported in achieving their full potential for SRH and well-being; their sexual and reproductive rights are respected, protected and fulfilled; and countries, individually and jointly, work towards reducing inequities in SRHR. It has 10 guiding principles that need to be reflected not only in the regional action plan, but also in national action plans, and five strategic directions: Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 8 • assess the current situation in order to define priorities; • strengthen health services for effective delivery of high-impact, evidence-based interventions and universal health coverage; • ensure broad cross-sectoral and societal collaboration; • improve leadership and participatory governance for health; and • enhance information and improve evidence. Its three goals are to promote sexual health and well-being and sexual rights, promote reproductive health and well-being and reproductive rights, and strive for universal access to SRHR and reduce inequities. Each goal has specific objectives. The action plan will coalesce with major policy documents, such as Health 2020 and the Global strategy for women’s, children’s and adolescents’ health, the SDGs and the Minsk Declaration, and will pursue a whole-of-government, whole-of-society approach. The structure of the action plan is shown in Fig. 1. Fig. 1. Structure of the action plan The main protagonists who will enable implementation of the plan are national ministries of health, the Regional Office, and nongovernmental partners. Monitoring will be implemented through indicators that are yet to be identified. Dr Van Look closed by inviting meeting participants to consider the following questions. • Are the vision and goals appropriate? • Are the strategic directions sufficiently inclusive? • Should there be more, or fewer, or different, objectives under each goal? • What additional key actions need to be included under objectives? Are some of the key actions superfluous? Do some key actions need to be rephrased? Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 9 • Are the roles of governments, the Regional Office and nongovernmental partners adequately comprehensive? • Which indicators for monitoring progress can be agreed? Ivo Rakovac, Technical Officer, Division of Information, Evidence, Research and Innovation of the Regional Office, then spoke about Health 2020 indicators and monitoring of the improvement of SRHR in the Region. He described how two working groups were set up to define indicators to measure achievement against Heath 2020’s six overarching targets. One of the groups focused on general indicators, the other on well-being indicators. The groups reported regularly to the Standing Committee of the Regional Committee, enabling them to continually check that they were on the right track. Their final monitoring framework was approved by the Standing Committee in May 2013, following which a web consultation with all Member States was conducted. Dr Rakovac briefly defined the principles for the indicators, which included using only data that were routinely available in countries and defining a manageable number of indicators (~20): the latter principle signals that it was recognized that not everything could be measured. Other important principles were to ensure existing frameworks were not contraindicated and other relevant indicators were not replicated. Member States are requested to report on all the core indicators (at least, and the additional indicators if possible) every 2–3 years. A technical monitoring and evaluation framework has been developed, focusing on inputs and processes, outputs, outcomes and impacts. Dr Rakovac closed by listing some indicators in the Regional Office database that have specific relevance for SRHR, including data on contraceptive use among currently married women aged 15–49, STI incidence and abortion rates. 2.5 The vision of WHO collaborating centres and partners Participants heard presentations from the following WHO collaborating centres and partners, emphasizing actions they are taking to support the development and implementation of the action plan and suggesting amendments and strengthening of the draft: • WHO Collaborating Centre for Sexual and Reproductive Health, Federal Centre for Health Education (BZgA), Cologne, Germany; • WHO Collaborating Centre for Research on Sexual and Reproductive Health, University of Ghent, Belgium; • WHO Collaborating Centre for Research in Human Reproduction, Russian Academy of Medical Sciences, Moscow, Russian Federation; • WHO Collaborating Centre for Perinatal Health, Institute for the Care of Mother and Child, Prague, Czech Republic; • WHO Collaborating Centre for Maternal & Child Health, Burlo Garofolo Institute for Child Health, Trieste, Italy; • WHO Collaborating Centre for Research in Human Reproduction, Karolinska Hospital, Stockholm, Sweden; • United Nations Population Fund (UNFPA); • United Nations Children’s Fund (UNICEF); • International Planned Parenthood Federation, European Network (IPPF EN); and • the European Board and College of Obstetrics and Gynaecology (EBCOG). Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 10 The Secretariat noted comments on the action plan draft (some of which are reflected in Section 3 of this report) and acknowledged the potential for ongoing collaboration in action plan development and implementation. 3. Country feedback on the draft action plan: summary The following section provides a brief summary of points raised in the feedback from countries on the draft action plan, presented by thematic area. Specific points submitted in written country submissions will be addressed by the Secretariat in developing the next draft of the action plan. All countries welcomed the action plan and expressed support, with several speaking of the significant potential it offers to countries nationally and internationally. 3.1 Human rights A few countries believed that the inclusion of sexual and reproductive rights in the action plan was inappropriate. There was no sanction for sexual rights in UN documents, one claimed, which would make the development of specific indicators very difficult. Another felt that a focus on rights was not within the mandate of WHO. An inappropriate focus on rights, it was claimed, detracted from what should be the primary purpose of the action plan – SRH. While the 2001 SRH strategy and the expert meeting in Trieste referred only to SRH, the issue of rights has now been added to the draft. Despite this, there is no mention of sexual and reproductive responsibilities, which the country considered an essential element. It was suggested that the action plan should retain the format of the 2001 strategy: this would lead to a clearly focused document that would produce tangible results in promoting health. Sexual health and sexual rights are different things and should be treated differently, the country suggested, while another asked that the action plan discriminate between sexual health and reproductive health – they are completely different frames and should not be linked. Participants accepted that this is a complex issue that requires sensitive recognition of the positions of individual countries. Generally, however, most strongly supported the inclusion of sexual and reproductive rights as an integral element of the action plan. One country believed that it was not possible to consider SRH without consideration of human rights, while another commented that without recognition of rights, health and well-being is put at risk. It was also suggested that if the action plan is to embrace the concept of social determinants of health, it must also embrace the concept of human rights, and that recognition of sexual rights is consistent with good public health practices. It was suggested that the needs and rights of refugees who have recently entered Europe must be prominent throughout the action plan and that the right of children to grow up in families should be respected if human rights are to be prominent in the action plan. The Secretariat stressed that the issue of rights is a fundamental construct of WHO. The WHO Constitution encapsulates people’s right to a high and sustainable standard of health, and the WHO Director-General has stated that human rights and gender equality are fundamental to all the work of WHO. The rationale for including a rights-based approach in the action plan can therefore be tracked back to the WHO Constitution. It was also suggested that to be serious about promoting health, a rights-based approach was necessary: people who are denied their human rights are denied the opportunity to have their sexual health and identity protected. Attempts to Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 11 deal with the perceived split between sexual health and reproductive health will be made in the narrative of the action plan, an issue that is currently also being addressed in the revision of ICD–11 (International Classification of Diseases 11th edition). The Secretariat also acknowledged the need to reflect the rights of vulnerable groups in fragile and crisis situations, such as refugees, whose access to SRHR services may be very limited. This is an area that WHO is taking very seriously and also represents a key pillar of the global strategy on women’s, children’s and adolescents’ health. It was agreed that the action plan will need to address directly the issue of access to SRHR services for these populations. While welcoming the focus on vulnerable groups, one country cautioned that the expression “special needs” should not be used in the action plan. It has a very particular meaning in some countries that is inappropriate for a SRHR action plan. 3.2 Men’s involvement and gender issues One country claimed that while men’s health had been discussed at the meeting in Trieste, it did not appear in the draft. A participant pointed out