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The International Conference on Population and Development Programme of Action (ICPD-POA, para 7.6) recommends that "all countries should strive to make accessible through the primary health care system, reproductive health to all individuals of appropriate ages as soon as possible and no later than the year 2015." Many governments have taken the approach of developing and implementing essential services package approach to achieve the above objectives.

The Report of the Ad Hoc Committee of the Whole of the Twenty-First Special Session of the General Assembly (A/s-21/5/Add.1) reiterates this goal and recommends that "governments should strive to ensure that by 2015 all primary health care and FP facilities are able to provide, directly or through referral, the widest achievable range of safe and effective family planning and contraceptive methods; essential obstetric care; prevention and management of reproductive tract infections, including sexually transmitted diseases; and barrier methods (such as male and female condoms and microbicides if available) to prevent infection. By 2005, 60 percent of such facilities should be able to offer this range of services, and by 2010, 80 percent of them should be able to offer such services."

The rationale of a package approach is to enable program managers and planners to: 1) assess the feasibility and management implications for implementing various combinations of health services at different levels and in diverse settings; and 2) examine the cost, financing and sustainability implications of implementing these health services. Programme planners should always have these questions in mind:

1) What are the best ways for the local area to expand in reproductive health (RH) care;
2) What needs to be done to implement the services in their particular area, what are the needed management tools; and
3) What are the costs and long-term outlook for the service expansion.

Notably, while package services may be defined, operationalising programmes effectively requires fundamental changes in the outlook and ethos of the health care delivery system.

In this package approach, the clients' needs and quality of care are placed at the heart of service provision and the partner to this approach is the services themselves. Together, the RH approach and the service package make up the RH service delivery package (sometimes referred to as the "package approach" in this chapter).

The major components of such a package should be integrated into basic national programmes for population and reproductive health (ICPD-POA 13.14) and include the following services: family planning, counselling, information; education and services; education and services for pre-natal care; safe delivery and post-natal care; prevention and appropriate treatment for infertility; prevention and management of abortion; and treatment and education on prevention of reproductive tract infections (RTIs), sexually transmitted diseases (STDs) and HIV/AIDS. Effective referral systems should be established and made available when required.

It is important to realise that no single set of services is appropriate for all states, districts, or communities. Rather, services must be tailored to fit the needs and capabilities of different kinds and levels of service provision. Given the variability of needs and capabilities among regions, the extent to which a programme could expand without compromising the quality and effectiveness of existing services must be seriously considered. There is a clear need to prioritise and develop a phased approach with incremental addition of health interventions.

Key cross-cutting themes in the RH package approach stress on the importance of managing the quality of care in addressing clients' reproductive needs and the importance of health, sexuality, and gender information, education, and counselling. All of these components reflect the placement of client needs at the centre of service provision and the holistic outlook embodied in the RH approach.

This package focusses primarily on the role of government programmes. Clearly, however, private sector and non-governmental organisations (NGOs) also play an important role in the provision of health care. Consequently, NGOs and the private sector are crucial partners in the effort to operationalise the package approach. Sharing ideas, experiences, as well as services (e.g. referral systems) greatly aid in any improvement effort.

As implementation occurs, operations research should form an integral part of programme implementation and experimentation, in order to ensure the effectiveness and feasibility of each step of service and managerial expansion. Given the current information gaps in many of the issues and questions relating to the package approach, such operations research must be coupled with advocacy on the policy level, to encourage continued support for this evolution in the health care system.

When designing and implementing a RH care package, planners must not lose sight of the health outcomes they hope to achieve. Strategies found to be effective in one setting should not be adopted in another, unless the appropriate resources for diagnosis and follow-up care are available. For example, pap smears are an excellent screening method for early cervical cancer. However, they require laboratory facilities and appropriate treatment. When these resources are not available, managers and planners must think in terms of alternative management, for example, visual screening, and refer clients to centres with facilities.

