The ICPD Programme of Action suggests a move from the narrowly defined MCH-FP to comprehensive reproductive health services programmes defined as follows:

Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes.  Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so.  Implicit in this last condition are the rights of men and women to be informed and have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.  In line with the above definition of reproductive health, reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems.  It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases. (para 7.2, ICPD Programme of Action)

The Platform of Action at the Beijing Conference builds on the ICPD.. "human right of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence".

Furthermore, it should be recognized that reproductive health does not only depend on health services; it is closely linked to the socioeconomic conditions and cultural practices, particularly women's status and gender relations.  Therefore, a broader reproductive health programme would take into account the latter issues as well as incorporate provision of reproductive health services in order to achieve comprehensive health care for women and men of all ages, including adolescents.

Reproductive Health

Reproductive Health Status
In the developing countries, about one-third of the total disease burden in women between 15 and 44 years of age is linked to health problems related to pregnancy, childbirth, abortion, human immunodeficiency virus (HIV) and reproductive tract infections (RTIs)^l.  Problems such as female genital mutilation, malnutrition and anaemia, unwanted pregnancy, reproductive tract infections including sexually transmitted diseases and HIV/AIDS, infertility, sexual and gender violence, unregulated fertility, maternal mortality and morbidity, reproductive tract cancers, osteoporosis and prolapse contributes to women's ill health throughout their life cycle².  Table 1 gives WHO's global estimates of reproductive ill health.

Components of Reproductive Health Services

Although the priority for specific reproductive health services will differ from country to country, the following services should generally be included:
 

• family planning counselling, information, education and services
• prevention and treatment of RTIs and STDs
• prevention, clinical assessment and referral of HIV/AIDS cases
• education and services for prenatal care, delivery and postnatal care including breastfeeding, and infant and women's health care
• prevention and appropriate treatment of infertility
• prevention of abortion and management of the consequences of abortion, and abortion services where legal
• services for women's gynaecological problems
• active discouragement of harmful practices such as female genital mutilation.

The constellation of services reflects a need to considerably broaden the range of services provided by most of the current MCH-FP programmes.  They need to respond to the needs of individuals, couples and families.  The quality of care improves as programmes become client-centred.  Clients are able not only to meet their contraceptive needs but could also seek services for other reproductive health needs.  If the services they seek are not available at the first point of contact, clients should have access to other facilities.  Quality implies sufficient information and choice of contraceptive methods.  Clients could also expect to participate in the design, implementation and evaluation of the services.  The transition from MCH-FP to reproductive health programmes has many managerial implications, and these are discussed in the following section.

Managerial Implications
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Paradigm Shift.
The transition from MCH-FP programmes to comprehensive reproductive health programmes requires not only the addition of services but a paradigm shift (Table 2).

Managerial Implications.
The paradigm shift has many managerial implications: (1) reorientation and restructuring of programmes; (2) addressing gender concerns; (3) establishing mechanisms for partnership and building linkages; and (4) strengthening leadership.

Reorientation and restructuring of programmes.
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A reproductive health approach requires that clients are guaranteed quality services that meet their needs, given informed choices, and treated with respect and dignity.  Since quality of care is the yardstick for measuring success of reproductive health services, there needs to be changes in monitoring and performance appraisal reflecting quality and not quantity.

Table 2. From MCH-FP programmes to reproductive health programmes:

In addition to MCH-FP services, other components of reproductive health services need to be included in the existing programmes.

With the expansion of services, redefinition of roles and training/retraining of providers and staff cannot be avoided.  Many existing programmes have female providers and if men's reproductive health needs are to be met, however, male providers must be recruited and trained.  At the same time, providers working with adolescents need to be trained to enable them to effectively reach adolescents.  The development of competencies must be accompanied by adequate supply and equipment.

Gender concerns.
Reproductive health services should respond to the needs, concerns, views and expectations of women as well as those of men.  However, because women suffer more from reproductive health problems, special attention should be given to them and their needs.

Furthermore, women's low social, political, economic and cultural status in most cultures has excluded them from making decisions concerning their health and lives.  In order to meet their needs, women who are often ignored in decision making must be actively involved in the design, implementation and evaluation of  programmes.

Many have argued that the disadvantaged position and discrimination suffered by women from birth to adulthood are strong factors contributing to women's poor health.  Since childhood, women have been conditioned to accept ill-health and consequently do not demand, services.  The culture of silence must be broken if women's health -is to improve.  Empowering women, particularly grassroots women, and' creating a supportive environment are powerful tools to break the silence.

Establish mechanism for partnership and building linkages.
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The interdependence of the various components of reproductive health call for partnerships with government, NG0s, and international agencies.  Partnership should be built on trust, respect and flexibility.  There may also be a need for a body to coordinate the various efforts by the partners. The private sector can play a significant role and the government should encourage their participation by developing supportive policies and including this sector in the overall programme strategy.

Reproductive health programmes also require building linkages with agencies or facilities offering various services.  Such linkages are particularly important for referrals as not all programmes are able to provide all the services related to reproductive health.

