Venkatraman Chandra-Mouli*; Olivia Lawe-Davies; Bruce Dick
Department of Child and Adolescent Health and Development, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland
The rationale for strengthening linkages between sexual and reproductive health and HIV programmes is well recognized,1 and benefits that have accrued from these linkages have been discussed in the November 2009 issue of the Bulletin of the World Health Organization and elsewhere.2,3 However, real progress in scaling up such approaches has been modest and slow to materialize.
The Department of Child and Adolescent Health and Development at the World Health Organization is supporting national sexual and reproductive health and HIV programmes to work together to better respond to the needs of adolescents, focusing on the following four key areas: (i) gathering, analysing and using strategic information from an adolescent perspective; (ii) developing supportive policies and strategies based on strategic information and sound evidence; (iii) scaling up the provision of health services and commodities; and (iv) engaging and strengthening other sectors.
A lack of accurate, up-to-date, age-disaggregated data on sexual and reproductive health and HIV/AIDS hinders well-informed policy and strategy development. We are supporting countries to analyse existing data from an adolescent perspective to advocate for coordinated attention to sexual and reproductive health and HIV/AIDS in this age group.4
While national sexual and reproductive health and HIV strategy documents generally contain statements about the need for collaboration, they provide little practical guidance on how this can be done. We are helping countries use national sexual and reproductive health and HIV programme reviews and sub-national strategy development exercises to identify opportunities for collaboration on a limited number of clearly defined issues of shared interest.
In Ethiopia, we supported the Ministry of Health in reviewing the national adolescent reproductive health strategy. As a result, tools have been developed to implement and monitor the provision of health services to adolescents that include both HIV and sexual and reproductive health (V Chandra-Mouli, N Kampatibe, unpublished report, 2008).
Adolescents face many barriers in accessing services to prevent HIV and unwanted pregnancy. Although national sexual and reproductive health and HIV programmes in most countries recognize the need to provide such services, concerted action is often hindered by a lack of clear understanding on how to reach adolescents with the information and services they need. There is often also discomfort about providing adolescents with such services. We are working with ministries of health to bring together national sexual and reproductive health and HIV programmes to define the package of health services, the standards of quality for service provision, criteria to achieve them, indicators to verify their achievement and actions required for scale-up in a phased manner.
In India, we supported the development of national standards and guidelines as part of the adolescent reproductive and sexual health component of the Reproductive and Child Health Project, with the full involvement of officials from the National AIDS Control Progamme.5 These standards and guidelines were introduced to all states' programme managers, and we supported field testing and demonstrations of their feasibility and utility in two states. Subsequently, a stock-taking report was shared at a national meeting of state Reproductive and Child Health programme managers and a plan developed for scaling up the initiative. (R Mehta, N Dawa, G Mehl, unpublished report, 2008).
Other sectors, such as education, social welfare and youth, have important contributions to make that complement the health sector's response to sexual and reproductive health and HIV. Unfortunately there are both missed opportunities and needless duplication in the work of different sectors. We are therefore supporting ministries of health to work with other sectors on specific activities that contribute to the twin goals of preventing HIV, sexually transmitted infections and pregnancy in adolescents.
In Bangladesh, a collaborative project, involving the national AIDS/sexually transmitted diseases programme, the Ministry of Health and Family Welfare and Save the Children USA, is drawing on the support of influential community members, including religious leaders, to provide young people with information and services on HIV and sexual and reproductive health.6
Heads of national sexual and reproductive health and HIV programmes are understandably focused on ensuring that their programmes deliver results, and are reluctant to do things that might distract from what they see as their primary purposes. These real and valid interests and concerns need to be taken into account for collaboration to succeed.
Supporting the collaboration of national sexual and reproductive health and HIV programmes on a limited number of strategic areas has resulted in winwin benefits both for programmes and for adolescents. With limited resources and a commitment to providing ongoing technical support, our focus has been on helping to link previously-unlinked processes and to strengthen them to produce results for the benefit of all stakeholders.
1. SRH and HIV/AIDS: a framework for priority linkages. Geneva/New York, NY/London: World Health Organization & Joint United Nations Programme on HIV/AIDS/United Nations Population Fund/International Planned Parenthood Federation; 2005.
2. Dickinson C, Attawell K, Druce N. Progress on scaling up integrated services for sexual and reproductive health and HIV. Bull World Health Organ 2009;87:846-51. doi:10.2471/BLT.08.059279
3. SRH and HIV linkages: evidence review and recommendations. Geneva/New York, NY/London/San Francisco, CA: World Health Organization & Joint United Nations Programme on HIV/AIDS/United Nations Population Fund/International Planned Parenthood Federation/University of California; 2008.
4. The future is in our hands: Tanzanian youth, RH and HIV. [Data from the 2004-05 Demographic and Health Survey (TDHS) and the 2003 Tanzania AIDS Indicator Survey (THIS)]. Research Triangle Park, NC/Dar es Salaam/Washington, DC: Family Health International/Ministry of Health and Social Welfare, Tanzania/USAID. Undated.
5. Implementation guide on RCH-2 ARS strategy for state and district programme managers. New Delhi: Ministry of Health and Family Welfare; 2006.
6. National standards for youth friendly health services. Dhaka/Westport, CT: Ministry of Health and Family Welfare, Bangladesh/Save the Children USA; 2007.