that men featured in the 2001 strategy and that the action plan must emphasize that it is for women and men, while another stressed that the action plan should start with girls and boys, as sexuality and the need for SRHR begins early in life. Some countries suggested that the draft as it currently stands requires a better gender balance. It needs to more explicitly include lesbian, gay, bisexual, transgender and intersex (LGBTI) people and emphasize gender equality, it was felt. For instance, while women more commonly suffer sexual violence, attention must be paid to sexual violence perpetrated on both genders: similarly, male infertility is a specific problem that should be addressed in the action plan. Disaggregated data would provide the means to tackle gender-specific problems, it was suggested. The Secretariat confirmed that it considers men’s SRHR to be just as important as women’s. The understanding that SRH is broader than women’s health, and women’s health is broader than SRH, will be reflected in the action plan and the regional strategy for women’s health. The Secretariat also noted, however, that there are risks in adopting a binary approach to gender in which content for women and men is presented separately. This could lead to the possibility of losing focus on the imperative of emphasizing the importance of promoting SRHR and services for all, including transgender and intersex people and those who have sexual identity issues. The Secretariat pointed out that LGBTI issues are addressed in the draft, but would review how the text might be strengthened to emphasize the central message of SRHR for all. It also agreed to review the general gender balance throughout, although there are sensitivities over issues such as men’s involvement in choice of contraceptive method. Extensive data disaggregated by age, sex and socioeconomic status from young people in 43 European countries on issues such as contraceptive use at last intercourse are available from the Health Behaviour in School-aged Children (HBSC) survey, which takes place every four years. HBSC data provide a very valuable resource not only for the regional action plan, but also for countries, the Secretariat suggested. Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 12 3.3 Unsafe abortion and infertility A few countries stated that efforts to increase access to abortion services threatened to break their constitutional laws. It was felt by some that generally, abortion is unsafe in countries where health services are not of high quality and access to services is poor: efforts to make abortion safer should therefore be focused on improving the quality of health services. One stressed that actions on unsafe abortion must be evidence-based, but another stated that abortion on socioeconomic grounds reflects a level of coercion that represents a form of gender-based violence against women. The Secretariat stressed that WHO guidelines on safe abortion are cognisant of the requirement to comply with countries’ laws and are in line with the position adopted by the Cairo programme of action in relation to access to safe abortion services. The guidelines do not prescribe gestational limits for artificial termination of pregnancy, but only the kinds of abortion procedure that should be used at different gestational stages, including late abortions. The Secretariat agreed that abortion should be avoided where possible and, when not possible, offered at the earliest possible stage, but suggested that the issue of abortion supported the need to include rights in the action plan: ultimately, abortion is strongly linked to rights issues. Conscientious objection of health professionals (which was referred to by one country) in emergency and life- threatening obstetric situations also raises human rights questions. One country stated that the focus on infertility should be widened beyond medically assisted reproductive technology to include other options, such as surgical and gynaecological interventions. Another spoke of the need for education and health promotion programmes to include content on how young people can protect their fertility for the longer term. The Secretariat commented that guidelines on infertility are currently being developed, addressing not only treatment modalities but also ethical issues. 