Workshop on Reproductive Health in the Western Pacific Region, Kuala Lumpur, Malaysia, 11-15 December 1995 : report

(WP)MCH/ICP/MCH/OO2-E

Report series no.: RS/95IGEI12(MAA)

English only

REPORT WORKSHOP ON REPRODUCTIVE HEALTH IN THE WESTERN PACIFIC REGION

Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

In collaboration with the: MINISTRY OF HEALTH and the MINISTRY OF NATIONAL UNITY AND SOCIAL DEVELOPMENT OF MALAYSIA Kuala Lumpur, Malaysia 11-15 December 1995

Not for sale Printed and distributed by World Health Organization Regional Office for the Western Pacific Manila, Philippines April 1996 WHO/Wl'fU) ubJU\H.V ManilD. j'lLilippinelJ

NOTE

The views expressed in this report are those of the participants in the Workshop on Reproductive Health in the Western Pacific Region and do not necessarily reflect the policies of the Organization.

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Members States in the Region and for those who participated in the Workshop on Reproductive Health in the Western Pacific Region, which was held in Kuala Lumpur, Malaysia from 11 to 15 December 1995.

CONTENTS

f.w SUMMARy .................................................................................................... 1 1.

INTRODUCTION ...................................................................................... 5 1.1 1.2 1.3 1.4 Participants ........................................................................................ 5 Opening ............................................................................................ 5 Objectives .......................................................................................... 5 Organization ....................... " .............................................................. 6

2.

PROCEEDINGS ........................................................................................ 7 2.1 Summary of country reports ................................................................... 7 2.2 Development of model national reproductive health programmes/plans of action ... 9 2.3 Outline of topics covered in the presented papers ........................................ 12

3.

CONCLUSIONS ...................................................................................... 22 ANNEXES: ANNEX 1 ANNEX 2 ANNEX 3 ANNEX 4 ANNEX 5 ANNEX 6 LIST OF PARTICIPANTS ..................................................... 25 OPENING REMARKS BY THE REGIONAL DIRECTOR ............. 33 OPENING SPEECH OF THE MINISTER OF HEALTH ................ 37 SPECIAL ADDRESS OF THE WIFE OF THE PRIME MINISTER .. 41 AGENDA .......................................................................... 45 CLOSING SPEECH OF THE REGIONAL DIRECTOR ................. 47

ANNEX 7 - CLOSING SPEECH OF THE MINISTER OF NATIONAL UNITY AND SOCIAL DEVELOPMENT ................. 51 ANNEX 8 ANNEX 9 FIGURES: FIGURE 1 FIGURE 2 Key words: Reproduction / Child health services I Child welfare I Maternal health services I Maternal welfare I Western Pacific I Malaysia

PROFORMA OF COUNTRY REPORTS ................................... 53 REGIONAL COMMITTEE RESOLUTIONS .............................. 55

COUNTRY PROFILES ......................................................... 61 CONTRACEPTIVE USE BY PRIORITy ................................... 63

SUMMARY

This regional workshop on reproductive health was planned in response to several global and regional recommendations. At the global level, the Programme of Action which was adopted by the International Conference on Population and Development (ICPD) in Cairo, Egypt, in September 1994 requested that: 'organizations of the United Nations system functioning at the regional level play an active role within their mandates regarding the implementation of the present Programme of Action (of the Cairo Conference) through sub-regional and regional initiatives' (Chapter XVI 16.16 page 113, Cairo Programme of Action) This request was reinforced by the UN General Assembly Resolution UNGA 49/128 which called upon the United Nations Agencies, including the World Health Organization to 'review and where necessary, adjust their programmes and activities in line with the Programme of Action' from Cairo. Similar calls have come from the Copenhagen Conference on Social and Economic Development and from the United Nations Fourth World Conference on Women in Beijing in 1995. At the regional level, the workshop was a response to the new approach to health policy and planning contained in New horizons in health. the blueprint for health development in the Region beyond the year 2000, from the WHO Regional Office for the Western Pacific (WPRO). This document offers an innovative approach to conceptualizing health and planning for future improvements in health status of countries of the Region. It is anticipated that the document will be used as a framework for countries to interpret and adapt according to their specific needs, in collaboration with WHO and other agencies. The document adopts a life-course approach to health suggesting strategies for improving the health of individuals at various stages of life. The Regional Committee at its Forty-sixth meeting in Manila in September 1995, endorsed the need for a review of country activities in reproductive health and the need to gather more reliable data for future planning. Prior to the meeting of the Regional Committee, countries of the Western Pacific Region were requested to provide the most up-to-date information on their respective country's reproductive health status, reproductive health service delivery and policies, legislation and programmes for reproductive health. That information was collated and a regional database constructed from which both regional and country policy planning could be developed. Many countries provided further updates to that database at the workshop in Kuala Lumpur in their country reports. The objectives of the workshop were: (1) to review the present status of reproductive health, and regional and country programmes and efforts on maternal and child health care; to suggest strategies and course of actions of programmes for the implementation (2) of World Health Assembly and Regional Committee resolutions related to reproductive health; and

-2-

(3) to promote reproductive health in the context of New horizons in health, theme I (preparation for life), and to review regional indicators and targets for the improved health of mothers and children. A total of 28 participants attended (mostly MCH/FP programme coordinators) from Australia, Cambodia, China, Cook Islands, Fiji, Japan, Kiribati, Lao People's Democratic Republic, Malaysia, Federated States of Micronesia, Mongolia, New Caledonia, Papua New Guinea, Philippines, Republic of Korea, Samoa, Singapore, Solomon Islands, Vanuatu and Viet Nam. Agenda topics for the workshop were selected based on the need to update information on reproductive health generally, to share new developments in reproductive health technology and ideas, to review country programmes and policies and to consider how the New horizons framework for reproductive health can be translated into activities and integrated programmes. Throughout the workshop, emphasis was placed on the need for countries to strengthen, coordinate and, if necessary, expand their own existing reproductive health programmes in the light of global and regional developments. The sharing of information and experiences highlighted both similarities and differences among countries and areas of the Region and the presence of many intracountry variations in reproductive health status, reproductive health practices, services and provision of programmes. A substantial part of the workshop programme was set aside for countries to report on their reproductive health status, activities and policies and to work in small groups to develop model reproductive health programmes and suggest goals and targets for the next five years to address the key reproductive health problems identified by each country. This process was supplemented with a series of technical papers delivered by th~ secretariat, consultants and advisers. The papers covered issues such as: the need for rethinking strategies to improve family and reproductive health in the light of global and regional developments; elaboration of the reproductive health implications of New horizons in health; an overview of reproductive health in the Western Pacific Region; components of reproductive health including: status, problems, cultural challenges and constraints, adolescent health, unmet needs, future needs and specific issues, e.g., infertility, family planning, abortion, STDs and AIDS, maternal health, perinatal health; possible interventions to improve reproductive health, including the mother-baby package, partograph, home-based maternal records, and clean delivery; technical support and implementation of national reproductive health programmes; quality of care in reproductive health; research in reproductive health;

-

- the role of education and training in reproductive health; the development of appropriate and gender sensitive indicators of reproductive health;

-3-

- community participation and involvement in reproductive health and the need for intersectoral cooperation. The following conclusions were drawn by participants: (1) The participants reviewed the country profiles presented at the workshop and considered existing elements of reproductive health in their respective countries, agreed to work towards developing country reproductive health programmes and take into consideration various factors including the five major priorities that are common to most of the countries of the Region: maternal mortality; contraceptive availability, accessibility and acceptability and affordability; sexually transmitted diseases, including HIV/AIDS and PID; abortion; and teenage pregnancy. (2) In order to address the above priorities close collaboration with WHO will be continued in the following areas: advocacy for reproductive health (as an important public health issue) at the national level; situation analysis and assessment of needs;

- developing and applying methodologies for planning programmes and interventions; - developing and applying effective, culturally sensitive, simple, inexpensive tools and technologies for the implementation of interventions required; reproductive health research to develop methods, devices and effective approaches that are appropriate to the country needs;

- developing, producing and disseminating training materials and guidelines for different levels of the health care system; monitoring and evaluation of programmes and their impact, identifying indicators and collecting and disseminating reliable data for assessing health status and monitoring progress.

(3) Recognizing that reproductive health is a health issue, there is a need for the health sector to take a lead role in planning and implementing reproductive health programmes within the framework of primary health care. (4) Addressing reproductive health concerns requires participation of other sectors and coordination of activities, the health sector should promote such intersectoral and multisectoral coordination. (5) In order to address reproductive health needs a more comprehensive and holistic approach is needed, linking programmes and integrating services where appropriate and feasible and taking into account families' and women's needs and perspectives. (6) To maximize resources and inputs available for reproductive health there is a need for greater coordination and collaboration among different agencies, both at national and international level.

-4-

(7) In addition to technical competence, reproductive health services need to pay particular attention to confidentiality, privacy, ambience, counselling and caring and be sensitive to social, cultural, and religious values, beliefs and traditions. (8) Community involvement is essential for the selection of priorities, development, implementation and evaluation of reproductive health programmes. (9) Women and men have different reproductive health needs, roles and responsibilities at different stages of life. reproductive health programmes need to take this into account within the broader framework of family health ensuring that all members of the family are appropriately served, and men are encouraged to participate fully and share responsibilities. (10) Recognizing the importance of adolescence in future health, there is an urgent need to support the healthy development of young people by promoting healthy behaviour and life-style and providing youth-friendly information and services. (11) The participants welcomed the New horizons in health document and found that it provides an excellent framework for the improvement of national reproductive health programmes and for strengthening cooperation between countries and WHO.

-5-

I. INTRODUCTION

\

In response to several global and regional recommendations and at the invitation of the . inistry of Health, Malaysia, the Workshop on Reproductive Health in the Western Pacific Region was held in Kuala Lumpur from 11 to 15 December 1995. In particular, the 1994 International Conference on Population and Development Plan of Action and the 1995 United Nations Fourth World Conference on Women recommended major rethinking on reproductive health in the light of a growing emphasis on human rights and in view of the need to take account of sustainable population growth and sustainable economic development. At the regional level, the September 1995 Regional Committee emphasized the need to review the current situation on reproductive health in the countries of the Region. Twenty of the thirty-six countries and areas in the Region sent participants to the workshop. I. I Participants

A total of 28 participants, five official observers, nine secretariat members from WHO, one UNFPA Representative, one temporary adviser, and three consultants attended the workshop. The list of participants is attached as Annex 1. 1.2 Qpenin~

The meeting was opened by Dr B.P. Kean, Director, Programme Management at WPRO, on behalf of the Regional Director (see Annex 2 for the speech). A representative of the Malaysian Government welcomed participants on behalf of the Ministry of Health and the Ministry of National Unity and Social Development who were the host country co-organizers of the meeting (Annex 3). Dato' Seri Dr Siti Hasmah bte Haji Mohd Ali, wife of the Prime Minister, provided a special address for the workshop (Annex 4). 1.3 Objectives

The main purpose of the workshop was to review existing country profiles and programmes on reproductive health with a view to developing ideas for appropriate national policies for reproductive health in consultation with WHO and other agencies dealing with reproductive health issues. Specifically, the objectives of the workshop were: (I) to review the present status of reproductive health, and regional and country programmes and efforts on maternal and child health care; (2) to suggest strategies and actions of the programmes to the implementation of the World Health Assembly and Regional Committee resolutions related to reproductive health; and (3) to promote reproductive health in the context of the WHO/wPRO document New horizons in health, theme I (preparation for life), and to review regional indicators and targets for the improVed health of mothers and children.