In operationalising RH service programmes, several cross-cutting issues need to be addressed before a service delivery package can be developed. These issues would include involving the community in the formulation of policies and programmes; monitoring and evaluation towards expansion of existing programmes; improving quality of RH services to extend beyond maternal health and FP services; mobilising the private sector providers, community-based distributors (CBDs), youth and other volunteers to reach larger areas/populations working towards programme sustainability and self-sufficiency; addressing the gender issues in programmes and empowering women to claim their rights to services and good reproductive health.

Different countries have arrived at different packages of services that reflect their needs. For instance, in India, one component of the package is the provision of RTI prevention and treatment services, including counselling, screening, case findings and diagnosis by clinical and laboratory procedures and treatment (Pachauri, 1995). This package has been accepted by the Ministry of Health and Family Welfare, Government of India and it is an integral part of the recently announced Reproductive and Child Health (RCH) programme (see Chapter 5). Similarly, Myanmar outlined four priority areas to be covered in an essential service package for RH: maternal health, including safe motherhood and prevention of abortion complications; birth-spacing; RTI/STDs; and adolescent reproductive health (ARH) issues. Other important elements such as infertility, reproductive cancers and menopause problems need to be included in a common framework in order to cover the whole lifespan.

Tables 1 to 4 illustrate the various services that need to be provided by the primary health service delivery system at the community, health centre, district hospital, and provincial hospital levels³. The tables also indicate the "missed opportunities" in the provision of RH care. It is important to note that ARH has only recently become an issue for discussion in these two countries, and the public health sector is currently in the process of developing appropriate programmes to meet the perceived needs of this group of young people.

In addition to merely adding new services, it will be necessary to strengthen the links between these service areas through an integrated, multi-disciplinary and inter-sectoral approach. For example, RH education should take place at all possible opportunities such as providing birth-spacing education/counselling as part of ante-natal/post-natal care. For linkages between areas of RH to be successfully formed, there is a need to orient health service providers to the overall reproductive health of men, women and adolescents.

Many countries are taking steps to package feasible RH services, testing ways of integrating them as well as including services for men and the young people. Special emphasis has also been given to quality of care in the provision of these services. It would be counter-productive to raise the expectations of potential clients without providing services to meet them, but there are limitations with regards to the process and resources to implement the packages, and there are few examples to study from.

Effective progress towards successful implementation of the RH services package requires full involvement of stakeholders in the making of policy and the planning of programmes; support for RH care from stakeholders; establishing priorities among the elements that make up the RH agenda; implementing a national RH service programme; and mobilising resources to support an RH programme.

The actions to implement RH services package are required at two levels: community, and clinic/health centre. Although examples from the government sector are few, there are many NGOs that have strengthened their community outreach to include a wider range of RH services. Below we illustrate community level actions with the experiences of two Indian NGOs. Community level outreach has, however, to be backed up by clinical services. Therefore, we will discuss examples of the clinics of these NGOs.

Society for Education and Research in Community Health (SEARCH)⁴, founded by Drs. Bang and Bang, a husband and wife team, is an NGO that has initiated innovative work in the area of reproductive health in India. The main objective of this NGO is to meet the health needs of the local people. To achieve this, SEARCH conducted community level research on the common health problems and, based on the findings, developed ways to tackle these problems with the help of trained local people.

As SEARCH was interested in action research, an intervention area of 53 villages and a control area of 72 villages were selected. Over time, selected programmes of SEARCH were implemented beyond the intervention and control areas. SEARCH has developed a team of professionals, paramedics, social workers, computer specialists and field workers to work on its community-oriented research and services. It has also developed a cadre of village level volunteers, who are trained to do selected health activities including acute respiratory infection (ARI) management. SEARCH has also trained traditional birth attendants (TBAs) to conduct women's health activities.

The community-based activities include: an education fair called the Stree Jagram Jatra to educate women on reproductive tract infections and other women's health problems; and an alcohol de-addiction programme to rehabilitate alcoholics to give up alcohol. Both these activities snowballed into successful people's movements, which pressured the government to take relevant actions and provide support.