3.4 Prevention, promotion, education and social determinants Prevention and promotion is reflected in the narrative of the draft, it was observed, but should be identified as a key strategic direction. The action plan should take the opportunity to promote positive SRH, not just highlight the negative consequences of poor SRH. The current focus is on strengthening health care services, but a clear and definitive strategic direction for prevention and promotion and the presentation of positive health messages should be added. A participant supported this position, emphasizing that adopting a preventative approach, and not just a care approach, was crucial. SRHR should be promoted as a key element of public health policies, it was suggested. The Secretariat was urged to ensure the action plan presented a very positive health promotion position based on strong education and awareness-raising activity. A number of countries mentioned that they would like to see more in the action plan about sexuality education, including recognition of the importance of values and norms around sexuality, and with a focus on life-course transitions, each of which offers opportunities for SRHR education and health promotion. Evidence-based sexuality education should be made available to all age groups, including children and adolescents, and their parents; it was suggested that the term holistic sexuality education be adopted. It is important to ensure sexuality education for children who are not integrated in regular school systems and other vulnerable groups. Appropriately budgeted specialist sexuality education programmes will be required in professional health care Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 13 programmes in universities and in the preparation of sexuality educators. It was also suggested that the media should be highlighted as having a very important role in disseminating messages for positive SRHR. The Secretariat agreed on the need to advocate for comprehensive, age- appropriate, evidence-based sexuality education for children, adolescents and adults. In keeping with the multisectoral spirit of the SDG agenda, it was suggested that the issue of determinants of health should explicitly be mentioned in the action plan, alongside a greater emphasis on promotion and prevention. The Secretariat conceded that the current draft may be too focused on health problems, and that a measured dose of positivity about promoting and enhancing health and rights should be instilled. It noted, however, that many of the elements in the action plan that relate to people’s entry points to SRHR services reflect violations of SRHR: consideration is required to determine how this issue should be addressed in the action plan. The Secretariat nevertheless agreed that elements of sexual well-being were not currently sufficiently addressed, although it was recognized that this might present some challenges when it comes to defining indicators. In relation to social determinants, the Secretariat agreed that they are not mentioned sufficiently in the current draft and undertook to strengthen in this area. 3.5 Menopause One country suggested that it would neither be right to consider menopause exclusively within the area of SRHR of older women, as many younger women enter the menopause due to physiological or therapeutic reasons, nor to consider women who enter the menopause naturally in their 50s as being either ageing or aged. A fundamentally different approach and mindset is required for the menopause, the country suggested. Several countries supported the suggestion of including actions related to menopause and quality of life. 3.6 Links with other initiatives and non-health sectors The draft action plan’s links with existing documents, programmes and initiatives was widely welcomed. The Secretariat assured participants that strategies and action plans currently in development, such as strategies on HIV, hepatitis B and STIs, will also be considered in relation to the SRHR action plan. Countries agreed that it was important for the action plan to link with other global, regional and national strategies and initiatives that may have an impact on SRHR. It was suggested that while the health sector and health systems will of course be very important in delivering on the action plan, sectors outside of health also play a significant part in promoting and protecting populations’ SRHR. Health professionals were identified as having a key role in protecting people’s SRHR and will be central to delivery of the action plan, but actors in non- health sectors will also be very influential. Imaginative thinking is required to identify wider initiatives and multisectoral collaboration that might support successful implementation of the action plan. One participant suggested, for instance, that this should include issues such as smoking and tobacco control: smoking affects fertility in women and men, contributes to impotence in men, increases the chances of miscarriage, preterm births and stillbirths, and increases neonatal and infant mortality. It is also intergenerational, as children born to smokers tend to become smokers themselves. An Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 14 opportunity therefore exists to stress that SRHR is not only about individual interventions, but also about national public health initiatives. The importance of joint working with the education and legal sectors was stressed, while a number of participants suggested that links should be made with key professional groups with specific experience and expertise in the