-6-

1.4

Oreanization

Preparation for the workshop Agenda topics for the workshop were selected based on the need to update information on reproductive health (Annex 5). Participating countries were asked to submit a country report prior to the workshop, giving details of the reproductive health status, basic demographic data, service delivery figures and policies, programmes and reproductive health legislation in their countries. For the country reports at the workshop, participants were provided with a template to prepare data on the above aspects of reproductive health as well as identifying the five major reproductive health problems faced by their countries. This formed the basis for the participants' input at the workshop. Responsibilities for preparing materials on key areas to be addressed at the workshop were divided between the consultants, adviser and secretariat according to the expertise of the personnel involved. In the months leading up to the workshop, such division of tasks was carried out and the final programme was reviewed in Kuala Lumpur during the five days prior to the commencement of the workshop. Running the workshop After the opening ceremony, a chair, vice chair and rapporteur were elected. The chair enforced time limits, punctuality and smooth running of the workshop in collaboration with the Operational Officer. He ensured that everybody participated fully and encouraged participation from those who are reticent about speaking in the forum. The secretariat, consultants and adviser met at the end of proceedings each day to review the day's activities, evaluate the progress of the workshop and to plan the finer details of the next day's proceedings. Formal sessions commenced at 8am and ended at 5pm although group sessions tended to continue outside these hours. Process Active participation was emphasized with consultants, adviser and secretariat only speaking after country participants had exhausted their input. The sharing of ideas and experiences among countries was the basic process adopted to review existing activities and develop national programmes in reproductive health. The role of WHO staff, consultants and adviser was largely to clarify issues on which there was uncertainty, to provide some of the background data for formulation of country strategies and to act as facilitators in group discussions. Some background papers were provided to participants along with copious amounts of technical literature from WHO headquarters and WHO Regional Office. In particular, the eight-volume women's health series developed by WPRO for the Fourth World Conference on Women, Beijing, 4-15 September 1995, and the reproductive health manuals produced by WPRO and WHO/HQ were offered as a key set of resources for future planning in reproductive health. All country reports were made available to all participants, as were the plans of action in developing reproductive health programmes prepared by the four groups. The groupings for small group discussions were:

-7-

Group I: Group II: Group III: Group IV:

Cambodia, Lao PDR and Viet Nam The Pacific Islands, including Australia and Papua New Guinea Malaysia, Philippines, Republic of Korea and Singapore China, Japan and Mongolia

Some groups developed subregional plans of action for their subregions, whereas others developed individual country plans of action. Closing The workshop was closed by the Regional Director, Dr S.T. Han (Annex 6) and was supported by two farewell speeches by the Ministry of Health and the Ministry of National Unity and Social Development (Annex 7). Participants thanked the organizers, WHO and the host country, via a short speech by one of the country participants.

2. PROCEEDINGS

2.1

Summary of country reports

The participants from the 20 countries represented at the workshop provided a 10-minute summary of the state of reproductive health in their country. The presentation followed a proforma sent out to participants prior to the workshop (see Annex 8). The areas covered reproductive health status (crude birth rate, number of live births, total fertility rate, population growth rate, maternal mortality rate, infant mortality rate, STDs/AIDSIHIV incidence or cumulative number of cases, contraceptive prevalence rate and main contraceptive methods used), the five most important reproductive health problems, and information on reproductive health programmes and policies in relation to safe motherhood, population and family planning, breast-feeding and infant nutrition. Although the data were not complete for many countries, some general observations can be made from the data. It was very encouraging that many countries presented very recent data to enable the WPRO records collected for the forty-sixth session of the Regional Committee in 1995 to be updated. The data on reproductive health status revealed huge disparities among countries. Total fertility rates varied from 6.7 in Lao PDR and 5.4 in Papua New Guinea to 1.4 in Japan. Crude birth rates similarly varied from 45/1000 population in Lao PDR to 7.111000 population in Japan. Population growth rate followed the same trend ranging from 2.9% in Lao PDR, 2.3% in Papua New Guinea to less than 1% in Australia. Maternal mortality rates were in the range of 12001100 000 live births in Papua New Guinea to 4.3/100 000 live births in Japan. Infant mortality too displayed a huge variance from 125/1000 live births in Lao PDR to 4.5/1000 live births in Japan. However, most countries have experienced significant decreases in infant mortality over the last 15 years which is reflected in the absence of infant mortality rate on the list of the five most pressing reproductive health problems provided by the 20 countries present at the workshop.

-8-

figur~ t? establish. Most countries took an 'educated guess'. Australia's tigures are based on prescnptlons for the contraceptive pills so cannot give an accurate picture. Some countries were u.n~ble to ~ven guess at the rate, especially the Philippines where contraception is against the rehglous behefs of the majority Roman Catholic population. However from figures supplied, contraceptive prevalence rates are assumed to vary from about 7 in Papu~ New Gui~ea and 10% in the Solomon Islands (both excluding sterilization) and 20% of marned .women 10 Cambodia up to 74% of married women in Singapore, 77% of married women 10 the RepUblic of Korea, and 91 % of married women in China. The major contraceptive methods used vary across the countries. Oepo-provera was named as the preferred contraceptive measure in five Pacific island countries. In the Pacific, the contraceptive pill and IUOs were the next most preferred methods while the use of condoms, vasectomy and tubal ligation were less preferred. The contraceptive p ill was the preferred method of contraception in Australia, Cook Islands, New Caledonia and Vanuatu. Cambodia and Lao POR also showed a preference for contraceptive pills. The contraceptive pill is rarely used, by any country, as a fourth, fifth or sixth preferred method (see Figure I). Similarly Oepo-provera is usually either a first choice, or not chosen at all. Tubal ligation, vasectomy, IUOs and condoms on the other hand are spread across the priority range. Vasectomy is the first choice in no country but is the second, third, fourth and tifth choice in several countries. Tubal ligation is the most favoured contraceptive method in Republic of Korea and Fiji but usually appears as a third or fourth contraceptive method choice. IUD use is the most widely adopted method in China, condom use is the preferred method in Singapore and natural family planning is the contraceptive method of choice in the Philippines.

Uniform and comparable contraceptive prevalence rates proved to be one of the hardest

%

Analysis of the tive major reproductive health problems identitied by countries led to the development of a priority list of five (see Figure 2). Some countries mentioned more than five problems and these extra issues were included. The most commonly mentioned problems which stood out from the rest were STOs/HIV / AIDS/pelvic inflammatory disease (PID) and contraceptive accessibility, availability and acceptability. These were followed by high maternal mortality rates, teenage pregnancies and various issues associated with abortion. As displayed in Figure 2, maternal mortality rate and contraceptive problems scored the largest number of priority I and 2 issues whereas STOs/HIV/AIDS/PID, teenage pregnancy and abortion were more spread between priorities I and 8. These tive areas of concern were shared by about half of the participating countries. The next most commonly mentioned group of problems included high infant mortality rates, lack of child health care, disparities within countries in access to services, lack of knowledge and skills among health workers, breast and reproductive organ cancers, decreasing levels of breast-feeding and infertility (most often caused by PIDs). The least mentioned problems included low birth rates (Singapore and Japan), high total fertility rate (Lao POR), low investment in reproductive health (Republic of Korea, Viet Nam), vaginal bleeding (Kiribati), anaemia (Fiji, Samoa), low numbers of midwives and trained staff (Cambodia, Viet Nam), high parity (Cook Islands, Federated States of Micronesia), ante-partum haemorrhage (Kiribati), poor birth spacing (Federated States of Micronesia), lack of data collection (Philippines, Republic of Korea), low provision of antenatal care (Cambodia, Lao POR), obesity and chronic diseases in pregnancy (Japan, New Caledonia,), high levels of home delivery (Lao POR), post-partum haemorrhage (Kiribati), low access to obstetric care (Cambodia, Republic of Korea), low birth weight, especially among aboriginal babies (Australia), lack of infrastructure and equipment (Viet Nam), particular issues of adolescent health (Malaysia), involvement in service and policy planning (philippines), high levels of obstetric intervention (Australia), lack of adequate reproductive health policy (Japan, Republic of Korea), puerperal pyrexia (Kiribati), insensitive political leadership (Philippines), lack of contraceptive choice (Australia), toxaemia of

-9 -

pregnancy (Kiribati), unsafe work environment affecting reproductive health (Philippines), inconsistent policies in abortion between states (Australia) and postnatal depression (Australia). Thus one notes some grouping of countries. Countries of the Pacific shared similar problems as did the countries of Indo-China and the developed market economies of Australia, Japan and Singapore. Despite having STDs/HIV / AIDS as the key problems in many countries, few countries could provide statistics on incidence and prevalence. HIV/AIDS incidence and prevalence was generally low. The largest cumulative numbers were reported in Australia 4102 (AIDS) and Japan 3022 (HIV positive) and 713 (AIDS). The next highest cumulative total was 200 HIV infections in Papua New Guinea, 119 in the Philippines and 116 in New Caledonia. Many countries did not identify whether their figures were cumulative or related to incidence. Very few countries reported that they had reliable statistics for the last calendar year. Figures were a bit clearer in reported STDs with China topping the list with a 300 000 cumulative total for syphilis and gonorrhoea in 1994. The Philippines also scored highly with a cumulative total of 41 336. Papua New Guinea topped the incidence figures with an incidence of 5000 new cases of syphilis and 20 000 new cases of gonorrhoea in 1994. Australia, Japan and Singapore reported relatively high rates, but this may represent an artefact of accounting processes in these countries compared with other countries in the Region. Having identified STDs, HIV/AIDS and PIDs as major reproductive health issues, the lack of data needs addressing. All countries have developed or are developing specific programmes and/or policies on safe motherhood, population and family planning, breast-feeding and infant nutrition. Some were more integrated than others but all took account of the specific needs of the particular country. Participants used these programmes and policies as the basis for considering the development of national reproductive health plans of action and programmes. 2.2 Development of model national reproductive health plans of action/programmes

The country participants used their country reports and the identified key reproductive health problems to develop model national reproductive health programmes and plans of action. The participants were divided into four groups as follows: Group I : Group II : Group III: Group IV: Cambodia, Lao PDR and Viet Nam The Pacific Islands, including Australia and Papua New Guinea Malaysia, Philippines, Republic of Korea and Singapore China, Japan and Mongolia

Each group identified priority problems (by individual country or as a group) and suggested strategies and targets, and proposed activities to meet the targets offering a timeframe for implementation of the activities.

Group I: Cambodia, Lao PDR and Viet Nam: separate plans of action 10 improve reproductive health Viet Nam identified six priority problems: reproductive health training, MCH family planning quality of care improvement, nutrition for pregnant women and infants under five years, perinatal health including reduction of maternal mortality rate, neonatal tetanus elimination and integration of all reproductive health projects.

- 10 -

The planned targets and strategies and proposed activities, with a timeframe for implementation, involved training, improving current indicators, providing choice of, and accessibility to, contraceptive, and integration of services. Lao POR identified a high maternal mortality rate and infant mortality rate, high total fertility rate, low ante- and pre-natal care coverage and a high level of home delivery as its key priority problems and suggested strategies and targets such as improved community involvement, integration of services, fixed and mobile teams of reproductive health workers, providing appropriate leadership and empowering women to make decisions about reproductive health. Activities such as a national reproductive health workshop, advocacy for reproductive health from all sectors, appropriate training and IEC materials and developing MCHlbirth-spacing guidelines were proposed, with a timeframe of achievement by 1997. Cambodia's priority problems mirrored those of Lao POR, but low access to family planning and increased incidence of STOs/HIV/AIOS were added. Strategies and targets proposed included better monitoring and better coordination, and activities suggested revolved around training and service provision. The timeframe proposed was to achieve major improvements by the turn of the century.

Group II: The Pacific Islands: a group and individual country proposals For the Pacific Islands as a whole, high maternal mortality and teenage pregnancy were identified as shared priority reproductive health problems. Targets and strategies included improving the knowledge of traditional birth attendants ([BAs), increasing the number of maternity waiting homes, improving access to emergency transport, introduction of information, education and communication (lEe) to youth clubs, producing videos for home use, and addressing the unique reproductive needs of adolescents. TBA training and retraining, holding meetings with donors and departments to increase access to transport and using the Cooks Islands' experience with adolescent information provision were some of the activities suggested over the next few years. Australia identified the particular needs of Aboriginal and Torres Strait Islander Australians suggesting the need for training of Aboriginal and Islander health workers, promoting land rights, developing culturally sensitive antenatal clinics and birthing units, improving literacy levels, supporting aboriginal radio for IEC, providing maternity waiting houses near hospitals and providing appropriate and Aboriginal-organized education. The particular information needs of Aboriginal men was also seen as a problem which could be addressed with men's meetings to discuss men's reproductive health needs, rights and responsibilities. Kiribati identified anaemia in pregnancy as a problem needing increased awareness via IEC and iron supplementation. Papua New Guinea and the Solomon Islands identified malaria in pregnancy requiring both service changes and changed behaviour, and male participation in family planning, as key problems to be addressed by culturally sensitive IEC, including radio messages. Papua New Guinea identified three priority problems: infant mortality rate, lack of access to health education materials and shortcomings in the cervical cancer programme in Papua New Guinea. Targets to address these problems included educating parents to improve attendance at vaccination and child health clinics, improving literacy through mandatory schooling and improving laboratory facilities and staff training. Activities proposed starting in 1996 included IEC· and strengthening of vaccination programmes, intersectoral cooperation with the Ministry of Education and the review of existing programmes.