SEARCH utilised local volunteers to provide services. The TBAs are one of those groups of volunteers recruited. With adequate training, the TBAs were utilised to provide basic health services at the village level where they relate best to the rural women. TBAs were also trained to treat common childhood ailments like diarrhoea and ARIs, other than their maternity skills. As TBAs are illiterate, training for them are conducted in the form of songs, poems and rhymes and games, to facilitate learning. The services of TBAs are well-received by the community as they began to provide more and more RH services. TBAs do not receive any salary or honorarium from SEARCH but every year they receive token gifts. TBAs are proud of their new skills and recognition they received from the community and SEARCH, which compensate for the non-salaried work they are doing.

Rural Women's Social Education Centre (RUWSEC) is a community-based NGO in South India that focusees on the rights of women within their households; which include the RH rights as well as rights to their overall well-being. This orientation is a direct result of the conviction arising from women's own experiences that they cannot be successful agents of social change without first having control of their bodies and their lives. The organization's objectives include helping women belonging to the lowest caste groups, who are, as a result, economically backward and socially marginalised, to develop critical consciousness and leadership skills so that they are able to collectively and constructively change the circumstances of their lives.

RUWSEC has sought to demystify the notion that health can only be delivered by doctors. It believes that people have to be organised to demand the fulfillment of conditions that make it possible for them to be healthy. RUWSEC seeks to enable women to initiate self-help at home through health education, through programmes that enhances their self-image and self-worth and empower them to access quality health services, be it from the government public health system or private practitioners.

A baseline survey was conducted in 43 hamlets by RUWSEC in 1988-89. Its findings showed that a high percentage of women marry and bear children in their teens; half the number of women suffered one or more complications in pregnancy and delivery; three-quarters of deliveries took place in the home; school drop-out as well as still birth and infant mortality rates were high. Prompted by the outcomes of this survey, the organisation began introducing RH services into their programme.

The community-based action for health promotion which started in 1981 forms the foundation for all RUWSEC's current activities. RUWSEC hired and trained community health workers (CHWs) to carry out this health promotion activities. They then mobilise the women from their areas to form women's sanghams (associations). Leadership training is provided to members of these sanghams. The strategy of forming sanghams and providing leadership training to village women has created groups that are nearly self-sustaining. These sanghams are capable of running their own programmes without much help from RUWSEC. Their activities included educating women in the community to demand their for rights and organise health education campaigns based on priority issues identified from time-to-time by CHWS with the sanghams.

Search's commitment to provide services to the community was based on research findings and the magnitude of health problems; it was evident that men suffered high degree of STDs; adolescent girls seek termination of pregnancy and treatment of vaginal infections and people are suffering from severe anaemia and not responding to iron therapy. Spurred by all these realities, SEARCH opened its first clinic in Gadchiroli, a remote town in rural India in 1989. Women's RH was given priority although the clinic provide general health services to women, men and adolescents. The clinic services include medical termination of pregnancy (MTP), dilatation and curettage (D and C) and other minor gynaecological surgeries - at low cost. Ante-natal care (ANC) services were provided but maternity cases were referred to government PHC where such services were available.

Earlier the clinic operated in a small, rented house on a shoe-string budget and limited staff, but provided high quality care. The staff of the clinic was limited to a doctor, a nurse, an attendant and a driver. Days are allocated for out-patient clients, and for operations and follow-up work. Due to the woman-friendly and quality services provided, patients from distant villages also came to the clinic to seek help. Eight years later, SEARCH moved its clinic to a small village in a forested area about 17 km from Gadchiroli. The clinic, together with training facilities, office building and quarters for all the staff, is located on a campus spread over 13 acres of land, the new clinic is well equipped with out-patient facilities, operating theatre and in-patient facilities. In addition, an ECG machine and an x-ray machine have been recently installed.

