HRP ANNUAL REPORT 2017
WHO Department of Reproductive Health and Research including the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP)
HRP ANNUAL REPORT 2017
WHO Department of Reproductive Health and Research including the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP)
WHO/RHR/HRP/18.09 © World Health Organization 2018 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; http://creativecommons.org/licenses/by-nc-sa/3.0/igo)
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Suggested citation. WHO Department of Reproductive Health and Research including the UNDP-UNFPA-UNICEFWHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction. HRP annual report 2017. Geneva: World Health Organization; 2018(WHO/RHR/HRP/18.09). Licence: CC BY-NC-SA 3.0 IGO. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.
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HRP ANNUAL REPORT 2017
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CONTENTS 01 About Us 02 Why sexual and reproductive health and rights? 03 Helping people to realize their desired family size Selected 2017 achievements in family planning and contraception Selected 2017 achievement in infertility
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04 Ensuring the health of pregnant women and girls and their newborn infants Selected 2017 achievements in maternal and perinatal health
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05 Preventing unsafe abortion
Selected 2017 achievements in preventing unsafe abortion
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06 Promoting sexual health and well-being Selected 2017 achievements in sexual health
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07 Combatting sexually transmitted infections
Selected 2017 achievements in sexually transmitted infections
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Selected 2017 achievements in sexual and reproductive health and rights (SRHR) and HIV linkages
08 Sexual and reproductive health in disease outbreaks 09 Healthy adolescence for a healthy future
Selected 2017 achievements in sexual and reproductive health in disease outbreaks
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Selected 2017 achievements in adolescent sexual and reproductive health
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10 Preventing and responding to violence against women and girls Selected 2017 achievements in violence against women and girls Selected 2017 achievements in female genital mutilation (FGM)
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11 Protecting and securing health with human rights Selected 2017 achievements in human rights Selected 2017 achievements in sexual and reproductive health and rights in humanitarian settings
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12 Supporting and strengthening national health systems Selected 2017 achievements in research capacity strengthening Selected 2017 achievements in digital health Selected 2017 achievements in measuring and monitoring global indicators Selected 2017 achievements in working with decision-makers
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13 Donors
Photographer credits
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ABOUT US HRP has been providing leadership on sexual and reproductive health and rights for over 45 years. Founded in 1972, we have a unique mandate within the United Nations (UN) system to lead research and to build research capacity for improving sexual and reproductive health and rights through generating high-quality evidence. HRP is based at the World Health Organization (WHO) headquarters in Geneva, Switzerland, within the Department of Reproductive Health and Research. We work collaboratively with partners across the world to shape global thinking on sexual and reproductive health and rights by providing new ideas and insights. We support high-impact research, inform WHO norms and standards, support research capacity-strengthening in low- and middleincome settings, and facilitate the uptake of innovations and new information – including through digital and mobile technologies. An ethical, human-rights-based approach is integrated throughout our work. HRP’s vision is the attainment of the highest possible level of sexual and reproductive health for every single person across the globe. 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.
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WHY SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS? The importance of universal sexual and reproductive health for sustainable development and for the wellbeing of individuals, families, communities and countries has been internationally recognized. The Sustainable Development Goals, the UN Secretary-General’s Global Strategy for Women’s, Children’s and Adolescents’ Health, WHO’s Reproductive Health Strategy, and the aims of the Programme of Action of the 1994 International Conference on Population and Development all reflect a collective vision, which underlines the importance of protecting all people’s human rights to access sexual and reproductive health information and services – to ensure physical and mental health as well as economic development. While great progress has been made, huge challenges remain. Too many women and infants continue to die in childbirth and in the first few days and weeks thereafter. Violence against women and girls, including harmful traditional practices, is a major global health challenge and human rights violation. Many individuals and couples are still unable to access information and services for their sexual, reproductive, maternal and perinatal health, putting their health, well-being and lives at risk. Humanitarian crises threaten lives, livelihoods, health and access to services for millions. And there are now more adolescents than at any period in history, greatly increasing demand for high-quality services that meet their needs. Better data are key. Accurate service statistics help front-line health workers to provide better care; rigorously collected evidence improves estimates of health conditions; and information from research on interventions informs policy, budgeting and health programming. Without continuing investments in research, as well as in improving capacity of countries to conduct research, it is unlikely that national health systems will be able to effectively implement global initiatives and strategies, or to achieve the goal of universal health coverage.
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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 with us in our efforts – with your help, we can continue to improve lives worldwide.
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HELPING PEOPLE TO REALIZE THEIR DESIRED FAMILY SIZE Access to quality, affordable contraceptive information and services, in addition to the prevention and treatment of infertility, allows people to attain their desired number of children and to determine the timing of pregnancies. 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. Some 214 million women of reproductive age in developing countries have an unmet need for contraception. 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. Infertility affects over 50 million people globally, the vast majority of whom cannot access the essential interventions they need. Despite the scale of infertility and its huge 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.
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Community health worker, in Mbale, Uganda, during a home visit, providing family planning services and options to women in the community.
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SELECTED 2017 ACHIEVEMENTS IN FAMILY PLANNING AND CONTRACEPTION 1 HRP published a series of evidence briefs jointly between WHO, UK Aid, STEP UP, and Population Council, on the occasion of the 2017 Family Planning Summit held in London. These evidence briefs take stock of the progress that has been made, and also share crucial data on what works to improve contraceptive services and uptake.