- 11 -

Vanuatu identified the long waiting lists for male vasectomy as a key problem needing improved services and training to improve accessibility.

Group Ill: Malaysia, Philippines, Republic of Korea and Singapore This group identified maternal and perinatal mortality, STDs/HIV/AIDS, adolescent health problems (pregnancy, substance abuse, smoking, promiscuity) and breast and cervical cancers as shared problems. Each country also identified a series of unique problems including Singapore's concern about its low birth rate. Strategies for addressing the identified problems included better data collection, multi-media education of target groups, appropriate legislation, surveillance of selected groups, integration of services and programmes, networking and the development of intersectoral and interagency collaboration, improving parenting skills, improved information services and counselling, inculcating moral and ethical values, increasing awareness of schoolchildren, using parent-teacher associations and developing a hotIine were suggested strategies. Activities included integrating adolescent health with youth programmes and night schools and workplaces. For breast and cervical cancer reduction, the proposed activities included programmes for early detection, education on healthy lifestyles, breast examination by health personnel and breast self-examination, as well as the extension of pap smear tests and the establishment of breast clinics in hospitals and well women clinics.

Group N: China, Japan, Mongolia This group identified maternal mortality and neonatal mortality, adolescent reproductive health (including sexuality and unwanted pregnancies), abortion and STDs/HIV/AIDS/PID as shared problems. Mongolia also identified lack of access to family planning, and China and Japan, a lack of informed choice in family planning, as problems. Strategies suggested to overcome all of these problems included social mobilization (of policy-makers, health consumers and health workers), support for rural, poor, remote or minority areas (POlicy, technical and financial support), multiple sector cooperation, encouragement of men to share responsibility for reproductive health of both men and women and to improve the quality of care. Specific targets were set for each country. Mongolia set targets of: reduction of maternal mortality rate by 50% increase contraceptive prevalence of 50% reduction of abortion rate by 50% reduction of teenage pregnancy by 20%

China suggested the need to: • reduce maternal mortality rate by 50% - broaden the contraceptive mix - reduce neonatal mortality by 50% increase the percentage of adolescents receiving reproductive health education to 80% Japan saw the need to: - create the environment for confidence in bearing children _ have 100% of adolescents receiving reproductive health education

- 12 -

Activities to achieve these targets for all countries included advocacy on behal~ of policy-makers, health consumers and health workers, training for ~ealt~ work~rs, uSI~g the mother-baby package, quality of ca~e guidel!nes, IEC a~d counselling, Improvl~~ basic equipment and essential drug supplies,. ~~dmg for ~pplled research and sup~rvlslOn, . monitoring and evaluation of these activIties. The tlmeframe suggested for Implementation was by the turn of the century. All groups incorporated into thei.r strategies, t.argets and pl~nned activit~es, ideas that they had gained from the various techOical presentatIons and the literature available at th~ . workshop. The concept outlined New horizons in health was seen as a framework for thmkmg about integrated service provision, appropriate monitoring or progress via the developmen~ of indicators sensitive to the needs of consumers of reproductive health programmes and servIces and community involvement and participation in promoting and maintaining good health of the family. 2.3 (i) Outline of topics covered in the presented papers Family and reproductive health

The opening paper presented by Dr T. Tiirmen, Executive Director, Family and Reproductive Health, WHO, Geneva, set the tune for the workshop, outlining the need to adopt a more integrated approach to reproductive health which incorporates issues around sexuality, responsibility and healthy aging. The International Conference on Population and Development (ICPD) in Cairo in 1994 was described as a watershed for reproductive health, closing the gaps in women's health thinking, policy and services. The paper identified the gaps as: inadequate knowledge, inadequate resources and services for reproductive health and lack of information and services for adolescents, older women, men and refugees. Dr Tiirmen called for a multi-disciplinary approach to reproductive health which takes account of the present and historical context in which ideas about reproductive health develop and which addresses the hitherto neglected areas of intimacy, cultural and social traditions, beliefs and values. The paper suggested that there were positive and negative aspects of sexuality and reproduction. On the positive side, the paper identified closeness and comfort, human growth and development, intimacy and the fulfilment resulting from the birth and rearing of a desired child. On the negative side are: diseases (especially STDs/PIDs, HIV/AIDS) abuse and exploitation, unwanted pregnancies and even death. The paper argued that good reproductive health depends on a favourable economic situation, education, employment, adequate living conditions, a positive family environment, good social and gender relationships and a supportive system of traditional and legal structures. Women were identified as bearing the largest burden of reproductive health problems: 36% of the burden of diseases in reproductive health is borne by women in the 15-44 age group while men carry only 12 % of the burden of reproductive ill health (and almost all of those are HIV/AIDS cases). Young men and women and older women were presented as being especially vulnerable. Issues such ~ female genital mutilation, malnutrition, unwanted pregnancies, osteoporosis and prolapse were seen as needing major resource and research inputs. The three priority issues identified were: family planning, safe motherhood and sexually-transmitted diseases prevention, in that particular attention needed to be paid to women, adolescents, men and under-served groups. Currently available integrated programmes such as the mother-baby package were seen to need dissemination and wider use. Integration also needed to occur in attitudes and management which implied additional training and retraining schemes for health and allied workers.

- 13 -

Dr Tiirmen saw the need for a preventive-curative mix at global, regional and country levels. At the country level, she saw cancer treatment (cervix, breast), infertility treatment, breast-feeding promotion, child survival, family planning and STD/AIDS prevention measures as needing to be interconnected and integrated into the primary health care provision arrangements of each country. In the process, she stressed the importance of taking into account women's perspectives and encouraging community participation. Rather than developing entirely new programmes, the need to use existing infrastructure was stressed. The challenge was to develop a new integrated reproductive health approach to existing programmes. Every opportunity should be taken to offer services to all people, especially mothers and children. For example, maternal and child health services could be offered to non-pregnant, non-contraceptive-using women (e.g. older women). Women must be ensured access to safe abortion services, referral systems need to be strengthened and links need to be established with sexually-transmitted diseases programmes. It was suggested that in the light of the recommendations of the Cairo and Beijing conferences, family planning should be the first priority in resource allocation. Dr Tiirmen described the new programme promoted by WHO wherein three divisions (family health, child health and development and reproductive health) have been brought together to address family and reproductive health problems globally. She encouraged countries to develop their own priorities. WHO's strategy is to provide: (1) (2) (3) (4)

advocacy a normative role technical support research.

In the implementation of reproductive health programmes several factors need to be taken into account, namely: - the sovereign rights of each country - consistency with national laws and development priorities - respect for religious and cultural traditions. (ii)

New horizons in health and the role of reproductive health

The global and regional context for the need of the workshop in reproductive health was outlined by Dr N.V.K. Nair, Director, Health Protection and Promotion, WHOIWPRO, and the contribution of the WHO Regional Office for the Western Pacific's New horizons in health to developing a framework for thinking about changes to reproductive health policies and programmes at the regional level was spelled out. The paper emphasized the need to develop an innovative approach to conceptualizing reproductive health and to planning for future improvements in the reproductive health status of countries in the region. However, the paper also stressed that countries should interpret and adapt New horizons .in health according to their specific needs, in collaboration with WHO and other agencies and that existing infrastructures and programmes should be enhanced rather than supplanted. The paper elaborated the reproductive health aspects of the life-course approach to health, suggesting strategies for improving the reproductive health of individuals at various stages of life. Thus, at the preparation for life, protection of life and quality of life in later years stages, reproductive health and sexuality issues are relevant and need to be addressed.

- 14 -

New horizons in health recognizes that sexuality and reproductive health (and illness) cover the entire life span and thus it proposes a creative, muItisectoral approach to understanding and dealing with key issues in family and reproductive health at all stages of life, even in old age. However, high levels of maternal mortality, infant mortality and in some countries, high total fertility rates in some parts of the region, suggest that resources should initially be directed to the preparation for life stage. The paper emphasized that alongside the prioritization of reproductive health issues in each country, development of new indicators which accurately reflect people's reproductive health experiences should be encouraged and that the WHO Regional Office could provide technical support to countries in such development. Although New horizons in health identifies the main issues to be confronted and resolved at the regional level, it acknowledges that the priorities set at the regional level may not coincide with those at the country level. (iii) Reproductive health in the Western Pacific Region (wPR)

Dr G. Deodato, Regional Adviser in Maternal and Child Health, WHOIWPRO, gave an overview of the reproductive health status, service provision and policy and programme development for the countries of the Western Pacific Region. He identified the most pressing reproductive health problems for the region as a whole (high infant and maternal mortality and high total fertility in some countries) and argued that the regional health-for-all targets for these health status indicators may need reviewing before the turn of the century. He also identified other key reproductive health problem for women's health and education, prenatal sex determination, the changing role of mothers, adolescent health, including teenage pregnancies, high parity, sexually transmitted diseases and sexual education, abortion, (safe and unsafe, legal and illegal), low contraceptive prevalence rates and closely spaced deliveries in many parts of the Region. He emphasized that these areas needed continued research, more reliable data to establish the true dimensions of the problems, better evaluation, assessment and monitoring (including the development of more sensitive indicators) and incorporation into an integrated maternal and child health/family planning and reproductive health programme. The achievements of the Maternal and Child Health programme in meeting these needs were outlined, including the production of an eight volume series of monographs on women's health and a series of technical manuals for health workers in the field of reproductive health. The WHO Regional Office for the Western Pacific has also been involved in developing a reliable database on reproductive health for the countries of the region which will become a major resource for priority setting at both regional and country levels and for formulating and reviewing country policies and programmes. The history of separate maternal and child health and family planning, sexually transmitted diseases services and health education facilities has produced a fragmented approach to family and reproductive health in the Western Pacific Region. The challenge is to integrate these services into more holistic programmes which consult consumers of reproductive health services and encourage intersectoral and community participation. Dr Deodato also called for a reproductive health approach to service provision and programme planning implemented by the health sector in collaboration with other sectors at global, regional and national levels. The reproductive health programme needs to be implemented within a primary health care framework and should include and promote the following elements in a cohesive and mutually supporting process:

- 15 -

-

family planning counselling, information, education, communication and services;

- education and services for prenatal care, safe delivery, postnatal care, breast-feeding and health care for infants and women; - prevention and appropriate treatment of infertility; - prevention of abortion and management of the consequences of abortion; - prevention and treatment of reproductive tract infections, STDs and other reproductive health conditions; information, education and counselling on human sexuality, reproductive health and responsible parenthood.

(iv)

Components of reproductive health in view of the country reports

The session on components of reproductive health consisted of a series of papers on general issues such as health status problems, cultural challenges and constraints, future needs and possible solutions and unmet needs. Also included was a set of particular reproductive health problems such as maternal health, perinatal health, adolescent reproductive health, infertility, reproductive tract infections (RTIs), STDs, AIDS, family planning, abortion (including unsafe abortion) and menstrual regulation. In the paper addressing general components of reproductive health, Dr E. Eckermann, WHO consultant for this workshop, outlined the key reproductive health issues of concern for the region (as outlined by Dr Deodato in his overview of the Western Pacific Region) and used the country reports to identify five priority reproductive health issues, namely: increasing STDs/ HIV/AIDS, RTls, abortion, low contraceptive prevalence rates, high maternal mortality and teenage pregnancy. Although each country in the Region had its own set of reproductive health problems, these five stood out as the most common to the Region with about half the countries mentioning them in their list of five major reproductive health problems. Dr Eckermann mentioned that the reason why reproductive rights in relation to health generate such widespread debate (as in both the Cairo and the Beijing conferences) is that ideas about reproduction are culturally formed and most cultural and religious traditions contain deeply held beliefs and taboos regarding reproduction and sexuality. This makes developing universal principles and global recommendations on reproductive health very difficult. On a regional level, too, pressure to develop regional strategy and policy have to take account of inter- and intra-country differences in sets of beliefs, attitudes, values and customs. These are often seen as a hindrance to development and advances in reproductive health but they also offer opportunities for creative and innovative reproductive health programmes. There is some shared heritage between the countries of the Western Pacific Region but in reproductive health and sexuality issues, significant differences between countries remain in terms of acceptable policies and actions. Dr Eckermann offered several examples from countries in the Region to illustrate this point. She also pointed out that cultural constraints and challenges are not confined to small traditional communities, modern scientific medicine too is culturally constructed and contains many practices and beliefs which relate to traditions - for example, birthing positions, and medical constructions of menstruation and menopause.