As the new clinic has more space, SEARCH is able to offer a wider range of services. The clinic continues to offer services for general health, but focusses on women's health. As the demand for RH services is high, special emphasis is given to the provision of ANC; diagnosis and treatment of RH problems such as RTIs and STDs; menstrual regulation services; and contraceptive services and advice. Supporting the above services are the laboratory and ECG services, counselling, and health education. One special feature in the ante-natal care service delivery is the home-based maternal record (HBMR) card developed by the World Health Organisation (WHO) in order to improve maternal care. It included details of risk factors, a weight gain graph, laboratory test results, advice to the mother, delivery detail and neo-natal details. The HBMR card has several benefits: it makes ANC more systematic and helps people understand the importance of weight gain and hence, the need for better nutrition and rest during pregnancy. It also helps identify high-risk cases and improve follow-up of the cases. The card also works as an educational tool.

Consultation and laboratory tests per patient cost Rs. 5 (US$0.15). Medicines are provided at cost, and prescriptions are usually the most rational and simple which keep the costs of the medicines low.

RUWSEC, initiated clinical services in June 1995. When the clinic started, only out-patient services were planned. These included diagnosis and treatment for male and female RH problems including STDs, pregnancy, post-partum care and birth control. Besides counselling and information on birth control methods, the clinic provided access to temporary methods such as oral contraceptive pills, IUDs and diaphragms. In response to numerous requests for providing facilities for abortions, deliveries, sterilisation and minor gynaecological procedures, RUWSEC approached the Government of Tamil Nadu for financial assistance. The Government responded positively and, subsequently, a well-equipped operation theatre was added and the clinic has been performing abortions, deliveries and female sterilization since April 1996. Most of the clients are women and children, but a small number of men seek advice and treatment, mainly for STDs. Nearly 40 percent of the women seek treatment for RTIs and the health workers have been able to follow up and ensure that the women's former partners also come for treatment. The success in partner treatment is largely due to the efforts of the health workers in motivating the men to undergo treatment.

Another important feature of the clinic is the clinical laboratory. This laboratory acts as an independent profit centre and provides testing facilities not only for clients who come to the clinic, but also for those referred to the laboratory by other doctors in the area. Initially, there were some problems with the marketing of the laboratory services to other doctors for referral since other private laboratories give commissions for referrals but RUWSEC, on principle, did not want to follow such a strategy. However, the prices for all the tests were deliberately kept nominal but the quality of the testing was of a high standard.

Health education is an integral part of the clinic's activities. After receiving treatment, clients meet the community health worker/health educator for further counselling and follow-up care. There is also a trained counselor available at the clinic who counsels the clients on various topics and issues. In addition, health education materials are distributed free of charge. Clients are invited to attend the RUWSEC inter-village workshop on RH issues and to participate in its various campaigns.

As RUWSEC felt that STD diagnosis and treatment camps would make services accessible to a greater number of people, a camp was conducted in collaboration with the women doctor's association and the STD department of the government hospital. While the crowd attending the camp was fairly large, but the quality of services offered was poor and treatment was not provided. As a result, no more camps were held. Meanwhile, RUWSEC has begun to bring services to the people through its outreach clinics on a pre-determined schedule. Doctors and nurses are transported from village to village to provide services. The transport/ambulance used by the team is also used to send women home after delivery or after surgical sterilisation. A small fee is charged for ambulance service.

Turkey's experience in integrating an expanded range of RH services, summarised below, is discussed in full details in Chapter 8. Earlier, the RH service provided at maternal child health/family planning (MCH/FP) health centres had been mainly on MCH and FP. Following the ICPD, services have expanded to cover RH care of adolescents, women of reproductive age and menopausal/elderly women. MCH/FP centres are mainly at urban and semi-urban parts of the country where the population is dense and the needs of MCH/FP services are greater in terms of quality. The Women Health and Family Planning Strategic Plan, adopted in 1995, broadened the functions and role of the traditional MCH/FP and improved their infrastructure. MCH/FP now provides training in RH as well as referral services to other health centres.