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Designing and delivering contraceptive information and services according to human rights principles is instrumental in ensuring that all individuals can receive high-quality, affordable care that meets their specific needs. To support countries in implementing rights-based approaches, HRP developed two tools that can be used for designing and monitoring programme implementation:
Read more and see the evidence briefs
i. Quality of care in contraceptive information and services, based on human rights standards This tool provides a user-friendly checklist for healthcare managers working at the primary health care level, responsible for the provision of contraceptive services and information; ii. Monitoring human rights in contraceptive services and programmes This tool is intended for use by national programme managers to help them safeguard human rights in contraceptive programming. Quality of care in contraceptive information and services, based on human rights standards: A checklist for health care providers
Monitoring human rights in contraceptive services and programmes
ISBN 978-92-4-151209-1
www.who.int/reproductivehealth Twitter: @HRPresearch
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HRP supported the WHO Regional Office for Africa to publish A guide to identifying and documenting best practices in family planning programmes. This Guide aims to help health programme managers identify best practices in family planning programmes, to document these in summary or detail, and to highlight elements that need attention when scaling up.
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A Guide to
Identifying and Documenting Best Practices in Family Planning Programmes
HRP collaboration with a range of actors – including WHO regional and country offices, ministries of health and professional associations – enabled 20 countries to update their national family planning policies, strategies and guidelines based on WHO recommendations. Forty-seven countries began to use the WHO medical eligibility criteria wheel for contraceptive use. In 10 African countries, the national policies and strategies for providing contraception to adolescents, and the training of health-care providers for postpartum family planning were assessed and areas for improvement identified. See the WHO medical eligibility criteria wheel for contraceptive use
See the Guide to best practices
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SELECTED 2017 ACHIEVEMENT IN INFERTILITY
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HRP, through providing the secretariat of the Implementing Best Practices (IBP) initiative, hosted a series of 15 webinars on WHO guidelines and high-impact practices in English, French and Spanish, reaching over 1000 participants from 45 countries around the world. These were achieved in partnership with Family Planning 2020, the Reproductive Health Supplies Coalition and the High Impact Practices collaboration.
To better understand the global burden of infertility, as well as the scale of unmet need for fertility care across the world, there is an urgent need to document the prevalence and distribution of infertility at national, regional and global levels, as such information is lacking. In recognition of this, HRP has developed a methodology to measure the global burden of infertility, using data from Demographic and Health Surveys (DHS). This methodology is now being piloted in 10 countries across five WHO regions.
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ENSURING THE HEALTH OF PREGNANT WOMEN AND GIRLS AND THEIR NEWBORN INFANTS Complications of pregnancy and childbirth, including unsafe abortion, continue to pose great risks to the health and lives of hundreds of thousands of adolescent and adult women. 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 young adolescents face a higher risk of complications and death as a result of pregnancy than older women. 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 AIDS. In addition, morbidity due to complications of pregnancy and childbirth includes many debilitating conditions such as obstetric fistula. More than two million women across sub-Saharan Africa and Asia live with untreated obstetric fistula, and up to 100 000 more develop this condition every year. Ensuring good quality of care throughout pregnancy, childbirth and the postnatal period is recognized worldwide as essential to reducing the rates of complications and deaths related to pregnancy and childbirth.
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Women at the maternity ward of Reproductive Health Uganda’s clinic in Mbale.
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SELECTED 2017 ACHIEVEMENTS IN MATERNAL AND PERINATAL HEALTH 1 A number of interventions delivered during antenatal care have been shown to improve maternal and newborn outcomes in many lowincome countries. Stock-outs of medical supplies at the point of care, however, can prevent the implementation of these services. HRP published a research study in The Lancet Global Health, which revealed that, in Mozambique, a simple supply chain intervention with four components (kits with medical supplies, a cupboard to store these supplies, a tracking sheet to monitor stocks and a one-day training session) resulted in significant increases in recommended antenatal care practices. Screening for anaemia, for example, increased from 15% to 98% and for proteinuria from 10% to 97%. See the research paper
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HRP disseminated the WHO recommendations on antenatal care for a positive pregnancy experience, in collaboration with WHO Regional Offices for Europe and Africa and other partners. This new WHO antenatal care model increases, from four to eight, the recommended number of contacts a pregnant woman has with health-care providers throughout her pregnancy, so that women have greater access to the recommended services and information needed during pregnancy. In 2017, nine African countries adopted the new WHO recommendations in their policies, and national scale-up in South Africa began in April 2017. See the recommendations
Despite being easily preventable, maternal and neonatal cases of sepsis continue to be major causes of death and morbidity for pregnant or recently pregnant women and newborn babies. In September 2017, HRP joined WHO and the Global Sepsis Alliance to host the World Sepsis Congress Spotlight: Maternal and Neonatal Sepsis – a free online congress shining a spotlight on this neglected aspect of sepsis. Around 8000 people from over 150 countries registered for the congress. In addition, HRP worked with WHO and partners to launch a multicountry study on maternal sepsis, in over 500 facilities in 54 countries, to better understand the prevalence of maternal sepsis and how it is prevented and treated across the world.
Read more
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HRP, in collaboration with research partners, published a special supplement with key findings of the first phase of the Better Outcomes in Labour Difficulty (BOLD) study. The papers highlight what good-quality maternity care means for all those involved – including women, families, communities and care providers – and gives important insights into how this care can be provided in low- and middle-income countries.
