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Draft Position Paper (version 22 April 2009)
A central role for Primary Care in Sexual and Reproductive Health in Europe
Introduction
Sexual and reproductive health (SRH) are relatively new concepts, particularly in Europe. The concepts were introduced and promoted during and after the International Conference on Population and Development (ICPD) in Cairo, 1994. At ICPD a 20 years Programme of Action (ICPD/PoA)[1] was adopted by the vast majority of world countries. The promotion of sexual health and reproductive health are core themes in this PoA. Because there is widespread international consensus for a “rights-based approach” to sexual and reproductive health, the acronym “SRHR” is currently very often used, in which the last “R” means “Rights”.
The emergence and subsequent prominence of the SRH or SRHR in international health debates and policies has everything to do with a strongly felt need to deal with health issues that are directly related to sexuality, pregnancy and childbearing in a comprehensive and integrated manner, particularly from the point of view of the health care consumer. For example, a 16 years old girl who has just had an unanticipated and unprotected intercourse is strongly in need of a health service that is easily accessible, that understands, and that can instantly respond to her variety of concerns. She doesn’t want to pushed through a complex system of various providers that council her, perform a pregnancy test, take blood samples for testing various possible STI infections, including even HIV, ask her who her partner was for reasons of STI contact tracing, advise her on what to do in case of pregnancy, prescribe emergence contraception, or be referred to an abortion provider. However, because of high levels of specialisation, in practice she may have to attend different specialists in different kinds of health care facilities, that may in fact initially discourage her to seek help anyway. Or, another example, a couple with two children that doesn’t want to have more may consider to prolong use of a reversible method of contraception, but may also look at the option of sterilisation. Ideally, they may want to be informed about the implications of the different options by one health care provider, and not discuss continuation of pill use with their family doctor, attend a gynaecologist for information about female sterilisation and visit a urologist to discuss the male sterilisation option. There are many real life examples like these. They all have two things in common: lack of quality of care from a consumer perspective and unnecessary high cost. Optimal integration of various SRH components in primary health care is in many cases a realistic possibility for improving the functioning of the health care system in this particular field. This paper explores some of those possibilities.
It is interesting to note that, on the European level, it has never been seriously attempted to answer the question how SRH services can be organised in a satisfactory way. Even the question that comes before this one has never been addressed: how are SRH services organised in different European countries? Probably there are several reasons for this lack of interest. First, SRH has hardly been looked at as one interrelated field of health care, although the European Office of WHO published an integrated regional strategy on SRH in 2001[2]. Secondly, it seems like the ICPD PoA has in Europe been largely perceived as an agenda for action for developing countries, and not for the rich European countries with their highly developed health care systems. Thirdly, there has not been much interest in cross-European comparative health systems analyses anyway. Still, such analyses could provide very useful insights in the relative quality, effectiveness and impact of different health care arrangements, from which countries could learn from each other.
Purpose and development of this position paper
This paper intends first of all to stimulate discussion, particularly in the field of Primary Care, on what should be important criteria for quality of SRH service delivery. It tries to do this by creating awareness of the very different ways of organising SRH service delivery across Europe. Secondly, it intends to make a strong plea for an integrated approach to SRH services, in which elements that do not require highly specialised (hospital) care are combined and are made easily accessible, which means in practice integrating those elements in primary care. And finally, it focuses attention on the need for a coordinating role of primary care where care is concerned that does require more specialised interventions.
The paper does not intend to provide a full comprehensive overview of SRH in the different European health care systems.
For this paper, a small research has been implemented among health professionals in various European countries that are knowledgeable on the way SRH services are organised in their respective countries. A special questionnaire has been developed that asks about rules, regulations and practices on four core aspects of SRH:
- Family Planning and contraceptive use
- Some aspects of pregnancy and delivery
- Sexually Transmitted Infections (STIs)
- Special SRH services for young people
… respondents in … countries have filled in this questionnaire. The results give a good impression of various ways SRH services are organised across Europe. An overview article of the first phase of the research has been published in the WHO European Region magazine “Entre Nous”[3]. Those, and additional results have been integrated in this paper.