At the primary health care level, the given services include: counselling, information, education, communication and clinical services for RH. These are ante-natal and post-natal care; safe delivery; FP; screening for STDs; monitoring growth and development of children under six years of age; immunisation; family health and early diagnosis and treatment of common infectious diseases. At the hospital level, besides these services, treatment for pregnancy complications, delivery and infancy are also provided. Since the RH care services became an integral part of primary health care, the service provided care for men and young people.

In an innovative approach, some MCH/FP centres in the more densely populated urban squatter areas have been converted into Free-standing Health Clinics providing RH services at the primary level. This reduced clients' visits to hospital as well as save their time and money. The hospitals benefit as well in terms of reduced workload and cost in providing such services. The services provided included 1) pregnancy termination; 2) tubal ligation and vasectomy; 3) early diagnosis of reproductive cancers; 4) STD prevention and treatment; 5) RH services for adolescents; 6) RH services for post-menopausal and elderly women; 7) IEC for men; and 8) services for referral cases from the health centres. Except for services like ante-natal care, immunisation and child follow-up care, a small fee is charged for laboratory and surgical procedures. An evaluation of the clinics' performance after two years of implementation in 1995 showed positive results and indicated that the quality of care had largely improved. The providers expressed satisfaction in this new set-up since they could contribute positively to improve the health status of women, and were happy to be working in better equipped centres.

Adolescent often lack basic RH information, skills in negotiating sexual relationships and access to affordable, confidential RH services. Concerns about privacy or the ability to pay and real or perceived disapproval by service providers further limit access to services where they exist, as do legal barriers to information and services.

In many countries, the issue of adolescent sexuality and reproductive health is still politically sensitive, and RH information and services simply do not reach most adolescent. However, some 55 countries have taken policy and programme measures to address the health needs of adolescents, including reproductive health.

Many schools offer population and family life education, which include sexuality education to older students, as part of a school curriculum, in almost all countries. However, their coverage and impact differ from one country to another and are not clear.

Teachers and parents play an important role in in-school programme. Although some programmes also educate parents on how to handle adolescent sexuality situations, the activities to improve interactions between parents and adolescents to nurture the process of maturation have not been emphasised.

Education in sexuality equips adolescents with better skills to care for their health and the health of their families. Schooling in general, helps girls delay marriage and child-bearing. Research has revealed that women without a basic education are three to five times more likely to give birth by the age of 20, thus leading to increased risks of complications in pregnancy and delivery. A review of some 35 studies conducted in developed and developing countries concluded that school-based sexuality education does not lead to earlier or increased sexual activity in young people. Programmes that encourage postponing sexual activity while providing information about safe sex and contraception are more effective than those that promote abstinence only.

A programme in Indonesia (Satia, 1998) organises families into small groups which meet periodically to discuss adolescent problems/issues. The meetings were facilitated by trained cadres. The Sri Lanka (Satia, 1998) in-school programme initiated in 1992 educate youth on the growing-up process, sexuality, STDs and HIV/AIDS. The favourable impact of the programme on in-school youth prompted its expansion in 18 districts by 1994.

School-based clinics are available in some developed and developing countries. The services provided vary considerably, but at a minimum include basic health monitoring and referral services. In developed countries, some school-based clinics provide condoms and counselling about pregnancy and STD prevention, as well as referral for other contraceptive and RH services. These services are often controversial, however. In developing countries, school-based services are often limited by restrictive policies, personnel shortages, lack of private areas for counselling, and poor links to resources outside the school.

Multi-service youth centres offer contraceptive services as part of the comprehensive programmes for youth, including education, recreation, and employment preparation. One successful programme is the Women's Centre for Pregnant Adolescent in Jamaica.

Adolescent clinic health services offered in countries like the Philippines are staffed by providers trained to deal with special adolescent health concerns and to counsel them about sensitive RH issues and contraceptive use. Adolescents often name the following as important in clinics for them: confidentiality; youth-friendly; open to young women and men; strong counselling component and a comprehensive clinical services.

