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Social determinants of sexual and reproductive health Informing future research and programme implementation Social determinants of sexual and reproductive health Informing future research and programme implementation WHO Library Cataloguing-in-Publication Data Social determinants of sexual and reproductive health: informing future research and programme implementation / edited by Shawn Malarcher. 1.Reproductive health services. 2.Sex factors. 3.Sexual behavior. 4.Research. 5.Socioeconomic factors. 6.Family planning services. I.Malarcher, Shawn. II.World Health Organization. ISBN 978 92 4 159952 8 (NLM classication: WQ 200) © World Health Organization 2010 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specic companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named author/editor alone is responsible for the views expressed in this publication. Cover photos: Photoshare Contents Acknowledgements iv Abbreviations and acronyms v 1. A view of sexual and reproductive health through the equity lens Shawn Malarcher 1 Section 1. Within the health system 13 2. Promote or discourage: how providers can inuence service use Paula Tavrow 15 3. Financing mechanisms to improve equity in service delivery Dominic Montagu, Maura Gra 37 4. Scaling up health system innovations at the community level: a case-study of the Ghana experience John Koku Awoonor-Williams, Maya N. Vaughan-Smith, James F. Phillips 51 Section 2. Beyond the clinic walls 71 5. Sexual and reproductive health and poverty Andrew Amos Channon, Jane Falkingham, Zoë Matthews 73 6. Migration and women’s reproductive health Helen Smith, Xu Qian 93 7. The role of schools in promoting sexual and reproductive health among adolescents in developing countries Cynthia B. Lloyd 113 8. Sexual violence and coercion: implications for sexual and reproductive health Sarah Bott 133 iv Social determinants of sexual and reproductive health Acknowledgements The World Health Organization gratefully acknowledges the contributions of the editor of this book, Shawn Malarcher, and those of the authors of the chapters: John Koku Awoonor- Williams, SarahBott, AndrewAmosChannon, Jane Falkingham, MauraGra, CynthiaLloyd, ZoëMatthews, DominicMontagu, XuQian, HelenSmith, PaulaTavrow, and MayaNicoleVaughan-Smith. Thanks is also extended to individuals of the WHOInterdepartmental Working Group on the social determinants of sexual and reproductive health: Marie Noel Brune, Jane Cottingham, Catherine D’Arcangues, Peter Fajans, Mai Fuji, MaryEluned Gaeld, Claudia Garcia Moreno, Ronnie Johnson, Nathalie Kapp, ShawnMalarcher, Francis Jim Ndowa, AlexisBagalwaNtabona, NuriyeOrtayli, Anayda Portela, JuliaLynnSamuelson, and Lale Say. Without the contribution of these individuals, this work would not have been possible. The editor is indebted to the reviewers MaiFuji, Mary Eluned Gaeld, Alison Harvey, ClaudiaGarciaMoreno, Dale Huntington, RonnieJohnson, Nathalie Kapp, Suzanne Reier, Julia Lynn Samuelson, and Lale Say for their helpful comments and guidance in development of authors’ submissions. A special word of thanks is extended to Iqbal Shah and Erik Blas for their guidance and support in producing this work. The Priority Public Health Condition Knowledge Network coordinated by the Department of Equity, Poverty, and Social Determinants and the Department of Reproductive Health and Research provided nancial support for this work. v Informing future research and programme implementation Abbreviations and acronyms AIDS acquired immunodeciency syndrome BPL below the poverty line CBD community-based distribution CHAG Christian Health Association of Ghana CHPS community-based health planning and services CHC community health compound CHN community health nurse CHO community health ocer CSDH Commission on Social Determinants of Health CYP couple-years of protection DALY disability-adjusted life year DHMT district health management team DHS Demographic and Health Surveys DMPA depot medroxyprogesterone acetate FBO faith-based organization GHI global health initiatives HIV human immunodeciency virus HMO health management organization HPV Human papillomavirus ICPD International Conference on Population and Development (1994) IMF International Monetary Fund IOM International Organization for Migration INSS National Social Security Institute (Nicaragua) IPV sexual intimate partner violence IUD intrauterine device MDGs United Nations Millennium Development Goals MEDS Mission for Essential Drugs and Services (Kenya) MMR maternal mortality ratio MVA manual vacuum aspiration NGO nongovernmental organization OECD Organisation for European- Cooperation and Development OPEC Organization of Petroleum-Exporting Countries PPH postpartum haemorrhage PRSP poverty reduction strategy paper QALY quality-adjusted life year RHR Department of