Read more
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Publications that report on health programmes often describe what was done, but not how it was done or in what context. This information is central for understanding how impact can be achieved, thereby helping programmes to be successfully replicated and scaled up. To address this, HRP supported WHO to publish standards for reporting on maternal, newborn, and other sexual, reproductive, child and adolescent health programmes. Access the guideline or read more
Postpartum haemorrhage is the leading cause of maternal death worldwide. The majority of these deaths could be avoided – but health-care providers, health managers, policy-makers and other stakeholders need up-to-date and evidencebased recommendations to inform clinical policies and practices to help ensure prompt and effective management of postpartum haemorrhage. In 2017, HRP research was used to update the WHO recommendation on using tranexamic acid for the treatment of postpartum haemorrhage, which supersedes the 2012 recommendation. See the recommendation on tranexamic acid
Programme reporting standards for sexual, reproductive, maternal, newborn, child and adolescent health
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PREVENTING UNSAFE ABORTION
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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. The major life-threatening complications resulting from unsafe abortion are 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, legal induced abortion, and timely care for complications.
A provider with a patient
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SELECTED 2017 ACHIEVEMENTS IN PREVENTING UNSAFE ABORTION 1 Researchers from HRP and the Guttmacher Institute published a study in The Lancet, which shows that an estimated 25 million (or 45%) of all abortions that occurred every year worldwide between 2010 and 2014 were unsafe, and that around 7 million women are admitted to hospitals in developing countries annually as a result of unsafe abortion. The majority (97%) of unsafe abortions occurred in developing countries in Asia, Africa and Latin America. Importantly, the study introduces a new categorization of safety, classifying abortions as “safe”, “less safe” and “least safe”. The study also shows that in countries where abortion is completely banned, or allowed only to save the women’s life or her physical health, only one in four abortions were safe – whereas in countries where abortion is legal on broader grounds nearly nine in 10 abortions were safe.
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HRP, WHO and the United Nations Department of Economic and Social Affairs launched a new, open-access database of laws, policies and health standards on abortion in countries worldwide in June 2017. The database aims to enable greater transparency of abortion laws and policies, as well as to improve countries’ accountability for the protection of women’s and girls’ health and human rights.
More about the database
See the estimates
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Among the many barriers that limit access to safe abortion care, a lack of trained providers is one of the most critical. In many contexts, provision of abortion-related care is limited to specialist doctors, yet many of the evidencebased interventions for safe abortion and postabortion care, particularly those used in early pregnancy, can be provided on an outpatient basis by primary care providers. The emergence of medical abortion (i.e. non-surgical abortion using medications) as a safe and effective option for abortion care makes it possible to consider expanding the range of cadres of health workers who can safely provide abortion care. A recently completed HRP study demonstrated the feasibility, safety and effectiveness of midwives and nurses providing early medical abortion in rural and peri-urban areas of Kyrgyzstan, which adds further evidence to support the WHO recommendations on task sharing for abortion care. See the research study
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PROMOTING SEXUAL HEALTH AND WELL-BEING Sexual health is much more than the absence of disease or infirmity. WHO’s current working definition describes sexual health as “…a state of physical, emotional, mental and social well-being in relation to sexuality…; 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”.
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A married couple travel to a local community dialogue to prevent gender based violence in Arua, Uganda.
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SELECTED 2017 ACHIEVEMENTS IN SEXUAL HEALTH
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Sexual health is fundamental to all people’s health and happiness. When we can enjoy good sexual health, it has a positive impact on many aspects of our lives, including our reproductive health and well-being. This in turn has a positive impact on our societies and countries. On World Sexual Health Day 2017, HRP supported WHO in launching a new framework, Sexual health and its linkages to reproductive health: an operational approach. This framework highlights the many areas where people’s sexual health must be safeguarded throughout the course of their lives – as well as the way in which sexual health and reproductive health are at once distinct yet inextricably linked. More about World Sexual Health Day Download the framework
Sexual health and its linkages to reproductive health: an operational approach Sexual health and reproductive health are closely linked, but crucial aspects of sexual health can be overlooked when grouped under or together with the domain of reproductive health. In order to create broader awareness of comprehensive sexual health interventions and to ensure that sexual health and reproductive health both receive full attention in programming (including provision of health services) and research, the World Health Organization (WHO) has reviewed its working definition of sexual health to create a framework for an operational approach to sexual health. The framework, which is intended to support policy-makers and programme implementers and to provide a stronger foundation for further research and learning in sexual health, is presented and described in full in this brief.
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COMBATTING SEXUALLY TRANSMITTED INFECTIONS Sexually transmitted infections (STIs) represent a massive global burden of disease – every day, more than one million people acquire an STI, which can have serious consequences beyond the immediate impact of the infection itself. STIs such as herpes and syphilis can increase the risk of HIV acquisition threefold or more, and motherto-child transmission of STIs can result in a number of negative health outcomes for newborn infants, including stillbirth, congenital deformities and neonatal death. STIs can lead to social stigma and psychological distress, and can have an important impact on quality of life and sexual relationships. Cervical cancer, which is caused by sexually acquired infection with certain types of human papillomavirus (HPV), is the second most common cancer in women living in low- and middle-income countries, and has a high rate of mortality.
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A number of barriers prevent or deter people from receiving prompt and appropriate testing, diagnosis and care, and the most at risk – including adolescents – often do not have access to adequate health services. Sensitivities surrounding discussions of sexuality present challenges for the promotion of sexual health and well-being, including ways of reducing STIs. More and better-quality research and data are needed to plan effective interventions and to advocate for resources to promote sexual health and well-being for couples and individuals.