These programmes are especially important to groups such as out-of-school youth, "street" youth, and girls who have limited freedom to leave their community. These community-based projects use a variety of formats to reach youth where they congregate for work or play. For example, in Mexico, gang members are trained to reach other out-of-school adolescents in partnership with the Mexican Social Security Institute and the Mexican Family Planning Association (MEXFAM). After attending educational sessions, interested members are invited to join a theatre group to perform in public places and schools to provide information to their peers.

Peer programmes train young men and women to reach out to their peers with information and referral for services. As peer influences are an important determinant of early sexual initiation, peer educators can often provide support that counters negative peer pressure. For instance, peer education can provide young men and women with opportunities to examine the myths that have shaped their own attitudes about themselves. Young people generally respond well to peer educators and welcome the opportunity to talk about their feelings and roles as they find peer educators credible, approachable and helpful.

In Mexico, peer educators of MEXFAM's Gente Joven project report that as a result of project activities, more young men are seeking information about contraception. In Namibia, the Strengthening Male Involvement in Reproductive Health project trains cadres of peer educators to conduct ongoing educational sessions for other young men within the defence and police forces, soccer clubs, and the Evangelical Lutheran church. In Ghana the Red Cross and the Scout Association have organised peer education programme that provides training in negotiating safer sex and refusal and assertiveness skills.

Counselling for women and men should form an integral component of all interventions that are included in the recommended package of RH services. In order to effectively integrate counselling activities, it is important to orient both public and private sector providers to consider the overall reproductive health of the client. They need to understand reproductive health as a comprehensive state and provide counselling and follow-up services for all who need such services.

Safety and side-effects of contraceptive methods;
Safe motherhood focussing on ante-natal care, safe delivery, emergency obstetric care, and family planning;
RTIs/STDs including HIV and their ill effects on mother and child;
Unsafe abortion and maternal morbidity and mortality;
Cervical and breast cancer detection at early stages and prognosis; and
Involving men in decision-making on the RH goals of their wives/partners.

Service Integration

Service integration is not entirely new in any country; most had previously combined FP/MCH programmes in public health care systems. Although integration is increasing and there is greater recognition of the inter-connectedness of the issues and needs involved, services are still planned and provided separately. There are isolated examples where services are integrated but there is no leadership from the upper echelons of the medical profession to substantially alter the existing service structure towards integration. However, many service programmes report that integration saves time for providers and the increased responsibilities have enhanced the status of providers.

In some countries, health centres now provide on a daily basis, family planning, pre-natal and post-natal care, RTIs and STDs, including HIV counselling, nutrition, education and child immunisation. Previously, only MCH/FP are offered on a daily basis and other specialised services may be offered on designated days. Most health systems do not screen clients' unmet need for family planning or other RH services.

However, service integration is not without challenges. There is a need for a comprehensive national sexual and reproductive health and rights strategy, which can serve as a point of reference for the co-ordination or integration of policies, programmes and services. Health professionals should have specialised training with regular updates, to enable them to serve the needs of the population. NGOs and the private sector also need to be strengthened to assume their expanded responsibilities in promoting and providing RH care.

In many countries, preventing, detecting, and treating STDs, is a critical component of RH. Since women's health programmes such as family planning and maternal health are often a client's primary, sometimes sole, contact with the health system, they provide opportunities to inform clients about STDs and HIV, help them assess risks, and offer contraceptive methods for STD protection. It is presumed, therefore, that clients' overall RH needs may be better met by providing convenient "one stop" integrated services. Thus, integration of STD/HIV services into RH means delivering two or more types of services previously provided separately, as a single, coordinated, and combined service. The integration may be viewed as a continuum running from an informal to a more formal combination of two or more services.