area, such as genitourinary medicine practitioners, specialists in child and adolescent mental health, and nursing and midwifery associations. The Secretariat noted that a representative of European nursing and midwifery associations had attended the meeting and will be consulted during finalization of the action plan. The crucial role of nongovernmental organizations (NGOs) in developing and implementing the action plan was emphasized. A representative of a NGO asked that governments’ responsibility to provide funding to support NGO activity be stressed in the action plan. The Secretariat added that it would be important to ensure involvement not only of civic society organizations, but also of professional and academic institutions. One country specifically referred to the Regional Office’s important role as a partner for countries. Implementation of the action plan will be a challenge for some countries, it was noted, and those countries look forward to ongoing technical support from the Regional Office. 4. Next steps and closing Gunta Lazdane stated that issue 83 of Entre Nous would soon be published, including information about the background to the action plan, and that a document focusing on sensitive issues raised during the meeting would be developed by WHO with the aim of publishing (in English initially) by the end of January. Participants were invited to submit their written comments on the draft by the end of December 2015,1 as the next version of the action plan would need to be completed by the end of January 2016. Gauden Galea reiterated the schedule for the action plan through to presentation to the Regional Committee in September 2016 and thanked all participants for their active involvement in the development of this important strategic document. 1 Russian-speaking participants were asked to submit earlier to allow time for translation. Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 15 Annex 1 PROGRAMME Monday, 14 December 2015 09:00–10:30 Opening session Chair: Ruta Nadisauskiene, Chair of the Regional Advisory Panel on Research and Training in Reproductive Health Welcome by Zsuzsanna Jakab, WHO Regional Director for Europe Process of development of WHO European strategic documents Gauden Galea, WHO Regional Office for Europe Objectives of the consultation and the outcomes of the expert meeting on the SRH strategy in Europe, Trieste, April 2015 Gunta Lazdane, WHO Regional Office for Europe Sexual and reproductive health and rights and Sustainable Development Goals Questions and answers Vicky Claeys, IPPF EN 11:00–12:30 Challenges of SRHR in the European Region Chair: Assia Brandrup-Lukanow, Medical Specialist, King Christian X Hospital for Rheumatic Diseases, Denmark Maternal and perinatal health Petr Velebil, Institute for the Care of Mother and Child, Czech Republic Family planning and infertility Helle Karro, University of Tartu, Estonia Sexually transmitted infections Gunta Lazdane on behalf of Lali Khotenashvili, WHO Regional Office for Europe Unsafe abortion Annette Aronsson, Karolinska University, Sweden Cervical cancer Marilys Corbex, WHO Regional Office for Europe Adolescent sexual and reproductive health Soley Bender, University of Iceland Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 16 13:30–15:30 The global and regional strategic priorities related to SRHR Chairs: Martin Weber, Monika Kosinska, WHO Regional Office for Europe UN Strategy on Women’s, Children’s and Adolescent’s Health Valentina Baltag, WHO headquarters Human rights and SRH – new WHO tools Rajat Khosla, WHO headquarters Health 2020 and the European women’s health strategy Isabel Yordi, WHO Regional Office for Europe Introduction of regional strategic documents related to SRHR recently approved by the WHO Regional Committee for Europe Juan Tello, Health Systems and Public Health Martin Weber, Child and Adolescent Health Manfred Huber, Healthy Ageing, Disability, Long-term Care Dinesh Sethi, Violence and Injury Prevention Matthijs Muijen, Mental Health Joao Breda, Nutrition, Physical Activity and Obesity Lars Møller, Alcohol and Illicit Drugs Jill Farrington, Noncomunicable Diseases Osman Niyazi Cakmak, Vaccine Preventable Diseases and Immunization Irina Eramova, Joint Tuberculosis, HIV/AIDS and Hepatitis Programme Presenting the draft European Action Plan for SRHR and suggested indicators Paul Van Look, WHO consultant 16:00–17:30 The draft European Action Plan for Sexual and Reproductive Health and Rights 2017–2021 Chair: Alberta Bacci H2020 indicators and monitoring of the improvement of sexual and reproductive health in the WHO European Region Ivo Rakovac, WHO Regional Office for Europe Plenary discussion on the country feedback on and suggestion for the draft European Action Plan Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 17 for Sexual and Reproductive Health and Rights Tuesday, 15 December 2015 8:30–10:30 Country feedback on and suggestion for the draft European Action Plan for