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SELECTED 2017 ACHIEVEMENTS IN SEXUALLY TRANSMITTED INFECTIONS 1 2 Gonorrhoea is a curable STI that can infect the genitals, rectum and throat. Complications of gonorrhoea disproportionally affect women, including pelvic inflammatory disease, ectopic pregnancy and infertility. The infection can also cause emotional distress as well as stigma and discrimination. In 2017, HRP published new data from 77 countries showing that antibiotic resistance is making gonorrhoea much more difficult – and sometimes impossible – to treat. In recognition of this, HRP has developed a roadmap to guide the discovery of new medicines to treat gonorrhoea, in collaboration with the Global Antibiotic Research & Development Partnership and WHO’s Global action plan on antimicrobial resistance. More on antibiotic-resistant gonorrhoea
HRP continues to be part of major efforts to ensure that women get the treatment they need to keep themselves well and their children free from HIV and syphilis. In 2017, six Caribbean nations and territories – Anguilla, Antigua and Barbuda, Bermuda, Cayman Islands, Montserrat, and Saint Kitts and Nevis – received WHO validation for the elimination of mother-to-child transmission of HIV and syphilis. This follows the validation of five countries by WHO as having eliminated motherto-child transmission of HIV and/or syphilis during 2015 and 2016: Cuba (both HIV and syphilis), Armenia (HIV only), Belarus (both), Republic of Moldova (syphilis only) and Thailand (both). HRP staff provided critical technical assistance to the WHO country offices to help them to undertake and complete the validation process. PAHO information on elimination of mother-tochild transmission of HIV and syphilis In support of these efforts, HRP updated the WHO Global guidance on criteria and processes for validation: elimination of mother-to-child transmission of HIV and syphilis, in addition to the new WHO guideline on syphilis screening and treatment for pregnant women.
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Neonatal herpes is a rare but potentially devastating complication of genital herpes during pregnancy. It can cause brain damage, breathing problems, seizures and even death. Researchers from HRP, the University of Bristol, and the University of Washington published new estimates in The Lancet Global Health of the global burden of this disease, indicating a rate of about 10 cases per 100 000 live births worldwide. More on the neonatal herpes estimates
GUIDANCE MONITORING AND EVALUATION GLOBAL GUIDANCE ON CRITERIA AND PROCESSES FOR VALIDATION:
WHO GUIDELINE ON
Syphilis screening and treatment for pregnant women
ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION OF HIV AND SYPHILIS SECOND EDITION 2017
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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. In 2017, HRP researchers and partners published a special supplement to the journal Sexually Transmitted Infections, highlighting the urgent importance of investing in the research, development and scaling up of the use of point-of-care tests. More about point-of-care tests
HRP staff guest-edited a PLOS journal collection on the prevention, diagnosis and treatment of STIs. This collection of articles focuses on global policy and systems aiming to achieve control of STIs and mitigation of their adverse effects on health. See the STI journal collection
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SELECTED 2017 ACHIEVEMENTS IN SRHR AND HIV LINKAGES
1 Consolidated guideline on sexual and reproductive health and rights of women living with HIV
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By the end of 2015 there were about 36.7 million people living with HIV globally, up to half of whom had HIV-negative partners. Fertility screening and HIV treatment and prevention – to minimize HIV infection while working towards achieving pregnancy safely – are crucial for all HIV-serodiscordant couples, regardless of whether or not they have fertility problems. HRP staff co-authored and edited a special supplement to the Journal of the International AIDS Society entitled, “Achieving pregnancy safely by HIV-serodiscordant couples”, which highlighted the needs of couples affected by HIV who would like children. More on achieving pregnancy safely
In 2017, there were an estimated 18.6 million women and girls living with HIV, making up more than half of the 36.7 million people living with HIV. HIV acquisition is driven by gender inequality, and HIV also further entrenches inequalities, leaving girls and women more vulnerable to its impact. To support countries in prioritizing the principles of gender equality and human rights while ensuring the well-being of women living with HIV, HRP published the WHO Consolidated guideline on sexual and reproductive health and rights of women living with HIV. This innovative guideline takes a woman-centred approach throughout to address and represent the needs of girls and women living with HIV, as well as the needs of their families and communities. More on the guidance
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SRHR and HIV are inextricably linked. Countries should therefore ensure a linked response to both. Measuring such linkages, however, can pose a significant challenge, and they cannot easily be captured in a single indicator. HRP and the Global Fund developed the SRHR and HIV Linkages Index, which provides the first-ever composite score for measuring country progress towards achieving a linked response to SRHR and HIV in 60 countries. The index can be used to support advocacy to improve SRHR and HIV linkages, guide decisionmaking to focus programming, and measure progress on SRHR and HIV linkages. Go to the SRHR and HIV Linkages Index
Over recent years, countries in eastern and southern Africa have made significant and commendable progress in preventing mother-to-child transmission of HIV and in scaling up HIV treatment. Despite these gains, there have been no significant reductions in new HIV infections, particularly among adolescent girls and young women. HRP published and disseminated an evidence brief, The importance of sexual and reproductive health and rights to prevent HIV in adolescent girls and young women in eastern and southern Africa, which identifies and describes the key steps needed to develop a comprehensive approach to HIV prevention for adolescent girls and young women in the context of SRHR. See the evidence brief
The importance of sexual and reproductive health and rights to prevent HIV in adolescent girls and young women in eastern and southern Africa Evidence brief
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SEXUAL AND REPRODUCTIVE HEALTH IN DISEASE OUTBREAKS The urgent and coordinated responses to the outbreaks of Ebola and Zika virus diseases have shown that disease outbreaks and their associated consequences present a number of significant challenges to the sexual and reproductive health and rights of the populations affected. In particular, a growing volume of data from careful clinical observation and testing of people who have recovered from acute Ebola virus disease indicates that the Ebola virus can persist in the body for many months in some people in various body fluids, including in semen, amniotic fluid, breast milk and the placenta. Sexual transmission of the Ebola virus, from males to females, is a strong possibility, but has not yet been proven. Less probable, but theoretically possible, is female-to-male transmission.