Integration of STD/HIV services has profound implications for staffing requirements, including recruitment policies and practices, and technical and supervision skills of staff. Similarly, all STD/HIV activities require effective logistic systems involving drugs, laboratory diagnosis, condoms and IEC materials. If availability of these supplies is a problem, then it may not make sense to integrate such a clinical STD activity. Integration of STDs/HIV services into RH settings has been implemented successfully in many developing countries. Examples from the Philippines (Chapter 11) and India are illustrated here.

The Philippines initiated RTI/STD activities into the local public health clinics after findings from situation analyses indicated that tests for detecting STDs/RTIs were limited; documentation was poorly maintained; few service providers were trained in RTI/STD management; and quality of care during pelvic examinations was often deficient. Integration started with training the health providers, upgrading the laboratory facilities and developing IEC materials and modifying the clinic record system. They ended up with two types of management: (1) pure syndromic management by paramedics, and (2) syndromic with microscopy. The other key issues were drug provision and commitment of service providers in terms of sustainability (Costello, 1997).

In India women will only seek treatment if they have severe pain, excessive discharge or infertility problems. The project started intensively in 1995 in two districts to really change the mind-set of the people and the providers towards providing more client-centred services. In terms of context or rationale, while prevalence of infections is reportedly high, as found in various studies, most women do not seek treatment, due to lack of awareness, lack of female doctors, passive acceptance of RTIs as a part of women's lives and lack of treatment availability. Treatment for RTIs is limited, both in public and private clinics. Also there is stigma attached. Three study sites were selected, and the Population Council has been working very intensively with the district authorities. At one site where there was no lady doctor, they have a private lady doctor visiting the hospital once a week. She receives 30-40 cases each day she is there, which indicates the high unmet need from the clients' side. In designing the interventions, they had several considerations. They used existing facilities and this was very effective, the guidelines were well received by both the trainers and trainees (Patel, 1997).

Current quality improvement must deal with the upgrading of existing services as well as the difficult transition to more comprehensive RH care services. Most health programmes in developing countries do not properly address the concerns for quality of care, and there are few opportunities for people to contribute to the development of such programmes. In addition, many programme staff are poorly trained and lack motivation. They have minimal or no supervision, low-salaries, ambiguous objectives, and are not appraised for their work. This leads to routinisation of the work and poor quality of care. The impersonal, indifferent, even negative attitudes of staff constitute a strong deterrent to clients' full utilisation of services.

The experiences to date of many programmes show that if quality RH care services are to be introduced, then the knowledge and skills of staff and service providers must improve in many areas. Staff in four case studies required considerable training to perform tasks that their programmes had not previously addressed, such as STD/HIV prevention, ARH, post-abortion care and so on. Inadequate technical skills may present a problem even for existing services.

In addition, a reorientation from a distribution-based service provision to one that focuses on client-centred care needs is required to ensure quality of care. Reorientation necessitates several actions, training and re-training, technical supervision, provision of necessary equipment and supplies, provision of manuals to health staff to guide them in their tasks and periodic monitoring and assessment of quality of care provided.

As for the private sector (general practitioners, TBAs, pharmacists), there is a need to improve the quality of services although clients appear to prefer private services and perceive them to be of better quality. Ideally, a partnership between the public and private sectors should be forged to improve the RH status of all individuals. Governments may need to consider introducing a regulatory framework that includes standardised management of various RH problems.

The introduction of new RH services will increase the pressure on referral points as RH services are added, the number of patients to the already overcrowded hospitals will increase and cost in government hospitals will increase in order for such services and the process of referral to be managed in an orderly manner.
There is a need to establish adequate standards for services and protocols for treatments, which are generally not there. Governments need to consider introducing regulatory frameworks that include standardised guidelines for management of all RH problems in both the government and private sector.
In the area of birth-spacing, efforts must be taken to reduce unmet need by introducing new methods into the programme, for example, implants and the monthly/three-monthly injectables. The counselling that accompany these methods needs to be improved as well.