Reproductive Health and Research RTI reproductive tract infection SRH sexual and reproductive health STD sexually transmitted disease STI sexually transmitted infection SWAp sector-wide approach TFR total fertility rate UNFPA United Nations Population Fund UNIFEM United Nations Development Fund for Women UN-HABITAT United Nations Human Settlements Programme USAID United States Agency for International Development YLL years of life lost vi Social determinants of sexual and reproductive health A view of sexual and reproductive health through the equity lens Shawn Malarcher Department of Reproductive Health and Research World Health Organization, Geneva, Switzerland 1 [...].. .Informing future research and programme implementation W hile the last two decades have seen improvements in access to and utilization of sexual and reproductive health (SRH) services, progress in many countries has been slow and – after decades of investments – disappointing Social activists and health analysts have highlighted the potential role... 1997 Rwanda 2000 300 250 200 150 100 50 0 Average number of births among adolescents per 1000 adolescent girls Source: Calculations by Gwatkins et al.15 6 Wealthiest quintile Informing future research and programme implementation Recent efforts to identify and address the social determinants of health challenge the notion that disparities in service utilization and health outcomes are unavoidable and. .. macro-level influences, Informing future research and programme implementation including national investments in human development, as well as factors at the individual and household level that influence utilization of sexual and reproductive health services This first chapter emphasizes the difficulty in describing the nature and direction of the influence that poverty exerts on sexual and reproductive health... health services which respond to their needs, and promoting voucher systems which allow individuals greater choice in seeking care to develop tools and methods for measuring the impact of innovative approaches on improving the sexual and reproductive health of the vulnerable 10 Informing future research and programme implementation References 1 Kindig D Understanding population health terminology The Milbank... right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive rights” (emphasis added).1 As human-services workers on the front line in clinics and hospitals, health providers possess the very information and means that can enable... or delayed Informing future research and programme implementation care-seeking because of stigmatizing behaviours and rude remarks from providers.61 Adolescents in developing countries often report avoiding clinics because they fear being scolded or humiliated by hostile and moralistic providers who want to discourage them from being sexually active.45, 62-65 Researchers in northern Thailand found that... assess how these attitudes and practices affect access to and use of sexual and reproductive health services, particularly by adolescents and women of low socioeconomic status; ●● seek explanations for the perpetuation of practices that inhibit health and rights, and describe promising strategies for addressing them; and ●● suggest where further research would be valuable and provide recommendations... provider practices and facility readiness.19-21 Informing future research and programme implementation The Bruce framework has six “fundamental elements”: choice of method, information given, technical competence, interpersonal relations, continuity of care, and appropriate constellation of services.2 However, as several analysts have noted, the framework is not empirically grounded and may not reflect... measuring programme success At the national and international levels, work is currently under way to define and develop standards of “equity” Advocates and practitioners of sexual and reproductive health must engage in these discussions to ensure that sexual and reproductive health and its determinants are considered in the development of conceptual models, development of interventions, and measurement... which inhibit access to and use of safe and effective health services A primary concern of public health programmes is the existence of disparities in access to and utilization of health services and information Data from population-based surveys document that women from the poorest households are less likely to use preventive and curative sexual and reproductive health services and products than women . sexual and reproductive health Informing future research and programme implementation Social determinants of sexual and reproductive health Informing future. Determinants and the Department of Reproductive Health and Research provided nancial support for this work. v Informing future research and programme implementation Abbreviations