- 16 -

Some cultural practices in reproductive health are efficacious, some are benign but others are dangerous, such as putting pressure on the birthing mothers abdomen during labour, restrictive nutrition for pregnant and breast-feeding women and the use of traditional vaginal potions. The challenge is to develop procedures and indicators for assessing the efficacy of a variety of traditional as well as modern scientific practices around reproductive health. This task is currently being undertaken in WHO Regional Office for the Western Pacific. Dr J. Annus, Medical Officer, Safe Motherhood, WHOIWPRO, discussed a series of particular reproductive health problems in the Western Pacific Region providing figures to support the need to recognize RTIs, STDs, AIDS/HIV, family planning, abortion (especially unsafe abortions) and infertility (largely produced by RTls) as major public health problems. He emphasized that these issues are becoming increasingly problematic in all countries of the Region, as confirmed by the country reports, and require urgent attention within an intej:rated primary health care framework. Dr A. Khan, MCH/FP Adviser, UNFPA, Bangkok, addressed the continuing problem of high rates of maternal and perinatal mortality and morbidity in the Region arguing, Iil:e speakers in earlier session, for an integrated approach to satisfy the unmet needs in these areas. He also reported on the principal areas where technical support could facilitate the development and implementation of reproductive health programmes, as follows: advocacy campaigns; identification of problems and determination of priorities; application of effective methodologies in research; formulation of reproductive health policies and strategies; application of new programme tools and strategies; transfer of knowledge and technologies; strengthening of national capacity evaluation and monitoring; utilization of international support.

Dr S. Katoanga, MCH/FP Adviser, UNFPA, Suva, covered the area of adolescem reproductive health suggesting that respect for adolescents as productive members of the community is the place to start in developing appropriate reproductive health programmts to meet their needs. He addressed the particular problem of teenage pregnancies which accounted for 15% of all pregnancies in the Pacific countries between 1990 and 1994. tie dispelled the myth that Pacific Island cultures were traditionally promiscuous suggesting that respect for women, respect for elders and marital fidelity were key aspects of traditional culture in the Pacific and that these fitted well into the imported Christian beliefs and values. However, these traditional values have been gradually undermined and contributing to the current problem of teenage pregnancy. The young people of the Pacific need the 'love a~d care that they deserve' and that they must be provided with 'respect' appropriate education and services to start addressing adolescent health problems such as teenage pregnancy. (v)

Possible interventions to improve reproductive health

Dr Carla Abou-Zahr, Maternal Health and Safe Motherhood, WHO, Geneva, and Dr Raj Karim, consultant for this workshop, outlined the key components of the mother-baby package and the advantages of its integrated approach to reproductive health. They also stressed the importance of other technical tools developed by WHO to improve family ard reproductive health including the partograph, risk approach, maternal and infant death alditing and home-based maternal records. The mother-baby package was identified as providinll useful guidelines for managers of health services to develop and implement national progr~es for safe motherhood involving both the mother and the newborn. The risk approach was described and was also presented as an invaluable tool for managing

- 17 -

reproductive health programmes. However, Dr Raj Karim warned that individual risk factors and cut-off points should be selected carefully. When applied properly, the risk approach strategy is an excellent method for improving the health of mothers and children but it must not be used merely as a screening mechanism. In every society there are individuals, families and communities whose chances of future illness, accidents and untimely deaths are greater than those of others. The challenge is to identify such vulnerable or 'at risk' group or individuals (such as pregnant women with high blood pressure) and provide the necessary basic services (e.g. trained birth attendants) and back-up services (e.g. obstetric care for unexpected complications). Dr Raj Karim pointed out the difference between individual clinical concepts of risk and population-based epidemiological understandings of risk. From epidemiological data, key biological, genetic, environmental and psychosocial risk factors that have been identified for pregnant women include: age (less than 18, more than 35) parity (5 and above) short stature obstetric history of previous complications poor antenatal care anaemia poverty and ill iteracy high blood pressure.

The need for screening all pregnant women to ascertain risk factors is emphasized in the risk approach as well as the need to follow-up with appropriate management. She also identified some of the shortcomings of the risk approach, including a tendency to use it as a substitute for care and the low sensitivity and specification of risk screening and its poor predictive value. The need to rethink the risk approach was stressed and using antenatal risk assessment as a way of managing individual pregnancies was promoted. The partograph is a simple labour graph developed by WHO which is designed for easy use by midwifery personnel in monitoring progress of labour and the health conditions of mother and child. Use of the partograph can prevent prolonged labour due to obstruction or other causes by providing a guide as to when intervention is required. It is recommended as a preventive tool against obstructed labour and its sequalae which are one of the major causes of maternal and morbidity and mortality. The home-based maternal record method was also outlined and its successful use in several countries of the Region was noted. Positive aspects of home-based maternal records were identified but it was stressed that it needed to be designed and applied appropriately and be kept simple since health workers felt overburdened by complicated new methods. Maternal and infant death auditing was also outlined and it was concluded that investigation of such deaths was essential for improving health services - this would also include evaluation of traditional practices. Mr N. Dreesch, WHO consultant for this workshop, outlined the Rapid evaluation methods (REM, specifically the REM and safe motherhood needs assessment tool). These methods are used to identify operational aspects of reproductive health services and have been tried in several countries of the Region, including Papua New Guinea and Viet Nam.

- 18 -

Dr Annus concluded this session with selected World Health Assembly and Regional Committee resolutions related to reproductive health (Annex 9). In the discussion that followed, it was agreed that reproductive health is primarily a health issue and that at country level, the health sector should playa leading role in planning and implementing reproductive health programmes. (vi) Technical support in the developmem and jmplememation of national reproductive health proeramroes: the need for jntersectoral cooperation. community Participation. and development of appropriate national policies for reproductive health. Dr Khan discussed technical support in the development and implementation of national reproductive health programmes arguing that countries should adapt what WHO has to offer at the global and regional levels to their own countries' needs. The technical tools described in the previous session were presemed as a 'smorgasbord' from which countries could choose and that this could also be a two-way process whereby country initiatives and discoveries could be shared with other countries either through WHO or directly. The need for community participation and intersectoral cooperation in developing national reproductive health programmes was stressed and suggestions for facilitating such processes were proposed. Dr Eckermann reviewed the currently applied reproductive health programmes for safe motherhood, population and family planning and breast-feeding and infant nutrition noting that all countries had well-developed programmes and policies. In some cases, these programmes and policies are integrated, in some cases they remain separate and distinct. Some of the barriers to integration of programmes and policies include: economic and financial constraints of countries whose governments have identified other priorities

- geographic constraints, which are difficult to negotiate alld which are poorly served by infrastructure - lack of commitment to family planning and available services by the popUlation cultural, social and religious taboos and customs lack of political will on behalf of governments.

To overcome these barriers policies which explore all possibilities and identify achievable goals must be developed and articulated. As outlined in the Reproductive Health for All document, a global reproductive health strategy must involve programmes which aim to: promote reproductive health prevent specific reproductive health problems provide care, treatment and rehabilitation to all address the needs of specific target groups, such as women, adolescents, men and families, as well as neglected groups such as refugees, and other displaced people.

- 19 -

Such a programme demands an intersectoral approach as outlined in New horizons in health and requires the development of appropriate indicators to monitor the progress towards improved health status and to set parameters to evaluate the extent to which health objectives are being met at all stages of the life course ensuring that measures of length of life and physical health (mortality and morbidity) are complemented with measures of quality of life (including social, economic, emotional, psychological and spiritual well-being). (vii) Ouality of care in reproductive health Professor Ratnam emphasized the need to assess and ensure quality of care in reproductive health and to develop measures for monitoring and evaluating quality of care. He stressed the need to interpret quality of care in its broadest possible sense as incorporating patients' and consumers' perspective of the quality of care as well as those of health professionals. (viii) Research in reproductive health Dr G. Benagiano, Director, Research Development and Research Training in Human Reproduction, WHO, Geneva, addressed research issues in reproductive health in two sections. Firstly, he discussed the current status of reproductive health research and emerging needs and directions including the new approach adopted by the Family and Reproductive Health Programme Area of WHO and by the Special Programme of Research Development and Research Training in Human Reproduction (HRP). Secondly, he provided updated information on research on selected types of contraceptive modalities under development in the Special Programme. It was stressed that as far as research on human reproduction is concerned, and also for its co-sponsors UNDP, UNFPA, WHO and the World Bank, a research programme is a service programme which serves the organizations in acquiring tools and information to carry out their mandates. The research programme developed and coordinated by HRP is thus sensitive and responsive to the needs and requirements of the individual countries and their reproductive health programmes. Its main goals in research are to: increase informed choice in reproductive health for women. Since women bear the bulk of the reproductive ill health burden, justice requires that research efforts be dedicated to improving their situation; increase male responsibility in ensuring reproductive health for all;

-

- respond to the needs of developing countries; coordinate global research at the international level.

The process of reproductive health research begins with situational analysis, whereby comprehensive assessment of reproductive health needs and identification of research required to address those needs, is carried out. Identification of the infrastructure required for a national research effort in identified areas is then done and the situational infrastructure infortnation enables the identification of the best course of action. Information from the situational analysis can point to the need for the development of new and improved technologies and methodologies or for the establishment of standards, guidelines and norms. Institutional development activities help maintain and further develop a unique worldwide network of centres which work with HRP to implement the global research agenda.

- 20 -

At the third stage, introduction and evaluation, change is introduced and its impact assessed. Activities at this stage are at the country level and are also concerned with longterm assessment of safety and effectiveness of fertility regulating methods and the strengthening of national capacity to undertake reproductive health research of local priority. Although HRP would like to address all reproductive health problems which present themselves, limited funding and other resources mean that to be effective, the programme must prioritize reproductive health issues, and this is done in collaboration with countries. In addressing contraceptive development activities at HRP, Dr Benagiano offered concrete examples to illustrate the activities of HRP. The first example used was anti-fertility vaccines which he saw as contraceptive of the future although they have a few shortcomings, including delay in effectiveness. He argued what research has shown that some tetanus vaccines contain anti-fertility vaccine, or abortifacient substances, to be false. Dr Benagiano discussed a new prototype of anti-fertility vaccines which is in its laboratory testing phase and probably will not be available until after 2000. He also discussed anti-progestines for fertility control which show promise in two circumstances, emergency contraception (,morning-after pill ') and early medically-induced abortion. Mifepristone has been shown to produce fewer side-effects than the earlier Yuzpe regimen, and the difference is statistically significant. He also presented the latest research findings on IUD technology suggesting that the TCU 380A IUD device is far superior to all other devices in terms of pregnancy rates. The side-effects of IUD, especially PID (which could lead to infertility or tubal occlusion), have been addressed by HRP, and guidelines for sterile insertion and proper screening of potential users, given that most PIDs develop at the time of insertion. Conclusions which can be drawn from the research on IUDs sponsored by WHO/HRP include: (1) The IUD is currently the most widely used method of reversible contraceptive worldwide - most users are in China. (2) The clinical performance of inert (plastic or steel) devices is inferior to that of copper IUDs and hence such devices should no longer be used. (3) Among copper devices the TCU 380A is preferrable because of its very low pregnancy rate, long duration of efficacy and relative ease and cheapness of manufacture. (4) Use of IUD is associated with a small risk of developing pelvic inflammatory disease, which is highest in the first few weeks after insertion. (5) Studies with the levonorgestrel-releasing IUD indicate that this device has an efficacy which, for the first two years, is at least as good as that of TCU 380A. Also, this IUD reduces menstrual blood loss and may provide some protection against upper reproductive tract infection.

(6) lnitial trials of frameless IUDs, developed to reduce pain, are yielding promising results. They suggest that expUlsion and bleeding, frequently associated with traditional IUDs, are less frequent with this new type of IUD. (7) A very important aspect of research carried out by HRP has to do with involving males in reproductive health, especially fertility-regulation.