A small working group was subsequently formed, consisting of health professionals that had specific knowledge of the ways SRH services were organised in their respective countries. They provided input and feedback on earlier drafts of this paper, and several of them participated in EFPC workshops on this paper in May and September 2009 in Cyprus and in Romania, where the final text was approved by the members of the working group.
Clarifying the concepts of Sexual and Reproductive Health
As mentioned before, the term “Reproductive Health” was defined at ICPD, Cairo 1994, as follows[4]:
"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 right of men and women to be informed and to 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 safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant."
This definition has become universally accepted. It stresses a positive approach by not limiting it absence of disease or infirmity, the term refers to a multi-disciplinary field, and it incorporates a rights-based approach. Furthermore, it includes, in the second part of the definition, three main areas:
- Sexual Health (satisfying and safe sex life),
- Family Planning (knowledge of and access to contraceptives, as well as treatment of infertility), and
- Mother and Child Health; nowadays often referred to as “Safe Motherhood” (safe childbirth and healthy infants)
In a more hidden way the issue of abortion is also addressed, where mention is made of
“other methods of their choice for regulation of fertility which are not against the law”. The reason for this has been that at ICPD there was quite heavy opposition, mostly from developing countries and the US, against treating abortion as a family planning method. However, in Europe abortion is mostly legal, with the notable exceptions of Ireland, Poland and Malta.
Although “sexual health” is, in this definition, and integral part of reproductive health, there is a strong tendency to add it as a separate issue, and thus refer to “sexual and reproductive health. The main reason for this is that sexual health gets easily lost, being a much more controversial issue, which is very difficult to address in various countries or cultures. For the same reason, sexual health has proved to be concept that is very difficult to reach international consensus on. The World Health Organisation has made serious attempts to reach such a consensus, but without a final result yet. In the meantime, the “suggested definition” of WHO is widely used, which reads as:
“Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.”[5]
Like reproductive health, sexual health is defined here in a positive manner; i.e. “positive and respectful approach” and “pleasurable and safe sexual experiences”. It also stresses multi-disciplinarity, and apart from medical safety, it focuses attention on being “free of coercion, discrimination and violence”.
In actual use, the term is often narrowed down to just “safe sex” or “being protected against HIV infection”. Here, the term is used in its official, more comprehensive meaning, including both positive aspects and potential health threats, where the potential threats are not only physical, but also social and interactive in character.
It should be stressed that sexual and reproductive health do not primarily refer to disease or illness. For that reason, the needed “interventions”, if that would be the right term to use, are not primarily diagnosis and treatment, but instead providing information and education, counselling and advice. Very often SRH deals with prevention.
[It could be decided to include here a bullet point listing of issues that come under the denominator of sexual and reproductive health. The question is whether this is useful or needed. If so, which issues should be mentioned here?]
[Also, some comparative epidemiological data could be included here, similar, but updated from those mentioned in the WHO SRH Strategy 2001; these are:
. Maternal mortality
. Perinatal and neonatal mortality
. Induced abortion
. Contraceptive prevalence
. Birth rate < 20 years
. STIs
. HIV/AIDS
. Cervical cancer
. Infertility
. Other?
To be decided on]
Rationales for a primary care approach to SRH
There are several reasons why PC should play a prominent role in the field of SRH, given the circumstance that many of the interventions, or better: “activities”, needed in this field are primarily in the sphere of passing and sharing of information, counselling, advice, and in some cases prescription of preventive devices or drugs (such as condoms or oral contraceptives). It is true that there is also a need for rather or highly specialised interventions (like for example infertility diagnosis and treatment, caesarian section, etc.), but in those more specialised cases PC could even play a useful role in informing and preparing patients.
Important rationales for a strong PC role in SRH are:
Accessibility. PC is community based, low barrier, usually low price, confidential, and ideally permanently available. Therefore, if SRH is largely integrated in PC, it guarantees easy accessibility.