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While Zika virus infection in pregnancy is typically a mild disease, an unusual increase in cases of congenital microcephaly, Guillain-Barré syndrome and other neurological complications in areas where outbreaks have occurred has raised concerns about the health and safety of pregnant women and their families. In addition, while Zika virus is primarily transmitted to people through the bite of an infected mosquito, Zika virus can also be transmitted through semen and other body fluids. Residents of Bouramayah Village in Guinea, welcome visitors while singing songs.
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SELECTED 2017 ACHIEVEMENTS IN SEXUAL AND REPRODUCTIVE HEALTH IN DISEASE OUTBREAKS 1 Due to the potentially harmful outcomes of pregnancy associated with the Zika virus, official advice has been given to women and couples to use contraception and to delay or avoid pregnancy. To understand whether countries affected by Zika have sufficient infrastructure to meet an increased demand for contraception and information, HRP staff and collaborators documented and compared contraceptive sales in Brazil before and during the Zika epidemic, using data from the local pharmaceutical sector. The study found that contraceptive sales in the 24 months of evaluation showed little variation, and no significant change was observed since the Zika outbreak. See the study
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In 2017, HRP and collaborators published key study results that confirmed the long-term presence (up to 18 months) of Ebola virus ribonucleic acid (RNA) in the semen of Ebola virus disease survivors, which declined with increasing time following discharge from the Ebola treatment unit. See the study
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HEALTHY ADOLESCENCE FOR A HEALTHY FUTURE 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. Behaviour and choices made during this time can determine a person’s future health and well-being.
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Adolescents across the world face considerable challenges to their sexual and reproductive health and rights. These include: sexual coercion and intimate partner violence; a 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 and child, early and forced marriage; and risk of infection with sexually transmitted infections (including HIV).
Adolescent girls in Jordan visit Petra.
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SELECTED 2017 ACHIEVEMENTS IN ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH 1 2 Since May 2014, HRP has supported the adaptation in Brazil of a prototype online version of the Quality assessment guidebook: a guide to assessing health services for adolescent clients, originally published by WHO in 2009. This version of the guidebook allows data to be collected digitally to assess the quality and youth-friendliness of health services for adolescents. In 2017, HRP formally handed the system to the Brazil Ministry of Health’s adolescent health and technology teams, who will now collaborate to scale the project nationally at a sustainable pace. Adolescent pregnancy remains a major contributor to maternal and child mortality, and to intergenerational cycles of ill-health and poverty. Much of the focus of research and programmatic action has been on preventing first pregnancies. Rapid repeat pregnancies – second and third pregnancies occurring in quick succession during adolescence, which are a substantial burden in some countries – have been neglected. In 2017, HRP staff co-authored a review of the impact of interventions designed to prevent unintended rapid repeat pregnancies among adolescents, as well as interventions intended to postpone intended closely spaced pregnancies, to promote healthy spacing. The review concluded that good-quality, proactive contraceptive provision and monitoring, complemented with non-clinical interventions that help young people chart out their futures and see purpose in contraceptive use, are most effective in preventing rapid repeat pregnancies. See the review
When children move into early adolescence, they begin to take on new gender roles associated with femininity and masculinity, often reinforcing socially and culturally conventional gender norms related with being women or men. These gender roles have an impact on the choices young adolescents make in relation to sexual and interpersonal relationships, which can have an effect on their health and well-being throughout the rest of their lives. In recognition of this, HRP and John Hopkins University led the first phase of the Global Early Adolescent Study, an international research consortium from 15 countries, to gather evidence on gender norms in early adolescence to inform interventions to improve health outcomes for young people. In 2017, the findings of phase one of the study were published in a special supplement to the Journal of Adolescent Health. More on the special supplement
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On the International Day of the Girl Child 2017, WHO Director-General Dr Tedros Ghebreyesus made a video statement, noting that “addressing harmful gender norms is a crucial part of protecting and promoting health, and preventing disease”. More on the International Day of the Girl Child
The world now has the largest-ever population of adolescents, and it is essential that countries meet their contraceptive needs, to ensure their present and future well-being, and also the well-being of their families and communities. On the occasion of the 2017 Family Planning Summit, HRP and partners published a commentary to call all stakeholders to take action to address several key areas holding adolescents back from accessing and using contraceptives. These key areas were highlighted by the annual progress report of the Family Planning 2020 initiative. See the commentary
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PREVENTING AND RESPONDING TO VIOLENCE AGAINST WOMEN AND GIRLS 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. Violence against women takes multiple forms, and includes intimate partner violence; sexual violence; female genital mutilation; child, early and forced marriage; femicide; and trafficking.
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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 sexually transmitted infections, including HIV. Intimate partner violence in pregnancy also increases the likelihood of miscarriage, stillbirth, preterm delivery and low birth weight 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.
A bicycle rally in Maldives, held to highlight the need to end violence against women and girls.