Sexual and Reproductive Health and Rights (SRHR) Chairs: Marija Kisman, Gunta Lazdane, WHO Regional Office for Europe Plenary discussion Country representatives 11.00–12:30 Vision of the WHO collaborating centres and ways in assisting finalization of the European Action Plan for Sexual and Reproductive Health and Rights Chair: Mihai Horga WHO collaborating centre panellists – representative from WHO collaborating centres in: • Cologne, Germany • Ghent, Belgium • Moscow, Russian Federation • Prague, Czech Republic • Stockholm, Sweden • Trieste, Italy Presentations followed by plenary discussion 13:30–15:00 Vision of the partners Chair: Tamar Khomasuridze, UNFPA EECA Presentations from: • UNFPA RO EECA • UNICEF RO • IPPF EN • EBCOG Presentations followed by plenary discussion 15:30–17:00 Next steps in development of the European Action Plan for Sexual and Reproductive Health and Rights Chair: Gauden Galea, WHO Regional Office for Europe Further actions in development of the European Action Plan for SRHR Plenary discussion Gunta Lazdane, WHO Regional Office for Europe 17:00 Closing of the meeting Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 18 Annex 2 PARTICIPANTS ALBANIA Dr Gazmend Bejta Director, Health Care Directorate Ministry of Health Bulevardi “Bajram Curri” 1008 Tirana ARMENIA Dr Nona Frolova Obstetrician/Gynaecologist Scientific Research Centre on Maternal and Child health Protection (RCMCHP) 22 Mashtots avenue 0002 Yerevan AUSTRIA Dr Renate Fally-Kausek Ministry of Health Radetzkystrasse 2 1030 Vienna AZERBAIJAN Dr Jamilla Gurbanova Director of Institute Scientific Research Institute of Obstetrics and Gynecology Ministry of Health B. Agayev 118 1001 Baku Dr Gulnara Rzayeva Head Ambulatory and Diagnostic Department Scientific Research Institute of Obstetrics and Gynecology Ministry of Health B. Agayev 118 1001 Baku BOSNIA AND HERZEGOVINA Dr Tatjanu Barišić Gynaecologist Clinical Hospital Mostar Kralja Tvrtka, bb, Mostar 88000 Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 19 BULGARIA Dr Angel Kunchev Chief State Health Inspecto Ministry of Health 5 Sveta Nedelja sq. 1000 Sofia CROATIA Dr Vlasta Dečković Vukres Head, Department on Primary Health Care Croatian Institute on Public Health Rockefeller str. 7 10000 Zagreb CYPRUS Mrs Chryso Gregoriadou Nursing Services Officer Ministry of Health 1 Prodromou & Chilonos Street 17 Nicosia 1448 CZECH REPUBLIC Dr Petr Velebil Chief, Perinatal Centre Institute for the Care of Mother and Child Podolské Nábřeží 157 147 10 Prague DENMARK Ms Marie Louise Bloch Rostrup-Nielsen Senior Advisor Danish Ministry of Health Holbergsgade 6 1057 Copenhagen Ms Sanne Frost Chief Advisor Global Health Ministry of Foreign Affairs Asiatisk Plads 2 1448 Copenhagen ESTONIA Ms Andrea Kink Chief Specialist Ministry of Social Affairs Gonsiori 29 15027 Tallinn FINLAND Dr Karin Gisela Blumenthal Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 20 Senior Health Adviser Ministry for Foreign Affairs Katajanokanlaituri 3 00023 Helsinki FRANCE Mr Jean-Christophe Comboroure Deputy Chief HIV, Hepatitis, STDs Office Ministry of Social Affairs, Health and Women's Rights 14 avenue Duquesne 75007 Paris GEORGIA Dr Lela Shengelia Head of Maternal and Child Health Division National Center for Disease Control and Public Health Asatiani 9 0159 Tbilisi GERMANY Ms Laura Brockschmidt Scientific Officer Federal Centre for Health Education (BZgA) Maarweg 149-161 50823 Cologne HUNGARY Dr Árpád Mészáros Deputy Head Ministry of Human Capacities Akadémia utca 3 H-1051 Budapest ICELAND Professor Sóley S. Bender Director of Research and Development regarding Sexual- and Reproductive health Faculty of Nursing University of Iceland Eirberg, Eiríksgata 34 101 Reykjavík ITALY Dr Serena Battilomo Director Unit office 10 Women and Children’s Health Directorate General for Health Prevention Ministry of Health of Italy Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 21 KYRGYZSTAN Dr Aigul Boobekova Head of Medical Service Delivery Department Ministry of Health Moskovskaya str., 148 720040 Bishkek LATVIA Ms Inese Arzova Senior Officer of Division of Quality of Treatment of Health Care Department Ministry of Health Brīvības street 72 LV-1011 Riga LITHUANIA Mrs Aušrutė Armonavičienė Head of Mother and Child Health Division Personal Health Care Division Ministry of Health Vilniaus str. 33 LT-01506, Vilnius MALTA Dr Raymond Busuttil Consultant Public Health Directorate for Health Promotion and Disease Prevention 5B, The Emporium. C. de Brocktorff Street MDS 1421 Msida Dr Karen Vincenti Consultant Public Health Medicine Ministry for Energy and Health (Health) Castellania Palace, 15 Merchants Street VLT 2000 Valletta NORWAY Mr Anders Lamark Tysse Senior Advisor Norwegian Ministry of Health and Care Services Postboks 8011 DEP 0030 Oslo Mr Lennart Lock Senior Advisor Norwegian Directorate of Health Universitetsgaten 2 0130 Oslo Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 22 Mrs Siv-Lise Stærk