- 21 -

Social science research provides insights on how men can be more involved in reproductive health promotion. Areas such as awareness, acceptability and approval by males of methods of contraception, inter-partner communication, extent of current use of male methods, potential demand for male methods and obstacles to the use of male methods are currently under investigation. Alongside the social science research, biomedical research continues on inhibition, interference and interruption of sperm productive function and transport, prevention of sperm deposition and prevention of sperm-egg interactions. (ix) Role of lEe and formal education in supporting rejlroductive health. indicators of rtmroductive health. gender issues including guide indicators Dr Katoanga outlined the role of lEe and formal education in supporting reproductive health emphasizing the need to be sensitive to the needs and requirements of the audience of education and to use appropriate levels of technology. Mr Dreesch outlined the initiative by WPRO in establishing a centralized database for effective policy formulation and planning for countries of the Region. He noted that a large number of data items were routinely reported for HFA monitoring and that these data should be used as the basis for the database rather than burdening country health departments with more bureaucratic form filling and data collection. The data used in the database come from WPRO socioeconomic indicators, consultant reports, UNFPA and other agencies publications and ESeAP collections and are supplemented with rapid evaluation data and safe motherhood assessments . There are certain limitations to the data base given that data collection is not uniform, data are displayed as available and often have different reference years and different baselines. Data based on surveys usually have different study designs and sample sizes. Thus caution must be used in interpreting the data for planning of intervention activities. The goal of the reproductive health database project is to improve the data quality and enhance the standardization of items collected for better planning, management and monitoring. Data are collected on demographic and population information (including life expectancy at birth, adult literacy) safe motherhood information (life births, unsafe abortions, etc.), maternal mortality information (including causes of maternal deaths), health status (infant mortality, weight/height ratios), and morbidity, infertility and violence (including STDs, HIV/AIDS, women raped, women reporting violence). The need to limit the number of indicators and the full and proper use of existing data were stressed. The paper on gender by Dr Eckermann suggested that despite better survival rates, women fare badly on morbidity, social and quality of life indicators. To address the particular needs of women, indicators of health status need to be disaggregated, gender sensitive, acknowledge the heterogeneity of men and women (by age, race, ethnicity. geographical location, social class) deal with specific reproductive health issues of women and gender specific in non-reproductive areas of health. There will always be a need to address the particular health needs of women not only because of their different biology but because of their experiences of being gendered subjects (their existence in CUlture). The challenge is to appreciate the differences between men and women and to support the notion of 'different but equal' rather than use difference to support inequality and discrimination. Where difference leads to inequality, policies must be put in place to eliminate or minimize that difference.

- 22 -

Men too have specific needs in relation to reproductive health which are often not acknowledged, under-researched and under-serviced. In reproductive health issues, men o.ften do not participate because this area is seen in many cultures as 'women's business' - even If they wanted to contribute, they are excluded by social customs and mores. Thus ~~s~ gender issues need to be addressed alongside the reluctance of some men to share responSibility for ensuring reproductive health.

3. CONCLUSIONS

Key themes which emerged from the workshop included the need for integrated services, the need for intersectoral cooperation in reproductive health, the need to include men in reproductive health activities and the lack of adequate data with which to conduct effective reproductive health policy planning and programme development. The issue of sovereign rights of individual countries was also stressed and the need for sensitivity to cultural, social and religious customs in reproductive health where health is not compromised. After discussion on various aspects and elements of reproductive health within the context of the family, participants concluded the following: (\) The participants reviewed the country profiles presented at the workshop and considered existing elements of reproductive health in their respective countries, agreed to work towards developing country reproductive health programmes and take into consideration various factors including the five major priorities that are common to most of the countries of the Region: maternal mortality, contraceptive availability, accessibility and acceptability and affordability, sexually transmitted diseases, including HIV I AIDS and PID, abortion, and teenage pregnancy. (2) In order to address the above priorities close collaboration with WHO will be continued in the following areas. advocacy for reproductive health (as an important public health issue) at the national level; situation analysis and assessment of needs;

- developing and applying methodologies for planning programmes and interventions; - developing and applying effective, culturally sensitive, simple, inexpensive tools and technologies for the implementation of interventions required; reproductive health research to develop methods, devices and effective approaches that are appropriate to the country needs; developing, producing and disseminating training materials and guidelines for different levels of the health care system; monitoring and evaluation of programmes and their impact, identifying indicators and collecting and disseminating reliable data for assessing health status and monitoring progress.

- 23 -

(3) Recognizing that reproductive health is a health issue, there is a need for the health sector to take a leadership role in planning and implementing reproductive health programmes within the framework of primary health care. (4) Addressing reproductive health concerns requires participation of other sectors and coordination of activities, the health sector should promote such intersectoral and multisectoral coordination. (5) In order to address reproductive health needs a more comprehensive and holistic approach is needed, linking programmes and integrating services where appropriate and feasible and taking into account families' and women's needs and perspectives. (6) To maximize resources and inputs available for reproductive health there is a need for greater coordination and collaboration among different agencies, both at national and international level. (7) In addition to technical competence, reproductive health services need to pay particular attention to contidentiality, privacy, ambience, counselling and caring and be sensitive to social, cultural, and religious values, beliefs and traditions. (8) Community involvement is essential for the selection of priorities, development, implementation and evaluation of reproductive health programmes. (9) Women and men have different reproductive health needs, roles and responsibilities at different stages of life. reproductive health programmes need to take this into account within the broader framework of family health ensuring that all members of the family are appropriately served, and men are encouraged to participate fully and share responsibilities. (10) Recognizing the importance of adolescence in future health, there is an urgent need to support the healthy development of young people by promoting healthy behaviour and life-style and providing youth-friendly information and services. (11) The participants welcomed New horizons in health and found that it provides an excellent framework for the improvement of national reproductive health programmes and for strengthening cooperation between countries and WHO.

- 25 -

ANNEX 1

LIST OF PARTICIPANTS, CONSULTANTS, TEMPORARY ADVISER, REPRESENTATIVE, OBSERVERS, AND SECRETARIAT

1. PARTICIPANTS

AUSTRALIA

Dr Margaret Dean Medical Advisor Family Health Care Group Department of Human Services and Health P.O. Box 9848 Canberra. ACT 2600 Dr Eng Huot Directeur du Centre National de Protection Maternelle et Infantile Minist~re de la Sante Phnom Penh Centre National de Protection Chef Bureau Technique du Dr Sann Chan Soeung Maternelle et Infantile Minist~re de la Sante Phnom Penh

CAMBODIA

CHINA

Dr (Ms) Pang Ru Yan Deputy Director General Maternal and Child Health Department Ministry of Health Beijing Dr (Ms) Li Jian Ling Maternal and Child Health Officer Maternal and Child Health Department Ministry of Health Beijing

COOK ISLANDS

Mrs Kathleen Koteka Charge Sister Obstetrician/Family Planning Ministry of Health P.O. Box 657 Rarotonga Dr Losevati Alefaio Medical Officer/Family Planning Clinic Colonial War Memorial Hospital c/o Ministry of Health

FIJI

SYYlI

- 26 Annex 1 JAPAN Dr Kishio Ono Director Planning Division Bureau of International Medical Cooperation International Medical Center of Japan 1-21-1 Toyama-cho, Sinjuku-ku Tokyo 162 Dr Takeieta Kienene Director of Preventive and Public Health Services Ministry of Health and Family Planning Tarawa Dr Sibounhom Archkhawongs Deputy Head Technical Administration and Management Services Department of Hygiene and Prevention Ministry of Health Vientiane Dr (Mrs) Khamseng Pbilavong Deputy Head, Research Division Mother and Child Health Institute Ministry of Health Vientiane MALAYSIA Dato' Dr Haji Abdul Aziz.bin Mahmood Director Division of Family Health Ministry of Health Kuala Lumpur Dr (Mrs) Nadeswary Kandiah Principal Assistant Director of Health Division of Family Health Ministry of Health Kuala Lumpur MICRONESIA, FEDERATED STATES OF Dr Elizabeth Keller Pohnpei State Health Services Reproductive Health and Planning Programme Public Health Division Pohnpei State Hospital Pohnpei Dr Baldan Tseve1maa Officer of Maternal and Child Health Services Department of Medical Care Ministry of Health Ulaanbaatar Dr Ishnyam Davaadorj Officer-in-Charge Maternal and Child Health/Family Planning Maternal and Child Health Services Ministry of Health Ulaanbaatar

KIRIBATI

LAO PEOPLE'S DEMOCRATIC REPUBLIC

MONGOLIA

- 27 -

Annex 1 NEW CALEDONIA Dr Charles Merger Chef du Service de Gynecologie H~pital de Magenta Noumea Dr Hilda Polume Senior Medical Officer (Maternal and Child Health) National Department of Health P.O. Box 3991 Boroko. NCO Dr Siroval Wat Specialist Medical Officer (Obstetrics and Gynaecology) Kavieng General Hospital P.O. Box 68 Kavieng New Ireland Province PHILIPPINES Dr Elvira SN Dayrit Director Maternal and Child Health Service Department of Health Manila Dr lovencia Quintong Director III Family Planning Service Department of Health Manila REPUBLIC OF KOREA Ms Hwang Na Mi Senior Researcher Korea Institute for Health and Social Affairs San 42-14 Bulkwang-dong Eunpyung-ku ~

PAPUA NEW GUINEA

SAMOA

Dr Semo Koro Senior Medical Officer Obstetrics Unit, National Hospital Private Bag

Allla SINGAPORE Dr Veronica Tay Lian Hwa Senior Registrar, Family Health Service Primary Health Division Ministry of Health College of Medicine Building 16 College Road Singapore Dr lun~lyn Pikacha Chief Medical Officer, Maternal and Child Health Ministry of Health and Medical Services Honiara

SOLOMON ISLANDS

·28 Annex 1 VANUATU Mrs Valentine Ronolea National Coordinator for Maternal and Child Health and Family Planning Department of Health Port Vila Dr Do Trong Hieu Director Maternal and Child Health/Family Planning Department Ministry of Health

SOCIALIST REPUBLIC OF VIET NAM

fun.Qi Dr Nguyen Quoc Gia Head, Department of Obstetrics and Gynaecology Provincial General Hospital Can Tho Province

2. CONSULTANTS

Mr Norbert Dreesch 11 B, rue des Belles Filles 1299 Crans Switzerland Dr Elizabeth Eckermann Faculty of Arts School of Social Inquiry Deakin University Geelong, Victoria Australia 3217 Dr Raj Karim Director-General National Population and Family Development Board Bangunan LPPKN, No. 12B lalan Raja Laut, Peti Surat 10416 50712 Kuala Lumpur Malaysia

3. TEMPORARY ADVISER , I

Professor S.S. Ratnam Faculty of Medicine Department of Obstetrics and Gynaecology National University of Singapore Lower Kent Ridge Road Sin~apore 0511 Republic of Singapore

- 29 -

Annex 1

4. REPRESENTATIVE UNITED NATIONS POPULATION FUND (UNFPA) Ms Yeoh Yeok Kim National Officer for UNFPA c/o United Nations Development Programme in Malaysia P.O. Box 12544 Kuala Lumpur Malaysia

5. OBSERVERS

MINISTRY OF HEALTH MALAYSIA

Dr Nik Shamsidah bt Nik Ibrahim Principal Assistant Director Division of Family Health Development Ministry of Health Kuala Lumpur Malaysia Datin Dr Harrison Aziz Deputy Director of Health Disease Control Division (AIDS/STD) Ministry of Health Kuala Lumpur Malaysia Ms Ajimah Hassan Principal Matron (Health) Family Health Division Ministry of Health Kuala Lumpur Malaysia Dr Kamal Bahrin Obstetrician and Gynaecologist National University Hospital Kuala Lumpur Kuala Lumpur Malaysia Dr Ismail Thamby Acting Director Reproductive Health Centre National Population and Family Planning Development Board Kuala Lumpur Malaysia

·30· Annex 1

6. SECRETARIAT Mrs Carla Abou-Zahr Maternal Health and Safe Motherhood World Health Organization Division of Family Health World Health Organization CH-121 I Geneva 27 Switzerland Dr Janos Annus Medical Officer Maternal and Child Health/Family Planning WHO Regional Office for the Western Pacific Manila Ph iI ippines Dr Giuseppe Benagiano Director Special Programme of Research Development and Research Training in Human Reproduction World Health Organization CH-1211 Geneva 27 Switzerland Dr Giovanni Deodato Regional Adviser in Maternal and Child Health/Family Planning WHO Regional Office for the Western Pacific Manila Philippines Dr Salesi Katoanga Adviser in Matenal and Child Health, Family Planning UNFPA Country Support Team Office for the South Pacific Suva Fiji Dr Atiqur Khan Adviser in Maternal and Child Health, Family Planning UNFPA Country Support Team Office for East and South-East Asia Bangkok Thailand

- 31 Annex 1

Dr N.V.K. Nair Director Health Protection and Promotion WHO Regional Office for the Western Pacific Manila Philippines Dr Tomris Tiirmen Executive Director Family and Reproductive Health World Health Organization CH-1211 Geneva 27 Switzerland

- 33 ANNEX 2

OPENING REMARKS BY THE REGIONAL DIRECTOR AT THE WORKSHOP ON REPRODUCTIVE HEALTH IN THE WESTERN PACIFIC REGION KUALA LUMPUR, MALAYSIA, 11-15 DECEMBER 1995 (read by Dr B.P. Kean, Director, Programme Management)