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SELECTED 2017 ACHIEVEMENTS IN VIOLENCE AGAINST WOMEN AND GIRLS 1 2 Health-care providers have an important role to play in identifying women who experience violence, and responding to them with empathy. For health-care providers to be able to respond appropriately, health systems need to be strengthened so that women receive high-quality and respectful care. In 2017, HRP published the WHO manual, Strengthening health systems to respond to women subjected to intimate partner violence or sexual violence: a manual for health managers. As a complementary volume to the clinical handbook for health-care providers, this manual aims to help health managers to design, plan, manage and implement health services to respond to intimate partner violence or sexual violence. Learn more and see the manual
Millions of children and adolescents across the globe are subjected to sexual abuse, including sexual assault or rape. Health-care providers have an important role in identifying abuse and providing child- or adolescent-centred care in response to the disclosure of abuse. They also have an important role in connecting survivors to other services that they may need. HRP conducted research for the development of the WHO clinical guidelines, Responding to children and adolescents who have been sexually abused, published in 2017. These guidelines aim to help primarily front-line health-care providers in low- and middle-income countries to give high-quality, compassionate and respectful care to children and adolescents through ethical, human rights-based, traumainformed good practices. Learn more and see the guidelines
RESPONDING TO CHILDREN AND ADOLESCENTS WHO HAVE BEEN SEXUALLY ABUSED WHO CLINICAL GUIDELINES
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SELECTED 2017 ACHIEVEMENTS IN FEMALE GENITAL MUTILATION (FGM) 1 On the 2017 International Day of Zero Tolerance for Female Genital Mutilation, a special supplement entitled, “Management of health outcomes of female genital mutilation: systematic reviews and evidence synthesis” was published by the International Journal of Gynecology and Obstetrics. Co-authored and guest-edited by HRP staff, the supplement focuses on the evidence base of best available health interventions for girls and women living with FGM. While work to prevent FGM is of key importance, there is an urgent need also to reach and support, women and girls who have experienced FGM with high quality healthcare. The reviews included in the special supplement show that health-care providers want and need to be supported with appropriate information and training, to help them better care for the girls and women who have experienced FGM. More on the special supplement
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There is no medical justification for FGM. Nevertheless, emerging evidence suggests that medical providers in many countries are increasingly being asked to carry out the harmful practice. Health workers who carry out FGM are actively causing physical and psychological harm, and helping to perpetuate gender-based discrimination against girls and women. To address such “medicalization”, HRP led a systematic review that summarizes the motivations of health-care providers for carrying out FGM. See the review
Health-care providers everywhere need to be prepared to provide treatment and counselling to girls and women who have undergone FGM. HRP is in the process of developing a tool to assess the efficacy of training programmes in ensuring that health-care providers have adequate knowledge and skills to address FGM. To inform the development of this tool, a systematic review was published to examine the existing quantitative tools – such as scales and questionnaires – for measuring health-care students’ and providers’ knowledge, attitudes and practice regarding FGM. See the review
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PROTECTING AND SECURING HEALTH WITH HUMAN RIGHTS Human rights are fundamental to the health of individuals, couples and families, and to the social and economic development of communities and nations. Human rights abuses continue to seriously undermine health, particularly for women and girls. Violence against women and girls remains the most frequent human rights abuse worldwide. Persistent inequalities mean that women, adolescents and children – particularly those who are poorer and living in hard-to-reach areas, and those living in emergency or crisis situations – often do not have equal access to key sexual and reproductive health services. This can have grave consequences for health and well-being, and can even result in death.
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Currently, there are over 66 million forcibly displaced people worldwide, or one in 113 individuals; of whom an estimated 32 million are adolescent girls and women of reproductive age. Women and girls are affected disproportionately in both sudden and slowonset emergencies, and they face diverse challenges to their sexual and reproductive health and well-being. The Global Strategy for Women’s, Children’s and Adolescents’ Health 2016–2030 underlines how, to achieve the vision of the Sustainable Development Goals to “leave no one behind”, it is imperative to protect and improve women’s, children’s and adolescents’ health and well-being at times of emergencies and in the context of humanitarian settings.
Syrian refugee, Danham Al Bilas, plays with his six month old son, Mohammed, in their tent in Zouq Bhanin Village, Lebanon.
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SELECTED 2017 ACHIEVEMENTS IN HUMAN RIGHTS 1 2 HRP’s Scientific and Technical Advisory Group and its Gender and Rights Advisory Panel published a joint Statement on the promotion, protection and fulfilment of sexual and reproductive health and rights. This statement underlines the critical need to ensure access to comprehensive sexual and reproductive health services and information, as well as to guarantee that scientific evidence is developed, shared and used by decision-makers. See the statement
Worldwide, the need to realize human rights to health, and through health, has never been more urgent. Discrimination, abuse and violence against women, children and adolescents erode physical and mental health, stealing the personal well-being of millions, and robbing the world of precious potential. A transformative, human-rights-based leadership agenda is vital if women, children and adolescents are to realize their health and well-being and to flourish and prosper. In recognition of this, HRP supported the development of a report by the joint WHO–Office of the United Nations High Commissioner for Human Rights (OHCHR) working group, which describes the key dimensions of such an agenda. The report, Leading the realization of human rights to health and through health, was launched at the 2017 World Health Assembly. Learn more and see the report
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Human rights and gender equality are crucial for ensuring universal access to sexual and reproductive health information and services. In recognition of this, HRP ensures the inclusion of rights and gender equality approaches within WHO guidelines, products and tools. Some examples from 2017 include the Global Abortion Policies Database and the WHO clinical guidelines, Responding to children and adolescents who have been sexually abused, Consolidated WHO guideline on sexual and reproductive health and rights of women living with HIV, and Monitoring human rights in contraceptive services and programmes. More on human rights and gender equality
SELECTED 2017 ACHIEVEMENTS IN SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS IN HUMANITARIAN SETTINGS 1 HRP launched the global roadmap for improving data, monitoring, and accountability for family planning and sexual and reproductive health in crises at the 2017 Family Planning Summit in London. This included a call to all relevant development and humanitarian actors – including countries, multilateral organizations, donors, civil society, private sector bodies, academia and professional bodies – to commit to a supportive and inclusive process to develop the roadmap, and to implement this once completed. See the roadmap
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SUPPORTING AND STRENGTHENING NATIONAL HEALTH SYSTEMS Many countries across the world lack the necessary human resources and infrastructure to undertake crucial research in sexual and reproductive health and rights. As the only body within the United Nations system with a global mandate to work on strengthening research capacity in sexual and reproductive health and rights, the HRP Alliance promotes and funds research, training, institutional development and networking to increase the research capacity of lowand middle-income countries. Rigorous scientific methods are essential to develop valid and credible evidence, which informs norms and standards that guide the provision of safe, effective, equitable and acceptable sexual and reproductive health services. Research and tools for digital and mobile health innovations are increasingly needed to improve the efficacy, accuracy and ease of data collection, analysis, reporting and use for improving the delivery of sexual and reproductive health interventions.