Affordability of Services/Cost of Health Care

Data on the cost of providing improved RH care and estimates of the budgets available are important for two reasons. First, valid financial figures can assist in assessing the gap between what is needed and what is available. Financial data are needed to track cash flow and expenditure earmarked for reproductive health by government and donors. Second, an assessment of costs and resources helps sets priorities. Existing system of estimates and costs are seriously deficient, partly because most budgets of government and non-government clinics are often multi-purpose, and it is difficult to isolate costs of one type of service. Virtually no data is available on what people might pay for RH care. Data on external funding, government expenditures and plausible estimates of cost recovery from consumers are required to improve decision-making on types of services.

The training currently provided to health care workers will not be adequate to address the needs of an expanded RH programme. To overcome this, a longer required period of training in the field would be a better strategy. In addition, the mode of training and the focus of the curriculum need to reflect better the orientation, as well as to equip workers to communicate with clients and address motivational issues. Non-governmental organisations have successfully designed appropriate, gender-sensitive and needs-oriented training modules for health providers and have helped grassroots workers adopt the new approach. The RH service package must consider how community-based experimental models can contribute to the reorientation of public health programmes to reproductive health. Cost-effectiveness, financing, and sustainability at the community health centre and hospital levels must also be taken into account.

Activities should focus on primary health care at the community level and the quality of care. Models of primary health care should include an appropriate referral system, particularly for RH services, for example, obstetric emergencies which require timely, specialised technical assistance to reduce the chance of maternal and infant death. Other essential elements of quality of care include information suited to the needs of users and the linking of service related to all aspects of reproductive health. In many areas, where services are lacking or are of poor quality, women will continue to rely on TBAs and other traditional health practitioners. One programme in India teaches technical skills to TBAs, most of who are from lower castes. Their new skills help enhance their self-esteem and the respect they are accorded by the community and health professionals, which subsequently improve their ability to provide effective care.

Another strategy is to empower women to act on their RH needs by supporting educational activities that enable women to make informed choices and encouraging women to raise questions important to them with their health providers and within the communities. Educational efforts can include support for print and electronic media, or following the RUWSEC example, for more traditional channels of communication such as theatre, music, community meetings, and other means likely to reach the intended audience.

Lack of financial resources is a major barrier to implementing RH care services. First, there are no universally agreed-upon definitions of what activities are included in this area. Second, even less information is available about what donors, governments and individuals are spending. As RH services that address critical health problems are cost-effective and have significant positive externalities, the government should consider allocating larger funds, in addition to pursuing international donor aid, for ensuring improvements in RH status.

With the recommendations of the ICPD-POA as guiding principles, many governments have adopted the services package approach. Like any approach, it has its successes and setbacks. For sustainability, may factors have to come into play. Basically, a fundamental change in the ethos and outlook of all concern is crucial. A key element is commitment/involvement of all stakeholders.

²This essential RH services package is recommended for nation-wide implementation in India, paper by Saroj Pachauri (1995) on "Defining a RH Package for India: A Proposed Framework."
³Tables 1 to 4 show the various services that needed to be provided at different levels of the public health services either as new interventions or required strengthening. (Unavailable in this page)
⁴A summary of ICOMP's documented case study on SEARCH

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Costello, Marilou P. (1997). "Integrating RTI Services into Public Health Clinics in the Philippines." International Shared Experience: Proceedings of a Two-day International Workshop, December 1997. The Population Council.

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Mavalankar, Dileep, Bang, Rani and Bang, Abhay (1998). Quality Reproductive Health Services in Rural India: The SEARCH Experience. Kuala Lumpur: ICOMP.

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Patel, Bella L. (1997). "Integrating RTI Services in the PHC System in India." International Shared Experience: Proceedings of a Two-day International Workshop, December 1997. The Population Council.

Satia, Jay (1998). "Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns." A theme paper prepared for The South Asia Conference on Adolescents, New Delhi, 21-23 July 1998, organised by UNFPA.

Subramanian, Sangeeta Sokhi (1998). Rural Women Take Reproductive Health Matters into Their Own Hands: Rural Women's Social Education Centre. Kuala Lumpur: ICOMP.