Strengthening leadership.
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To successfully move towards a reproductive health programme, strong leadership is needed at both the top and the middle management levels.  Top level managers need to create and sustain national commitment, establish partnerships and linkages, create values among staff and in society conducive to reproductive health services, and finally strengthen programme implementation.  Middle management is required, amongst others, to improve programme management, ensure quality of services, build support for reproductive health services, and establish networks with the commitnity and community resources.  To effectively perform their roles, managers must develop these skills, either through long-term technical and management training or through short management courses.³

What can be Done?

There are no comprehensive reproductive health programmes yet.  However, despite the problems described above, numerous agencies particularly NG0s have successfully implemented innovative projects in addressing specific issues of reproductive health.  This issue of Innovations presents four case studies highlighting innovative approaches as well as shedding some light on how problems were overcome and issues addressed.

Male Responsibility

Myths that men are not willing to take an active role in fertility regulation and be responsible for the reproductive health of their spouses and the health of their families abound.  The few experiences of male motivation and service provision projects, however, have indicated otherwise.  These experiences show that men are willing to be responsible provided that they are well-informed and that services meet their needs.  Unfortunately, efforts to educate men and provide services to meet their needs have been largely ignored.
Although there have been calls for male responsibility and involvement, the strategies for motivating them and for service provision remain unclear.

RTIS, STD and HIVIAIDS
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STDs and HIV/AIDS can no longer be associated with high risk groups only.  Statistics show that each year 250 million men and women are infected with some form of STDS.  In Thailand, the nationwide average rates of HIV infection among women attending antenatal clinics between 1990-93 grew from 0.4 per cent to 1.8 per cent.⁴A study in two rural villages in India found that among 650 women, an alarming 92 per cent suffered from one or more gynaecological or sexual diseases^5.  The average number of these diseases per woman was 3.6. In Bangladesh, 25 per cent of almost 3,000 women surveyed reported symptoms of a reproductive tract infection and two-thirds of these had clinical or laboratory evidence of an infection.⁶ In rural Egypt, 52 per cent of 509 non-pregnant women had a RTI, 56 per cent had uterine prolapse, 14 per cent had a urinary tract infection, 11 per cent had an abnormal pap smear and 63 per cent were anemic.⁷

Advocacy for the integration of RT1s, STD and HIV/AIDS in MCHFP programmes is strong and is making an impact.  However, progress in implementation is rather slow.  While integration is one of the best approaches to addressing the problem, starting an integrated approach has numerous managerial and financial implications and may not be an effective solution in many settings.  An integrated programme has to deal with training and/or retraining of staff, provision of adequate supplies, development of relevant IEC materials, etc.  With these activities to be implemented, in addition to existing MCH-FP programmes, the cost will increase.

Responding to STDs and HIV/AIDS in Kenya
Through improving quality of services and motivating staff to treat clients with respect, this pilot project shows how an STD clinic can be a friendly service outlet and attract the general population to utilize the services provided.  The project also strengthened its linkages with primary health centres and other development programmes which inform the public about the services offered at the STD clinic.

Family Welfare Services: The Tata Steel Experience in India
What can the private sector do to enhance the health and quality of life of its employees?  The case study of the Tata Iron and Steel Company is a classic example of how commitment at the highest level allows employees and their families to enjoy health services as well as other development efforts.

Youth Sexuality and Reproductive Health
A growing number of young people are engaging in sexual activities.  This development is compounded by societal stigma against teenage sexuality and social constraints against providing contraceptive services to unmarried couples, resulting in a significant increase in teenage pregnancy and induced abortion. 15 million children are born to teenage mothers annually, thus putting the health of these mothers as well as that of their babies at risk.  As many as 5 million abortions involving young girls take place annually, of which thousands die under clandestine, dangerous and unhygienic circumstances.  While there are health implications with teenage pregnancy, it is also a social problern.

Another issue related to youth sexuality is the prevalence of STDS including HIV infection.  Statistics show that STDs are highest amongst young people between the ages of 20-24 followed by 15-19 year age groups.  Worldwide, between 20-25 per cent of HIV infections are estimated to occur among young people⁸

Many are in agreement that youth sexuality and reproductive health need to be addressed urgently.  However, they differ in what actions to be taken.  Numerous NG0s and some international agencies have taken the lead in implementing small scale projects.  While the majority of these projects focus on educational activities and almost no services, the issues addressed vary from biology to STD and HIV/AIDS to relationships, depending on the environment where the projects are being implemented.  Unfortunately, most governments have yet to take action.  The sensitivity of the subject coupled with the lack of capacity and widely accepted programme models are reasons for inaction on the part of most governments.

Youth Helping Youth in Tanzania
The UMATI youth programme is based on the experiences of similar programmes carried out in Sweden.  In the programme, a core group of youth are trained to reach out to their peers.  Linkages with health clinics were established so that medical services are available to youth in need of such services.