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Within the UN system, HRP is responsible for the measurement and monitoring of over 20 sexual and reproductive health and rights indicators for reporting on progress towards multiple Sustainable Development Goals, selected World Health Statistics indicators, and the Indicator and Monitoring Framework for the Global Strategy for Women’s, Children’s and Adolescents’ Health.
HRP seeks to ensure that scientific evidence is generated, shared and used by key decision-makers to inform best practice in national health systems. HRP continues to work with parliamentarians in recognition of their critical role in using evidence to protect rights through legislation and allocate resources towards achieving universal health coverage. Parliamentarians can therefore act as powerful advocates for sexual and reproductive health and human rights.
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INDICATORS OF THE SUSTAINABLE DEVELOPMENT GOALS WHERE HRP AIMS TO MAKE AN IMPACT GOAL 3 INDICATOR By 2030, reduce the global maternal mortality ratio to less than 3.1 70 per 100,000 live births
By 2030, ensure universal access to sexual and reproductive 3.7 health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes
GOAL 5
INDICATOR
End all forms of discrimination against all women and girls 5.1 everywhere
5.2
Eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation
Eliminate all harmful practices, such as child, early and forced 5.3 marriage and female genital mutilation
Ensure universal access to sexual and reproductive health 5.6 and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences
GOAL 9
INDICATOR
Enhance scientific research, upgrade the technological 9.5 capabilities of industrial sectors in all countries, in particular developing countries, including, by 2030, encouraging innovation and substantially increasing the number of research and development workers per 1 million people and public and private research and development spending
GOAL 16
INDICATOR
16.2
End abuse, exploitation, trafficking and all forms of violence against and torture of children
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SELECTED 2017 ACHIEVEMENTS IN RESEARCH CAPACITY STRENGTHENING 1 The HRP Alliance selected five institutions in low- and middle-income countries as long-term institutional development hubs (LID-HUBs). These regional hubs are being supported by the HRP Alliance to reach the status of independent regional leaders in sexual and reproductive health and rights implementation research and knowledge transfer. They will support national institutions wanting to strengthen their research capacity by providing research training and mentoring through collaboration in HRP research projects. More on HRP alliance LID-HUBs
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The HRP Alliance also continues its long-term support to a limited number of national research institutions (in Guinea, occupied Palestine territories and Pakistan) to support their continued growth and active collaboration on HRP projects. More on the grant modalities
The HRP Alliance, in collaboration with WHO’s Regional Office for the Americas (PAHO) and the Special Programme for Research and Training in Tropical Diseases (TDR), is supporting 17 new research proposals aimed at identifying solutions to address the Zika virus in seven Latin American countries. They range from identifying transmission risk factors to evaluating diagnostic tools and examining the use of prenatal counselling and contraceptives. More on the research
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SELECTED 2017 ACHIEVEMENTS IN MEASURING AND MONITORING GLOBAL INDICATORS 1 Worldwide, about 10% of pregnant women and 13% of women who have just given birth experience a mental disorder, most commonly depression or anxiety. In low- and middle-income countries, the prevalence is even higher. Poor mental health can have serious long-term consequences, and is a significant contributor to the global burden of disease. Despite this, little is known globally about the prevalence of common mental disorders during and following pregnancy and childbirth, including rare or more severe mental disorders, such as psychosis. To address this gap, HRP led a systematic review to obtain up-to-date global estimates on psychosis prevalence among women in the period following childbirth (puerperal psychosis). The review confirms the relatively low rate of puerperal psychosis, but also that greater attention needs to be paid to this maternal health issue to help health-care workers provide appropriate treatment to prevent harmful consequences for both women and their infants. See the systematic review
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Complications during and following pregnancy and childbirth – or maternal morbidity – are common, and yet their measurement remains somewhat neglected and their impact on women’s health and well-being is poorly understood. The burden caused by maternal morbidity is significant, and can affect the well-being of girls and women throughout their lives. While many more women and girls are surviving childbirth than ever before, they continue to face a wide range of potentially negative health outcomes. To address this, HRP joined collaborators in publishing a systematic review to assess the scope of published research on the consequences of maternal morbidity for women’s and girls’ health and well-being worldwide. The study found that much research has not been comprehensive and has failed to address important issues for the well-being of pregnant women and those who have recently given birth. In particular, there is a concerning lack of attention to consequences on well-being associated with the main direct obstetric complications. The authors concluded that the development of a comprehensive research tool for maternal health would greatly advance understanding of the burden of ill health associated with pregnancy and childbirth. See the systematic review
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SELECTED 2017 ACHIEVEMENTS IN DIGITAL HEALTH
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The Digital Health Atlas is a WHO global technology registry platform that strengthens the value and impact of digital health investments, improves national coordination in planning digital investments, and facilitates institutionalization and scale-up (www.digitalhealthatlas.org). In 2017, HRP began extensive dissemination of the Digital Health Atlas across countries through regionallevel consultations. These consultations gave training and direct support to seven countries on the use of the Digital Health Atlas, and provided an opportunity for regional and country focal points to provide feedback. Access the Digital Health Atlas
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While digital and mobile technology is being used increasingly in the health sector, there is little evidence on the technological performance of mobile health programmes, nor on whether people are able to use these technologies as intended. To address this research gap, HRP supported a case study of the “Mobile Technology for Health” programme in Ghana, to assess the effectiveness of the platform in delivering messages and to study the response of users to the programme. Part of this programme was “Mobile Midwife”, which sends automated educational voice messages to the mobile phones of pregnant and postpartum women. The study found that while the majority (around 77%) of pregnant women owned a private mobile phone, only 25% received the expected messages. The authors concluded that caution should be exercised in making assumptions that digital health programmes perform as intended. See the case study
HRP led the development of the Open Smart Register Platform (OpenSRP), a software system that supports front-line health workers to electronically register and monitor data on the health of their clients. Using mobile phones or tablets, the system frees health workers and their managers from cumbersome paperwork and helps to ensure that every individual is reached with essential health services appropriate to their needs. In 2017, OpenSRP was adopted by the Ministries of Health of Zambia and Tanzania. Integrated with other national-level digital health systems, OpenSRP is now being deployed in both countries to support community-level digital health information systems for immunization, as well as for reproductive, maternal, child, malaria, tuberculosis and HIV programmes. HRP is helping to ensure the quality of health content as well as the integrity and fidelity of national deployments.