THE HONOURABLE MINISTER OF HEALTH, HON. DATO' SERI DR SITI HASMAH BTE HAJI MOHD ALI, LADIES AND GENTLEMEN, It gives me great pleasure to be with you here today, on behalf of the Regional Director of the WHO Western Pacific Regional Office, to open this important workshop on reproductive health. This is the first Regional workshop on reproductive health in the Western Pacific Region, following the International Conference on Population and Development held in Cairo, Egypt in 1994. For decades, there have been programmes on maternal and child health care. However, the implementation of these programmes has often been fragmented. They have focused on specific components according to the interests at that time, such as donor-driven priorities or prevailing advocacy work. However, health issues related to reproductive organs and processes, for instance, have always been very important aspects of general health. So too has family planning, which contributes substantially to the reduction of maternal mortality in many countries. Services for control of sexually transmitted diseases have also been provided in separate clinics as part of public health care. Other efforts to reduce child morbidity and mortality through the expanded programme of immunization, control of diarrhoeal diseases and Recognizing the fragmentation of the approach in the past, WHO has developed a more comprehensive approach to reproduction and family health. The programme has been designed in broad terms, and gives a general indication of strategies and expected results, while taking into consideration the economic and cultural diversity in our Region. When it comes to the implementation phase, however, we have to be country or even area specific, focusing on the issues relevant to local conditions, on high-risk groups, and dealing with the priorities identified in each community. For improved effectiveness, all the elements of the programme are integrated to ensure a holistic approach: that is, one which is not restricted to human reproduction and family planning. Issues such as sexuality and control of sexually transmitted diseases, the health of adolescents, quality of care, expanded access to services, information and education, freedom of reproductive choice, better nutrition, and equal survival chances for boys and girls are all important elements of a coordinated programme. It is my view that the health sector has a key role to play in this, but that it cannot operate in isolation. For instance, the collaboration from other sectors such as edUcation, planning and finance, labour and employment, is crucial to ensure that gender perspectives are taken into account when formulating laws which affect women's health or gender discrimination. A wide range of cultural and economic differences in this Region need to be taken into account when dealing with the medical, social and cultural problems affecting human reproduction. There is a growing need to openly face and discuss sensitive aspects such as adolescent sex education and the provision of counselling and medical services to sexually

- 34 Annex 2 active young people. Other sensitive matters warrranting discussion include sexually transmitted diseases and HIV/AIDS, abortion and its consequences, fertility regulation methods and forced pregnancies, and freedom of choice and self-determination in reproductive matters. Reproductive health has a wide range of implications and significant demographic and economic consequences, because it affects the environment and the entire development of a country. In fact in many countries, rapid population growth may put a considerable strain on limited economic resources and on all the services required to deal with a rapidly growing population. This problem has been acknowledged by two recent international United Nations conferences: the first was on Population and Development held in Cairo, Egypt last year, and the second, conference on women, held in Beijing, China this September. These conferences affirmed the WHO policy of advocating comprehensive Reproductive Health programmes. Reproductive health programmes should also be concerned with human rights when taking into account the benefits of good health for the entire society. Programme activities for instance, should include the provision of quality care which addresses the needs of specific target groups such as adolescents, out-of-school youth, the urban poor, isolated rural communities and the marginalized and undernourished. Human rights issues are also often associated with the prevention of unwanted pregnancies, access to education and a wide range of appropriate contraceptives, abortion, and the availability of safe medical care whenever there is an interruption in pregnancy. While it is essential that women play an active role in the development of reproductive health programmes to improve women's access to reproductive health services and assert reproductive health choices, programmes should not be limited to address women's concerns only. We need to get other members of the family to participate too. It is important to increase men's involvement in sharing responsibilities for sexual and reproductive behaviours, and to enhance their role in responsible parenthood within the family and the community. In all societies, families are still the main focal unit, and reproductive health is one of the most important components of the health of the family and of the entire society. We must make sure During the next few days you will be discussing how to improve reproductive health in our respective countries. Proposed directions and possible solutions must be country and area specific, taking into consideration existing situations, and prevailing cultures, norms, attitudes and religious beliefs. We know that political support, good physical and psychological environments, and a steady income are prerequisites to preserve and enhance physical and mental well-being. However these will not ensure health unless individuals are capable and willing to live healthy lifestyles and put into practice some of the principles for good health. Public health efforts have therefore to be complemented by personal endeavours to improve any situation which may bring about better health. These principles have been articulated in our WHO regional document entitled "New Horizons in Health". I commend this document to you, as it outlines new directions for public health in the future, and provides a clear framework for the implementation of reproductive health programmes. WHO has two main mandates in the field of reproductive health: they are, to provide technical cooperation to countries; and second, to establish norms, policies and guidelines. Under these mandates, we will continue to play an advocacy role by promoting the concepts of a comprehensive programme for reproductive health among the Member States, as well as among the international community and the nongovernmental sector. We will also continue to conduct operational research in reproductive health which is aimed at developing new approaches and However, WHO cannot operate in isolation. Close cooperation and

- 35 Annex 2 coordination with all the Member States is a prerequisite to achieving our goals. This is one of the main reasons for your meeting this week. Only by sharing common experiences and learning from successes as well as from failures, can we advance our knowledge and establish appropriate and effective reproductive health programmes. I hope, therefore, that this workshop will provide a rich opportunity to disseminate knowledge, and to learn from each other for the benefit of women, mothers, children, families and the entire community. I am sure that you will be able to identify and implement the most cost-effective interventions required to improve the outcome of family and reproductive health. I would like to express my appreciation to the Government of Malaysia for its support to WHO in organizing this meeting and express my appreciation to all the participants for coming together to work on this very important area of health and human development. I wish you all the very best with this workshop, and look forward to hearing the results of your week's work. Thank you.

- 37 -

ANNEX 3

OPENING SPEECH OF THE MINISTER OF HEALTH AT THE WORKSHOP ON REPRODUCTIVE HEALTH IN THE WESTERN PACIFIC REGION" KUALA LUMPUR, MALAYSIA, 11-15 DECEMBER 1995

I am greatly honoured to have been invited to address the distinguished delegates to this workshop on Reproductive Health for the Western Pacific Region in Kuala Lumpur from 11 to 15 December 1995. I wish to thank the organizers for giving me this opportunity. It gives me great honour and pleasure on behalf of the Government and the people of Malaysia to welcome all of you present here. Malaysia is proud to have been selected by the WHO to host this important meeting on Reproductive Health. I understand that the objectives of this workshop are to review the present status of reproductive health, to suggest strategies and actions for implementation of the World Health Assembly and WHO Western Pacitic Regional Committee resolutions on reproductive health, and to review regional indicators and targets for health of mothers and children. Traditionally, health aspects of human reproduction have been dealt with by "Maternal and Child Health" (MCH) programme. Over the past two decades however, important sociodemographic changes has taken place rendering the MCH approach too narrow to meet the current concerns. Several United Nations forums have made resolutions on reproductive health in close Technical Cooperation with WHO, the latest being the forty-sixth session of the WHO Regional Committee for the Western Pacific Region held from 11-15 September 1995 in Manila. Hence, a broader concept of "Reproductive Health" has emerged offering a more comprehensive and integrated approach to the current health needs. Reproductive Health touches on and affects the lives of everyone, and spans over the whole lifestyle of man and woman during childhood, adolescence and beyond. The various elements of reproductive health are strongly integrated and has a bearing on fertility regulation, prevention of sexually transmitted diseases, consequence of unwanted pregnancies, infertility, sexuality, child survival and safe motherhood. Considerable progress has been made by the national Maternal and Child Health programme in Malaysia. Through the five-year socioeconomic development plans a comprehensive network of health facilities has been developed throughout the country. The Rural Health facility to population ratio has increased from 1:21 055 TO I: 15 653 from 1985 to 1994. There has been an overall increase in the availability of health manpower with doctor population ratio improving from 1:2858 to I :2301 during the same period. Remarkable achievement of MCH programme in 1994 include: • 69 % antenatal coverage • 85 % coverage for newborn

• 990% coverage for DPT3 immunization • • 81 % coverage for measles immunization 85% coverage for Hepatitis B, third dose

• Deliveries by TBAs has declined to 0.1 % of total deliveries

- 38 • • • • • Incidence of immunizable diseases like polio, tetanus, whooping cough, measles, childhood TB, diphtheria has declined greatly Prevalence of severe malnutrition has declined to only 0.44% Maternal mortality rate of 0.411000 LB - 1992 Infant mortality rate of 11.4 - 1993. and life expectancy of 69.0 for males and 73.5 years for females

Ladies and gentlemen, In line with the WHO New horizons in health, Malaysia will continue to strengthen existing activities and implement new ones which will assist in preparation for life, protection of life as well as improving quality of life. Several specific issues need to be focused. They include: • • • • • • • • • • • • • • • Acute respiratory infections Communicable disease control including STD, HIV/AIDS Perinatal care National plan of action on nutrition Baby friendly hospital initiatives Home and work place injuries Health promoting schools Adolescent's high-risk behaviour Healthy lifestyle programmes Intersectoral and interagency collaboration Increasing role of women in family development Strengthening of primary health care programmes Human resource development Quality control programmes Behavioural research

In order to implement the resolutions made at the International Conference of Parliamentarians on Population and Development (ICPPD) held in Cairo 1994, several World Health Assemblies, forty-sixth session of the WHO Regional Committee for the Western Pacific as well as the fourth World Conference on Women held in Beijing, a Technical Committee on reproductive health has been formed in Malaysia which includes members from the Ministry of Health, Ministry of National Unity and Social Development, FPA, NGOs such as MMA, Academy of Private Practitioners, National AIDS Council and others. The committee decided that the ICPPD programme of action be implemented in accordance to national laws, policies and in the context of national ethics, cultural, religious and social values.

- 39 -

Annex 3 I am confident that this meeting will provide a forum for policy makers and senior managers with technical inputs of WHO officials to discuss the resolutions made on reproductive health and to arrive at a consensus on strategies and activities to implement these resolutions. Thank you.

- 41 -

ANNEX 4 SPECIAL ADDRESS BY HER HON. DATIN SERI DR SITI HASMAH BTE. HAJI MOHD ALI AT THE OPENING OF THE WHO WORKSHOP ON REPRODUCTIVE HEALTH FOR THE WESTERN PACIFIC REGION, KUALA LUMPUR, MALAYSIA, II-IS DECEMBER 1995

I am happy and privileged to be invited here this morning at the opening ceremony of the WHO Workshop on Reproductive Health for the Western Pacific Region. To all distinguished participants, consultants, representatives from international agencies and WHO secretariat members, I wish you a warm welcome to Malaysia. Selamat Datang and I hope your visit here will be fruitful and memorable. I take this opportunity to specially thank Dr S.T. Han, Regional Director, WHO Regional Office for the Western Pacific and his team who have made this workshop a reality and to have chosen Malaysia as the host country. I would also like to extend my appreciation to Dr Tomris Turmen, Executive Director of Family Health, WHO Geneva and to Dr Benangiano, Director of Human Reproduction Program, WHO Geneva for their presence is indicative of their personal support and commitment to the reproductive health programme of this region. Ladies and gentlemen, Having led the official delegation to the recent "Fourth World Conference on Women" in Beijing and as chairman of the International Steering Committee for International Fund for Agriculture Development ((FAD) for Asia and the Pacific Region which covers 27 countries, many of whom are represented here today, I am personally pleased to see that all of you have taken the challenge to address this important and yet controversial issue of reproductive health for the Region. Looking back at the heated debates and discussions surrounding reproductive health at the International Conference on Population and Development last year and at the World Conference on Women this year, a clear fact and message emerge. This is a message which says that reproductive health is an urgent issue requiring urgent attention, commitment and action; that the problem must meet both present and emerging needs and problems; and must consider women's participation and perspectives. Reproductive health touches upon and effects every stage of life and development of men, women and families with intergenerational implications. It is a difficult and complex issue spanning across cultural, religious, ethical, social and behavioural variations which requires a careful and sensitive approach in the formulation and implementation of the programme. The health of a woman is important not only for her but for survival of her infants and young children and for the health, happiness and well-being of her family. She is the primary educator, health worker, one who supplements food and income, and provides love, guidance and support to her family. As planners and policy makers, we therefore owe our commitment and support to improve her status and health and to facilitate her vital role in nurturing the development of our future generations. Ladies and gentlemen, Many of the women in developing countries in our Region still face the adversity of poverty, illiteracy, ill health, malnutrition and complications related to frequent and poorly spaced pregnancies. Coupled with the lack of inaccessible or unaffordable basic health, and maternity care and services, poor transport and communication or inadequate life-saving facilities for emergency obstetric care; women in this Region continue to suffer from the high and unnecessary toll of death due to complications of pregnancy and childbirth.