Advisor Norwegian Ministry of Health and Care Services Postboks 8011 DEP 0180 Oslo POLAND Ms Joanna Banasiuk Lawyer Ministry of Health Miodowa 15 00-952 Warsaw PORTUGAL Dr Lisa Ferreira Vicente Head of the Division of Infant, Youth, Reproductive and Sexual Health Directorate-General of Health Alameda D. Afonso Henriques, 45 1049-005 Lisbon Portugal REPUBLIC OF MOLDOVA Dr Rodica Scutelnic Head of Department for Hospital Care Ministry of Health 2, V. Alecsandri Street MD-2009 Chisinau ROMANIA Dr Petronela Stoian Senior Advisor Ministry of Health 1-3 Cristian Popisteanu Str. Bucharest-1 010024 Bucharest RUSSIAN FEDERATION Professor Oleg S. Filippov Vice Director of the Department of Womens and Childrens Health Care Ministry of Health Rakhmanovsky per., 3/25 127994 Moscow SERBIA Dr Katarina Sedlecky Gynecology and Obstetrics Advisor Senior Adviser in the Family Planning Centre Republic Centre for Family Planning Institute for Health Protection of Mother and Child of Serbia "Dr Vukan Cupic" Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 23 Radoja Dakica St. 6-8 11070 Belgrade SLOVENIA Dr Sonja Tomšič MD, Specialist of Public Health National Institute of Public Health Trubarjeva 2 1000 Ljubljana SPAIN Dr Isabel Saiz Programme Coordinator Ministry of Health, Social Services and Equality Paseo Del Prado, 18-20 28071 Madrid SWEDEN Ms Anna-ChuChu Schindele Analyst Public Health Agency of Sweden Folkhälsomyndigheten 17182 Solna SWITZERLAND Mrs Sirkka Mullis Project Manager Federal Office of Public Health FOPH Schwarzenburggstrasse 157 3003 Bern Mrs Susanne Rohner Baumgartner Advocacy officer Sexual Health Switzerland Marktgasse 36 3011 Bern TAJIKISTAN Dr Gulnora Akmedzhanova Deputy Director National Reproductive Health Center M.Tursunzoda Street 38 734000 Dushanbe TURMEKISTAN Dr Aytgeldi Toylyyev Head of Reproduction Health Department of “Ene-Myakhri” International MCH Centre, Archabil shayoly 744036 Ashgabat Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 24 UKRAINE Dr Natalia Bodnaruk Deputy Chief of the Head Office - Head of the department of obstetrics and gynaecology assistance of the Office of care for mothers and children Medical Department, Ministry of Health of Ukraine 7, Hrushevskyi Street 01601 Kiev Dr Galyna Maystruk Chair of the Board Women Health & Family Planning 9a Tolstogo Street, 01004 Kiev UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND Dr Gwenda Hughes Consultant Scientist (Epidemiology) and Head, STI Section Department of HIV and STIs Centre for Infectious Disease Surveillance and Control National Infection Service Public Health England 61 Colindale Avenue NW9 5EQ London Dr Gina Radford Deputy Chief Medical Officer Department of Health Richmond House, 79 Whitehall SW1A 2NS London EXPERTS Dr Dan Apter Chief Physician Sexual Health Clinic Väestöliitto VL-Medi Kalevankatu 16 00100 Helsinki Finland Dr Alberta Bacci Obstetrician Gynaecologist European School for Mother, Newborn, Child and Adolescent Health WHO CC Trieste, Italy Via Aristo 2 34135 Trieste Italy Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 25 Mrs Vivian Barnekow Consultant Bakkedraget 31 3480 Fredensborg Denmark Dr Assia Brandrup-Lukanow Medical Specialist King Christian X Hospital for Rheumatic Diseases Toldbodgade 3 6300 Gråsten Denmark Dr Serena Donati Researcher of the Maternal and Child Unit National Centre for Epidemiology, Surveillance and Health promotion National Health Institute (Istituto Superiore di Sanità) Viale Regina Elena, 299 00161 Roma Italy Dr Lisa Ferreira Vicente Head of the Division of Infant, Youth, Reproductive and Sexual Health Directorate-General of Health Alameda D. Afonso Henriques, 45 1049-005 Lisbon Portugal Dr Mihai Horga Senior Adviser East European Institute for Reproductive Health 1 Moldovei Street 540493 Tirgu-Mures Romania Professor Helle Karro Head Department of Obstetrics and Gynaecology University of Tartu L.Puusepa 8 51014 Tartu Estonia Dr Louise Mannheimer Head of Unit, The Swedish Public Health Agency Nobels vag 19 Stockholm Sweden Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 26 Professor Rūta Jolanta Nadišauskienė Head Department of Obstetrics and Gynaecology Lithuanian University of Health Sciences 44244 Kaunas Lithuania Professor Paul F.A. Van Look Consultant in Sexual and Reproductive Health Route des Crosets 48 Case postale 51 CH-1873 Val-d’Illiez Switzerland Ms Hilary Wareing Public Management Associates 16a–18a Market Place, Warwick CV34 4SL United Kingdom WHO COLLABORATING CENTRES Dr Annette Aronsson Head of the WHO Collaborating Centre Karolinska Institutet Karolinska University Hospital 17176 Stockholm Sweden Mr Dirk Van Braeckel Director F&A International Centre for Reproductive Health (ICRH) Gent University De Pintelaan 185 UZ114 Gent Belgium Dr Ekaterina Yarotskaya Head Department for International Cooperation Research Centre for Obstetrics, Gynaecology and Perinatology 4, Akademika Oparina Street 111997 Moscow Russian Federation PARTNERS