Continuity of care. PC is in a good position to guarantee continuity in SRH care, because usually patients stay with their PC provider for longer periods of time, and have regular contacts for various reasons. The PC provider “knows” his or her patients. In cases where higher specialised services are needed, PC can properly refer patients and they can be referred back for check-up or follow-up.
Comprehensiveness. Although PC providers cannot offer all services in the field of SRH, for example contraceptive sterilisation or certain STI treatments, in principle they are in a position to give information on all available services. Therefore PC should have an important role in informing and counselling SRH patients on various medication and treatment options.
Integration. Again, because SRH aspects are often interrelated, it is important that one service provider is able to handle these different aspects in one consultation. A classical example is STI prevention and prevention of unwanted pregnancy. A client in need of STI diagnosis and treatment is very often also in need of protection against unwanted pregnancy. A specialised STI clinic is not likely to discuss and handle both needs, whereas a PC provider usually is.
Social-medical approach. PC providers are usually trained to take social and psychological aspects of SRH requests into account, and not to over-emphasise technical medical aspects unnecessarily. They usually apply a client-centred instead of a disease-centred approach. This is particularly important in the sensitive area of sexuality related questions or problems, where social, psychological and cultural aspects are often as important as physical ones. PC workers are usually better trained to meet these particular needs than medical specialists.
Promotion and prevention orientation. Because several SRH issues are (sexual) behaviour related, people need to gain control over their behaviour. In other words, there is a need for a health promotion and disease prevention approach, for which PC workers are better equipped than medical specialists.
Coordination. It is important that there is an institution or service provider that coordinates service provision in SRH, because the different elements of SRH are often closely related. For example, women who undergo an abortion in a clinic should subsequently be offered contraceptive services. If these women are counselled and referred to a clinic by their PC provider, there are good guarantees for contraceptive follow-up and continuation by the same PC provider.
In summary, in principle PC is in the best position to provide basic high quality and effective SRH services, and where more specialised interventions are needed PC can play an important role in counselling on different treatment options, coordinating different interventions, providing for follow-up or check-up, and guaranteeing continuity of care.
However, what is the reality in Europe?
Development of SRH service delivery in Europe
In western Europe, the concepts of sexual and reproductive health were initially only used by NGOs that had been working in the fields like family planning, promotion of sexuality education, and advocacy for safe and legal abortion services. These NGOs, often called “family planning associations” (FPAs), had developed particularly during the first half of the 20th century, and they had filled a gap in an era when family planning was hardly acceptable, and when everything related to sexuality (including abortion) was taboo. As a result, mainstream medical care was largely unwilling at the time to step in, and thus these “family planning clinics” developed as a separate “vertical” structure at the edge of health systems. Many of those later collaborated under the guidance of the International Planned Parenthood Federation (IPPF)[6].
During the last two or three decades of the 20th century, after family planning had become acceptable and most of the taboos surrounding sexuality had been lifted, there has been a tendency in most western European countries to integrate what is nowadays called SRH service delivery in mainstream medical care. As a result of this, the old family planning NGOs became more or less redundant, particularly as service delivery institutions. In reaction, most of them started concentrating on public education and advocacy for sexual and reproductive rights. Some of them also focused on adolescent SRH service delivery, because adolescents often faced access problems to mainstream SRH services. However, the ways in which SRH was integrated in mainstream medical care has been very different across western Europe. In some countries, like the UK and the Netherlands, family doctors became primarily responsible for SRH. In some others, like Sweden and Portugal, more or less specialised SRH centres themselves became integrated elements of the health system, sometimes adding new services to their packages. In still others, like Germany, independent gynaecologists integrated most SRH services in their practices.
The result of these, largely unplanned developments has been the current wide variety of SRH care arrangements across Europe. One of the consequences of this gradual development has been that in most cases SRH is hardly or not at all an organisational principle in mainstream medical care. Bits and pieces of SRH care are more or less loose and haphazard elements in various medical practices and institutions. Similarly, SRH as such is not a subject in medical training in universities and medical schools; there are no SRH departments in hospitals or clinics, and neither are there SRH university professors or SRH sub-faculties.