- 42 Annex 4 The most important and critical events of a woman relates to her basic biological function of childbearing which is also the time when most of the demands of her health and nutrition status are put to trial. This period brings with it major mortality and morbidity more than any other period during the life cycle of a woman. It is therefore important that provisions for reproductive health care be focused primarily on meeting these needs. In this regard, I welcome the initiative of WHO in designing the mother-baby package - which consists of a cluster of interventions for maternal health and safe motherhood and which emphasizes on maternity care, provision of essential obstetric care, and family planning amidst other interventions to reduce maternal and newborn mortality and morbidity. I believe that the life cycle approach to reproductive health is a logical one but it also brings to light many emerging problems and issues that have yet to be dealt with effectively and in an acceptable way. Issues of adolescent reproductive health, reproductive tract cancers and infections, management of infertility, prevention of domestic violence and abuse, and provision of relevant services such as counselling, information and education have yet to be discussed and the best possible means be found for implementation into existing health care and related systems. STO's, HIV and AIDS is posing a serious threat to the survival and health of women and children in this Region and services for their prevention, counselling and care must necessarily be a major focus in the reproductive health and care package. Ladies and gentlemen, While we pursue to develop plans of action for reproductive health for our countries, 25 years of experience in hospital, rural health, and MCH has led me to the conviction that maternal or reproductive health cannot be achieved without longer term investments in education, advancing socioeconomic status and income opportunities for women, and increasing their participation in society. Only then can women, given access to appropriate and timely services and information, be able to make responsible and sound decisions for their own health and that of their families. This includes the ability and choice to decide on the number, timing and spacing of their children. Equally important is the need for and the will to remove existing barriers that impede advancement of women's health and acceptance of health care and services whether they be physical, social, mental or attitudinal constraints. In many of our countries for example, the health and lives of women and children continue to be jeopardized by prevailing beliefs, traditions and harmful practices related to pregnancy and childbirth. In some areas discrimination against the female infant and girl child still exist, thus denying her basic human right to health care, education, food and nutrition and to her survival. In other conditions, women continue to be subjected to heavy domestic and agricultural chores, while being expected to be productive both in work and in bearing children. Opportunities for their personal development are denied and they have little or no control over their own life situations. It is in this context that I am happy to note that the concept of reproductive health as proposed goes beyond biomedical and health considerations and takes into account social, cultural, educational and other factors and Lieir necessary intervention. We need to cut across sectors and existing inequalities and problems in order to improve the reproductive and health status of women and children. Ladies and gentlemen, Much has been said about the high maternal and infant mortality and morbidity that is still a major problem in this Region and of women dying from complications of haemorrhage, sepsis and unsafe abortions. WHO reports have indicated that 99% of the 1/2 million maternal

- 43 Annex 4 deaths each year occur in developing countries, that the complications and contributory factors are the same in all these countries; that more than 3/4 of these deaths are preventable or avoidable and that technology to prevent them exists. I urge this group as key health planners to pay special attention to devising a plan of action to implement these simple yet life-saving technology and interventions. This would prevent the unnecessary wastage of women's lives or life-long disabilities arising from complications or poor management of pregnancy and delivery. Our future role will be even more challenging and uphill as we continue to be faced with problems for which no technology for prevention or cure exists as in HIV/AIDS and reproductive tract cancers. Therefore the dissemination of correct information, education and communication to men and women in an effective way as to affect their health behaviour, practice or lifestyle will be one of the critical strategies in addressing these emerging issues. Ladies and gentlemen, At home ground, Malaysia has put concerted efforts in upgrading Quality of care and improving accessibility to MCH care and family planning. One of the major focus of the last decade has been on strategies to reduce maternal and infant morbidity and to introduce newer initiatives in this direction such as the risk approach in MCH care, and the safe motherhood initiative. Efforts are underway to define our concept, content and package of reproductive health services that would be acceptable and affordable to all our population groups. As a member of the International Steering Committee for IFAD, I will follow with interest your deliberations as the interplay between health and advancement of rural women is very close and mutually dependant. Once again, I would like to congratulate WHO for convening this workshop and for providing the necessary support and technical guidance to countries of this Region. I wish you every success in your endeavours to improve the heath and well-being of all our women, men, children and families of the Western Pacific Region. Thank you.

- 45 -

ANNEX 5

AGENDA

1. 2. 3. 4. 5. 6.

Opening ceremony Family and reproductive health New horizons in health and the role of reproductive health Reproductive health in the Western Pacific Region Country reports Possible interventions to improve reproductive health, including the mother-baby package, partograph, home-based maternal records, and clean delivery Quality of care in reproductive health Research in reproductive health Discussion on various topics related to reproductive health, including: IEC, community participation, indicators, targets, policies and intersectoral cooperation Presentation of model national reproductive health programme/plan of action, national reproductive health indicators Conclusions Closing ceremony

7. 8. 9.

10. 11. 12.

PROVlSIONAL TIMETABLE Workshop on Reproductive Health in the Western Pacific Region Kuala Lumpur, Malaysia, 11-15 December 1995 Time 0800 0815 Mondav, II December Registration Tueseday, 12 December Report on the previous day Brief country reports on reproductive health status, reproductive health programme Opening ceremony Wednesday, 13 December Report on the previous day I I Possible interventions to improve reproductive health - Dr A. Borra - Dr Raj Karim - Mr N. Dreesch I - Dr J. Annus I - Ms C. Abou-Zahr ! - Discussion COFFEE BREAK ! Continuation of previous session: I

;.. ::l ::l

Thursday, 14 December Report on the previous day Research in reproductive health - Dr G. Benagiano - Discussion

Fridav, 15 December Report on the previous day Group sessions (continuation) Presentation of model national RH programme/ plan of action, national RH indicators

'X"

V>

0900

I Discussion on: ! (a) Role of IEC/formal educatio~ in supporting reproductive healt (b) Indicators of reproductive I health - Dr S. Katoanga - Mr N. Dreesch Discussion continued on: (a) Community participation and involvement in reproductive health (b) Gender issues - Dr S. Katoanga - Dr A. Khan - Dr E. Eckermann Group sessions: Development of model national reproductive health programme/ plans of action/national reproductive health indicators

1000-1030 1030

Family and Reproductive Health - Overview - Dr T. T iirmen - Discussion

Country reports (continuation)

Draft conclusions Closing ceremony - Report of the Chairman - Closing remarks - Farewell

I

.,. 0-.

1200-1400 1400

1500

New Horizons in Health and the Role of Reproductive Health - Dr N. V.K. Nair - Discussion

Components of reproductive health in view of the country reports - Prof. S. S. Ratnam - Dr E. Eckermann - Dr 1. Annus - Dr S. Katoanga - Discussion

LUNCH BREAK Discussions on national RH programme - Dr A.Khan - Dr E. Eckermann

I

1530-1600 1600

Reproductive Health in the Western Pacific Region - Dr G. Deodato - Discussion Cocktails

COFFEE BREAK Continuation of previous session Quality of Care in Reproductive Health - Prof. S. S. Ratnam - Discussion Secretariat meeting Secretariat meeting

1700

- 47 ANNEX 6

CLOSING SPEECH OF THE REGIONAL DIRECTOR AT THE WORKSHOP ON REPRODUCTIVE HEALTH IN THE WESTERN PACIFIC REGION KUALA LUMPUR, MALAYSIA, 11-15 DECEMBER 1995 MISTER CHAIRMAN, HONOURABLE MINISTER OF NATIONAL UNITY AND SOCIAL DEVELOPMENT, LADIES AND GENTLEMEN, I am very happy to be present amongst you today. I would first like to sincerely thank the Government of Malaysia for its invitation to hold this WHO regional workshop here. The hospitality and cooperation of the Government of Malaysia have contributed substantially to the success of this meeting. I am sorry that I was unable to attend the opening of this workshop, due to a very urgent commitment. As I attach great importance to the issues you have been discussing, I have followed developments closely. I understand that you have had a successful and useful workshop. This gives me great satisfaction. I am confident that the experience you have gained here will be valuable in your everyday work when you return home, which was the main purpose of this regional meeting. I am glad to know that in your discussions you have taken . New horizons in health' into account. This is the Western Pacific's new approach to public health for the rapidly changing conditions at both regional and national level. There is a need to review our present thinking about health. We are working towards and expecting active participation by the individual and by the community in maintaining and improving their health. A real partnership with shared responsibilities has to be built between the providers and the community. We also need to review the relationship of health issues with the environment we live in, the resources that are available, and a variety of other social factors. Additionally, it i~ important that we are able to respond to the different needs of individuals as they grow up. These needs change as the individual grows from an infant to an adult. National health programmes need to ensure that people do not die prematurely, that they can lead productive lives and can enjoy good health as they get older. Each stage in life has an important bearing on better health or iIIhealth. Reproductive health is of concern for the entire life-span of people, both women and men. The most important determining period is pregnancy and the early days and weeks of life of each individual. During this period a person can be well prepared or badly prepared for life. That is why we place great emphasis on safe motherhood and infant health. During adolescence, and in adulthood, reproduction and sexuality are central components affecting the quality of life of every person. Reproductive events, such as pregnancy, and sexually transmitted diseases may cause long-lasting consequences that can ruin the years ahead. From your conclusions I can see that you are well aware of the importance of the influence that reproductive health has on every person's life. Reproductive health is primarily a health issue. The managers of country and provincial health programmes have an important coordinating role in the planning, implementation, monitoring and evaluation of activities related to reproductive health. A comprehensive approach is needed. This requires intersectoral cooperation, as well as cooperation within the health sector, at both national and international level. Government authorities, nongovernmental organizations and other community-based groups concerned with health iSsues need to work together to solve the health problems associated with reproduction in each country.

- 48 -

Annex 6 Your recognition of the need for simple, inexpensive but timely interventions is very important. Resources available for health programmes do not permit wide-scale use of sophisticated, high-tech solutions. During the past few years, WHO has developed guidelines on the various technologies that can be applied in reproductive health programmes. I would like to remind you in this context that the Mother-baby package is a very useful tool for managers in planning and developing future activities. I fully agree with your opinion that without good and reliable data the management of health programmes, at any level, is a very difficult task. The starting point of health management should be situation analysis, based on reliable data from good indicators of reproductive health. Monitoring and evaluation is also unrealistic without good data. We need to know the impact of our programmes. Unless we are properly aware of the health status of the population we cannot assess the usefulness of health programmes. I am sure you agree that our mutual goal is to maintain and improve the health of our people. Health improvement covers reduced mortality and morbidity as well as increased quality of life. Therefore it is of paramount importance that our interventions are those that most effectively support the achievement of that goal. For this we need not only appropriate public policies, but also the full cooperation and participation of families, women, men and children alike. Health programmes are aimed at improving the health of the individual. The individual also has to do his or her best to maintain, protect, and promote health - not just their own - but also that of others. A real partnership between health care providers and acceptors needs to be built and maintained. Resources for health programmes all over the world are scarce. Active community involvement and participation is one possible additional resource available to us. When you return home from this workshop, I am sure that you will discuss the reproductive health situation of your own country with your colleagues and co-workers. You will analyse the situation, review and revise your targets in reproductive health, formulate and legislate policies where there are none, develop national programmes, draw up plans of action, and look into the resources at your disposal. You will have to take into account certain components of reproductive health when planning future programmes in health care. It will be essential that you develop cooperation and integration of services such as maternal care, child health care, immunization, sexually transmitted diseases and cancer prevention and control. Please look into these matters critically. Do not be afraid of introducing changes, reallocating funds and building up new intersectoral partnerships with possible national and international counterparts. The Regional Committee, at its last meeting in September 1995, established policy guidelines for our future cooperation in the field of reproductive health. It is up to us to put that policy into everyday practice. From this week's work it will be clear to you that WHO regards reproductive health very seriously. We have identified future needs and trends, introduced the necessary changes, and developed the necessary guidelines and technical materials. We are now ready to cooperate with countries on implementation. In the Western Pacific Region, the Women and Child Health Programme will have the primary responsibility for coordinating reproductive health related activities, in close collaboration with other programmes. Our approach will be holistic, but our activities will focus on the most important issues. Many mothers and infants still die in this Region. The programmes we develop and implement have to help save lives and reduce the suffering of people. They should especially concern mothers and children. Close collaboration with other UN agencies will continue to be important, especially with UNFPA and UNICEF, as well as with nongovernmental organizations in the field of reproductive health.