Ms Lillian Bondo Midwife Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 27 President of Danish Midwives Association Representing EFNNMA Danish Midwives Association, Sankt Annæ Plads 30 1250 Copenhagen K Denmark Mr Bjarne Bo Christensen Secretary General Danish Family Planning Association Lergravsvej 59, 2.th 2300 Copenhagen Denmark Mrs Vicky Claeys Regional Director IPPF European Network Rue Royale 146 1000 Brussels Belgium Dr Tamar Khomasuridze SRH Regional Advisor for EECA UNFPA EECA Regional Office Istanbul Turkey Dr Peter Hornnes Treasurer of the European Colleague and Board of Obstetrics and Gynaecology Head of Department Nordsjællands Hospital Dyrehavevej 29 3400 Hillerød Denmark TEMPORARY ADVISERS Mrs Elizabeth Bennour Consultant 23 rue de la Philanthropie 1000 Brussels Belgium Dr Dijana Mayer HBSC Head of Unit for School and Adolescent Medicine Croatian National Institute of Public Health Rockefellerova 7 10000Zagreb Croatia Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 28 Dr Saoirse Nic Gabhainn Senior Lecturer Responsible for HBSC Department of Health Promotion Aras Moyola National University of Ireland University Road, Galway Ireland WORLD HEALTH ORGANIZATION WHO HEADQUARTERS Mrs Valentina Baltag Scientist Dr Claudia Garcia Moreno Esteva Medical Officer Adolescents and at-Risk Populations Dr Rajat Khosla Human Rights Advisor Reproductive Health and Research REGIONAL OFFICE FOR EUROPE Dr Mavjuda Babamuradova Medical Officer Maternal and Newborn Health Division of Noncommunicable Diseases and Promoting Health through the Life-Course Dr João Breda Programme Manager Nutrition, Physical Activity and Obesity Division of Noncommunicable Diseases and Promoting Health through the Life-Course Dr Osman Niyazi Cakmak Technical Officer, Communicable Diseases Vaccine Preventable Diseases and Immunization Communicable Diseases, Health Security & Environment Dr Marilys Anne Dominique Corbex Technical Officer Division of Noncommunicable Diseases and Promoting Health through the Life-Course Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 29 Dr Irina Eramova Medical Officer Division of Communicable Diseases, Health Security & Environment Dr Jill Farrington Senior Technical Officer Division of Noncommunicable Diseases and Promoting Health through the Life-Course Dr Gauden Galea Director Division of Noncommunicable Diseases and Promoting Health through the Life-course Mr Manfred Huber Coordinator Healthy Ageing, Disability, Long-term Care Division of Noncommunicable Diseases and Promoting Health through the Life-Course Ms Nathalie Germain-Julskov Secretary Division of Noncommunicable Diseases and Promoting Health through the Life-Course Dr Marija Kishman Strategic Desk Officer Ms Monika Danuta Kosinska Programme Manager Governance for Health Division of Policy, X-cutting Programmes, RD's Special Projects Dr Gunta Lazdane Programme Manager Sexual and Reproductive Health Division of Noncommunicable Diseases and Promoting Health through the Life-Course Dr Matthijs Muijen Programme Manager Mental Health Division of Noncommunicable Diseases and Promoting Health through the Life-Course Ms Annemarie Stengaard Epidemiologist Division of Communicable Diseases Health Security & Environment Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 30 Dr Lars Møller Programme Manager Alcohol and Illicit Drugs Division of Noncommunicable Diseases and Promoting Health through the Life-Course Ms Åsa Hanna Mari Nihlén Technical Officer Policy, Cross-cutting Programmes, Regional Director’s Special Projects Dr Ivo Rakovac Technical Officer Division of Information, Evidence, Research and Innovation Dr Dinesh Sethi Programme Manager Violence and Injury Prevention Division of Noncommunicable Diseases and Promoting Health through the Life-Course Ms Ida Strömgren Programme Assistant Division of Noncommunicable Diseases and Promoting Health through the Life-Course Dr Juan Tello Programme Manager Health Service Delivery Mrs Isabel Yordi Technical Officer Gender and rights Division of Policy and Governance for Health and Well-Being Dr Martin Weber Programme Manager Child and Adolescent Health and Development Division of Noncommunicable Diseases and Promoting Health through the Life-Course WHO COUNTRY OFFICES Dr Aiga Rurane Head WHO Country Office Pils street 21 LV-1050 Riga Latvia Regional consultation on the development of the European action plan for sexual and reproductive health and rights page 31 Dr Larisa Boderscova National Professional Officer WHO Country Office Sfatul Tarii 29 MD-2012 Chisinau Republic of Moldova Dr Zulfiya Pirova National Professional Officer Reproductive, Maternal, Newborn, Child and Adolescent Health 37/1 WHO Country Office, Tajikistan UN House 2 Vefa Center' 37/1 Bokhtar St Dushanbe 734019 Tajikistan INTERPRETERS Mr Vladimir Ilyukhin Moscow Russian Federation Mr Georgy Pignastyy Moscow Russian Federation RAPPORTEUR Mr Alexander Mathieson 15 Riselaw Terrace EH10 6HW Edinburgh United Kingdom