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SELECTED 2017 ACHIEVEMENTS IN WORKING WITH DECISION-MAKERS 1 Enabling key technical and political leaders to be able to make evidence-informed decisions is not only a technical process of knowledge exchange and translation, but often poses substantial political challenges that require dialogue between health experts and policy-makers. At the 70th World Health Assembly, held in May 2017, HRP convened a dialogue between parliamentarians from more than 50 countries and the global health community on the role of scientific evidence in guiding health policy and resource allocations, and in particular on health issues that may be undermined or neglected. More on the dialogue
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Drawing on HRP’s long experience in addressing HIV issues from the perspective of sexual and reproductive health, HRP convened an event at the 137th Inter-Parliamentary Union Assembly in October 2017, held in Russia, to highlight the need for urgent parliamentary action to end AIDS through improving sexual and reproductive health and rights. The event opened a series of workshops in countries on the issue of linkages between HIV and sexual and reproductive health and rights in the Pan America Health Organization (PAHO) region. More on HRP at the 137th Inter-Parliamentary Union Assembly
HRP has played a key role in supporting the inclusion of women’s, children’s and adolescents’ health, as well as sexual and reproductive health and rights, in the Group of Seven’s (G7) health priority areas. HRP supported partners in helping to organize the G7/G20 Parliamentarian Conference, The Challenges of a World on the Move: Migration and Gender Equality, Women’s Agency and Sustainable Development, which had a particular focus on sexual and reproductive health and rights in emergency and humanitarian settings, and took part in the G7 Presidency and the European Parliamentarians Forum on Population & Development. To support civil society to promote women and children’s health, including sexual and reproductive health and human rights within the G7 agenda, HRP also contributed to the “Women 7 Forum” – Starting from girls: women’s forum on inequality and sustainable growth.
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DONORS HRP cosponsors and other UN agencies United Nations Population Fund (UNFPA) World Health Organization (WHO) WHO Member States Federal Republic of Germany Flemish Government, Belgium Grand Duchy of Luxembourg Kingdom of Norway Kingdom of the Netherlands Kingdom of Sweden Kingdom of Thailand People’s Republic of China Republic of Finland Swiss Confederation United Kingdom of Great Britain and Northern Ireland United States of America Foundations and other sources Bill and Melinda Gates Foundation David and Lucile Packard Foundation Family Health International Jhpiego Corporation March of Dimes Foundation Merck Sharp & Dohme Corp. The Global Fund to Fight AIDS, TB and Malaria
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PHOTOGRAPHER CREDITS Cover: © Dominic Chavez/World Bank Page iv: © WHO/Yoshi Shimizu Page 3: © Jonathan Torgovnik Page 4: © WHO /Sergey Volkov, © Haydee Lemus/ Courtesty of Photoshare Page 6: © Jonathan Torgovnik Page 8: © DFID/Pippa Ranger Page 9: © WHO/Yoshi Shimizu, © WHO/WPRO/ Yoshi Shimizu, © Tracy McClair/ Courtesy of Photoshare Page 10 : © Sara Gómez, Ipas Page 11 : © Marie Stopes International Page 12 : © 2016 Kato James, Courtesy of Photoshare Page 13 : © CC by Alex Van Page 14 : © CC0 Creative Commons Page 15 : © WHO/Sergey Volkov, ©United Nations Page 16 : © WHO/Yoshi Shimizu, © CC by Garry Knight Page 17 : © WHO/SEARO/Gary Hampton Page 18 : © World Bank Page 19 : © WHO/PAHO Page 20 : © CC by D-Stanley Page 21 : © DFID/ Ricci Coughlan, ©UNICEF/Pirozzi Page 22 : © UN RCO Maldives/Lara L. Hill Page 23 : © UN Women/Gustavo Stephan Page 24 : © UNICEF/Asselin, © UNICEF/Noorani Page 25 : © UNICEF/Noorani Page 26 : © Dominic Chavez/World Bank Page 27 : © WHO Page 30 : © WHO/PAHO, © Mohamed Abdelwahab/USAID/Egypt Page 31 : © CC BY-SA3.0 Page 32 : © Ueli Litscher, Courtesy of Photoshare Page 33 : © IPU
World Health Organization Department of Reproductive Health and Research Avenue Appia 20 1211 Geneva 27 Switzerland Email: reproductivehealth@who.int Website: www.who.int/reproductivehealth