- 49 -

Annex 6 Finally, I would like to thank all of you for your active participation and very valuable contribution to this workshop. I appreciate very much the input and help of the consultants, in particular Dr Raj Karim and Professor Ratnam as temporary adviser. I am also grateful for the efforts and work of the officers of this meeting, namely Dr Dato Abdul Aziz as chairman, Dr Losevati Alefaio as vice-chairperson and Dr Elvira Dayrit as rapporteur. I wish you all a safe journey home, and good health and energy for your future work in the field of reproductive health.

- 51 ANNEX 7

CLOSING SPEECH, MINISTER OF ECONOMIC DEVELOPMENT AND SOCIAL UNITY AT THE WORKSHOP ON REPRODUCTIVE HEALTH IN THE WESTERN PACIFIC REGION KUALA LUMUPR, MALAYSIA, 11-15 DECEMBER 1995

It gives me great pleasure to meet you again at this closing ceremony of the WHO Workshop on Reproductive Health. I would like to pay special acknowledgement to Dr S.T. Han, Regional Director of WHO, Regional Office for the Western Pacific, for making this special trip to Malaysia to grace this important workshop. First of all, let me say how happy and honoured we, Malaysians are to host this workshop, to receive all participants and WHO secretariat members. I am sure all of you have had challenging and thought-provoking discussions on various aspects of reproductive health over the last five days. I also hope you had some time to do some sightseeing and shopping inspite of the tight workshop schedule, considering that the weather has been sunny and the city atmosphere cheerful with the yuletide spirit. Now that the workshop is coming to its end, and most of you will be eagerly preparing to go back home to spend the christmas hoi idays with your family, I do hope that part of your christmas resolutions will be to embark on preparing strategies and approaches towards promoting the concept of reproductive health and implementing whatever is urgent and possible into health and related programmes relevant to the needs of each of your countries. Ladies and gentlemen, I have taken note that you have been introduced to the concept of reproductive health, its approaches, applications, important interventions, IEC and community participation and gender issues relating to reproductive health. This will assist us in the plauning and implementation of our programme in Malaysia. Following the programme of action of the ICPD, Malaysia through the National Population and Family Development Board has initiated discussions in policy and strategy directions with various interested parties in government and private sector, with nongovernmental organizations and the universities. These discussions and negotiations will lead towards the formation of national policy guidelines on reproductive health with special regard to the "contentious" issues. These problems are being re-examined today in light of the advances made in Cairo and Beijing. In this regard, the deliberations and conclusions of this workshop will be useful in the planning and formulation of strategies and programmes. It is the hope of the Ministry of National Unity and Social Development that the multisectoral dimensions required of a reproductive health programme is kept in perspective and that roles of various agencies be identified and coordinated. The National Population and Family Development Board through its reproductive health specialist centre has pioneered new services in reproductive health which amongst others are management of infertility, cervical cancer and menopause, genetic diagnostic and counselling, premarital and marital counselling and introduction of new contraceptive technology. In an effort to improve quality of life of women, men and families, the Board has also developed training modules on various aspects of family development including parenting skills, counselling the family on HIV/AIDS, and adolescent reproductive health.

- 52 Annex 7 In this spirit of technical cooperation, we will be pleased to collaborate with any country of this region through WHO. Ladies and gentlemen, I am sure the plans of action and conclusions of this workshop will give a headstart to you and your countries in developing a reproductive health and programme based on your problems, needs and resources. On this note, I end by wishing all of you merry christmas, happy new year and a safe journey home. I hope you enjoyed your short stay in Kuala Lumpur and we will be happy to welcome you again. With that it gives me great pleasure Thank you. to

declare this workshop closed.

- 53 ANNEX 8

PROFORMA OF COUNTRY REPORTS

Name of Country

Crude birth rate Number of live births Total fertility rate Population growth rate Maternal mortality rate Infant mortality rate STD incidence or cululatiive number of cases; HIV, AIDS, gonorrhoea, syphillis, etc. Contraceptive prevalence

Main contraceptive methods used:

• • • Five most important reproductive health problems:

• •

• • •

- 54 Annex 8

Programme and Policies

Safe motherhood:

Special project/s

Key policies and legislations

• • • •

•

• • • • •

Population and family planning:

Special project/s

Key policies and legislations

• • • •

•

• • •

• •

Breast-feeding and infant nutrition:

Special project/s

Key policies and legislations

• • • • •

• • • • •

- 55 -

ANNEX 9

FORTY-EIGHTH WORLD HEALTH ASSEMBLY Agenda item 19

WHA4B.10 12 May 1995

Reproductive health: WHO's role in the global strategy The Forty-eighth World Health Assembly, Noting the report by the Director·General) on maternal and child health and family planning: quality of care • reproductive health: WHO's role in the global strategy; Recalling resolutions WHA32.42, WHA38.22, WHA40.27, WHA41.9, WHA42.42, WHA43.10, WHA47.9 and EB9S.RlO concerned with many different aspects of reproductive health; Welcoming the Director·Genera!'s reporr on collaboration within the United Nations system: the International Conference on Population and Development, and in particular the WHO position paper on health, population and development prepared for the Conference; Noting United Nations General Assembly resolution 491128, on the report of the International Conference on Population and Development (ICPD), particularly operative paragraph 22 which requests the specialized agencies and all related organizations of the United Nations system to review and where necessary adjust their programme and activities in line with the programme of action; . Recognizing that, as a central component of women's health, reproductive health needs to be promoted by WHO at the forthcoming Fourth World Conference on Women in Beijing and other international forums; Noting the present fragmentation of reproductive health activities within WHO, and calling for a more coherent approach in priority setting, programme development and management, I. ENDORSES the role of the Organization within the global reproductive health strategy, as expressed in document A48JIO; 2. REAFFIRMS the unique role of the Organization with respect to advocacy, normative functions, research and technical cooperation in the area of reproductive health;

I

Document A48/10. Document A48/3S.

2

- 56 Annex 9 WHA48.10

3. UNDERLINES the need to coordinate with other agencies of the United Nations system to provide international support for the development and implementation of reproductive health strategies in countries in keeping with the principles elaborated in the Programme of Action of the {CPD and in particular with full respect for the various religious and ethical values and cultural backgrounds and in conformity with universally recognized international human rights; 4. URGES Member States to further develop and strengthen their reproductive health programmes. and in particular: (I) to assess their reproductive health needs and develop medium- and long-term guiding principles on the lines elaborated by WHO. with particular attention to equity and to the perspectives and participation of those to be served and with respect for internationally recognized human rights principles; (2) to strengthen the capacity of health workers to address. in a culturally sensitive manner, the reproductive health needs of individuals, specific to their age. by improving the course content and methodologies for training health workers in reproductive health and human sexuality. and to provide support and guidance to individuals, parents. teachers and other influential persons in these areas; (3) to monitor and evaluate, on a regular basis, the progress, quality and effectiveness of their reproductive health programmes, reporting thereon to the Director-General as part of the regular monitoring of the progress of health-for-all strategies.

5.

REQUESTS the Director-General: (I) to include the progress made in reproductive health in his regular reporting of the progress of health-for-all strategies;

(2) to continue his efforts to increase the resources for strengthening reproductive health in the context of primary health care, including family health; (3) to develop a coherent programmatic approach for research and action in reproductive health and reproductive health care within WHO to overcome present structural barriers to efficient planning and implementation. This would be carried out in close consultation with Member States and interested parties, and a report submitted to the ninety-seventh session of the Executive Board and the Forty-ninth World Health Assembly; (4) to promote ethical practices in the field of human reproduction to protect the health and human rights of individuals in different social and cultural settings.

Twelfth p1cnuy meeting, 12 May 1995 A48lVRll2

=:

=

=

2

- 57 -

Annex 9 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE

RESOLUTION

REGIONAL COMMITTEE FOR THE WESTERN PACIFIC

CO MITE REGIONAL DU PACIFIQUE OCCIDENTAL

WPR/RC46.RI5 15 September 1995

REPRODUCTIVE HEALTH

The Regional Committee, Having considered the Regional Director's report on reproductive health in the Western ·ftIC R' Paci eglOn; 1

Recalling resolutions WHA32.42, WHA38.22, WHA40.27, WHA41.9, WHA42.42, WHA43.10, WHA47.9, WHA48.lO, EB95.RlO and WPRIRC39.RI2 related to the issue of reproductive health; Noting the progress made in maternal and child health, especially through the Maternal Health and Safe Motherhood programme, and the availability of a wide variety of technical and managerial tools such as the Mother-baby Package, to help improve women and children's health and survival; Noting also the need to reduce the large disparities still existing between and within countries and areas of the Region regarding reproductive health and to expand the access to appropriate, adequate and good quality health care; .. .1

Annex 9 WPR/RC46.RI5 page 2

- 58 -

Noting further that young people in particular, need to have better knowledge of all reproductive health issues and access to suitable fertility regulation me!hods of their choice; Recognizing that health staff need to be better equipped to provide proper counselling and motivation on all the reproductive health aspects, and adequate medical services prior to and during - pregnancy, delivery and post pactum; Being aware that changes in some harmful existing practices and the application of simple and inexpensive technologies, along with appropriate obstetric practices and family planning services may signifIcantly reduce maternal and infant morbidity and monality; I.

URGES Member States, particularly keeping public health in mind, with its social and

demographic implications: (I)

to review their reproductive health status and programmes;

(2)

to develop and implement policies, strategies and plans of action in order to

considerably improve reproductive health care;

(3)

to allocate resources required for wider coverage, and better access to such

services;

(4)

to ensure that women and men. regardless of age. social status or any other

characteristics, have adequate knowledge of reproductive health issues, so as to be able to make informed and free choices regarding their own fertility, and the positive health effects of spacing children, and that they have easy access to the means to do so;

(5)

to upgrade and update the curricula for both basic and in-service education of

health professionals;

.. ./

- 59 Annex 9 WPRlRC46.R15 page 3

(6)

to ensure also that. under the leadership of the health sector. an appropriate

coordination mechanism for reproductive health programmes is established with other government and nongovernmental sectors and organizations. as well as with professional. scientific and other relevant associations. and the mass media; and

(7)

to develop a series of health and social indicators. and the mechanism for their

regular collection. collation and analysis. to help monitor the progress of the reproductive health programme;

2.

REQUESTS the Regional Director: (1) to support the planning and implementation of reproductive health programmes;

(2)

to advocate providing men and women with information which allows them to

decide if. when and how often to reproduce. giving them the means to do so, in order that they may experience a healthy. safe and rewarding reproductive process;

(3)

to support improvements in the basic and in-service training of health

professionals in order to ensure better service performance and quality of care; and

(4)

to encourage the collection and use of data for better management of the

reproductive health programme.

Ninth Meeting. 15 September 1995 WPRlRC46/SRl9

- 61 -

FIGURE 1: COUNTRY PROFILES

Major Reproductive Health Problems Identified by 20 Selected Countries of the Western Pacific Region No. of Countries Identifying Issue by Priority

NO. OF COUNTRIES IDENTIFYING ISSUES STD/HIV /AIDS/PID

PRIORITY 1 2

3 I

4 4

RANKING 5 6-8

TOTAL

3 3

I

1

3 1

12 13

Contraceptives Access/ Availability/Acceptability

5

2

I

Maternal Mortality Rate

3 2 2 2

4

-

2 I I

1 2 2

1

8 8 7

Teenage Pregnancy

2

1

Abortion

I

Infant Mortality Rate

4

-

-

4

Child Health Care

2

I

.1

4

Disparities within Country

1

-

3 3

Knowledge/Skills Health Workers

-

I

I

Cancer

I I

I

-

-

3 3 3

Low Breast-feeding

-

1

2

I

Infertility

-

I

-

- 63 FIGURE 2: CONTRACEPTIVE USE BY PRIORITY

20 Selected Countries in the Western Pacific Region

CONTRACEPTIVE USED Depo Provera Oral Pills Tubal Ligation Vasectomy Intra-Uterine Device Condom Norplant Natural family planning

1

2

PRIORITY RANKING 4 5 3

6

TOTAL 7

5

1 6 1

3 3 2

1

.

1

6 2 1

4

2

16

1 1

11

2 4

2

9 15

6 3 -

3 5 I

2 I

1

1 -

1 -

-

12 2 2

-

I

-

-

-

I