The Chief Guest Hon. Maithreepala Sirisena Minister of Health, Guests of Honour Dr. Quazi Monirul Islam, Director of Family Health and Research of WHO – SEARO and Emeritus Professor M. Sivasuriya Chancellor of the University of Jaffna, Prof. A B Bhuiyan Immediate Past President SAFOG, Prof Wilfred Perera Patron of SLCOG, Dr.Ananda Rantunga President of SLCOG, Past presidents of SAFOG and SLCOG, Councils of SAFOG and SLCOG, Members and Fellows of SLCOG, Visitors from overseas, Distinguished Guests, I am deeply touched and honoured by the trust the Council of SAFOG has placed on me by selecting me as the 8th President of the South Asia Federation of Obstetrics and Gynaecology for the term 2011 to 2013. I am totally aware of the responsibilities involved and extend my heartfelt thanks to the Council of the SLCOG for the confidence placed in me by nominating me to this office.
The South Asia Federation of Obstetrics and Gynaecology resulted from an idea that was generated in Colombo in 1996. Initially the federation consisted of the member national societies from five countries Bangladesh, India, Nepal, Pakistan and Sri Lanka. With the last council it has been decided to explore the possibility of incorporating Afghanistan, Bhutan, Maldives and Myanmar as they have close national links to the present members of the federation. While SAFOG has consolidated its intra – regional links amongst the five original countries it has also been effective in establishing links with the other professional organizations such as the Asia and Oceania Federation of Obstetrics and Gynaecology (AOFOG), the International Federation of Obstetrics and Gynaecology (FIGO) and the Royal College of Obstetrics and Gynaecology (RCOG). It has also interacted effectively with the UN agencies the WHO – SEARO, UNICEF and UNFPA in enhancing Reproductive Health Care (RH care) in South Asia in general and reaching the Millennium Development Goals 4 and 5 in particular. All three agencies are active partners in the present conference as well.
The leadership provided by the past presidents ensured that SAFOG would progress steadily to what it is today. The first three presidents of the Federation Prof. Rashid Latif Kahn, Prof T A Choudhury and The late Dr. Lakshman Fernanado ensured that the SAFOG concept would be established and the member national societies would get familiarised with each other and interact professionally. The tenure of Dr. D K Tank saw the initiation of advocacy with government and a path developed for partnership between the national societies and the state organization particularly in India.] The presidency of Dr. Sudha Sharma saw a serious attempt being made to develop an effective network between the federation, the UN agencies and other stake holders involved in provision for the health of the mother and new born. This process continued during tenure of Prof Farouk Zaman. During the presidency of Prof. A B Bhuiyan the SAFOG Journal and the web site have been established mainly due to the efforts of Dr. Narendra Malhothra.
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Following such achievements what of the future of SAFOG? In this context it is relevant to consider what the "Mission" of SAFOG would be. The mission statement could be "to see South Asia achieving the status of the region with the highest standard of Reproductive Health". Yes, the target is a difficult one to reach and is as high as Mount Everest. I am hopeful that this conference which is organized with the theme "New Horizons for Reproductive Health in South Asia" will be the start for such an achievement. The mission of SAFOG to ensure that this vision becomes a reality is "to commission the strengths of the national societies so as to work with commitment, dedication and wisdom to provide the professional inputs required to enhance Reproductive Health Care needed by the people of their individual countries and to overcome the barriers which affect the implementation of such provision of care and to support the human resources and expertise needed by other member countries in achieving the vision of SAFOG".
At the very outset it is necessary to review what is meant by "Reproductive Health". It is most convenient to look at it in terms of the "Life time events". Life begins as a foetus during intrauterine life and then progresses through infancy, childhood to reach adolescence. The biological changes of adolescence involve menarche in the female, andrarche in the male and puberty in both. The reproductive phase of life follows and the female could go through the pregnant and non – pregnant states. The reproductive phase of life declines leading to the climacteric in the female which is indicated by the menopause. In the male a more prolonged transition occurs into the andropause. The age of 60 is considered as the commencement of the elderly period of life which culminates in death.
Accordingly Reproductive Health services have been organized to cover the needs of each phase of life. These are services for the adolescents, Maternal and Child Health (MCH), Family Planning services (FP), services for genital tract infections including STDs / HIV – Aids, management of reproductive tract neoplasms and Care during post reproductive life. In recent times it has been necessary to provide for victims of gender based violence and the rapidly enlarging area of nutrition during all phases of life. When the concept of Reproductive Health was first introduced it encompassed two basic phenomena. Firstly it was the intention to have services for the different components of the life cycle of events integrated horizontally; this process needs to be revived once again. The second issue in reproductive health services is that involvement of and services for the male need to be considered as well. Further it is of note that satisfactory completion of one phase of life ensures good progress in the next. The health services in Sri Lanka operates in such a continuum where the government is responsible for providing care to all its citizens from birth to death without a fee. In all countries of the region the fee- levying private care services are available and have to be accounted for.
The development of the RH care services historically in Sri Lanka and elsewhere has been the integration and interaction of health and non – health interventions. Health interventions include human resource development, health infrastructure enhancement etc. while educational, social and economic development constitute non – health interventions. Population control and family planning services would then fit into both. Maternal and child health is the most quantifiable and accepted outcome measure amongst all components of Reproductive Health. The millennium development goals 4 and 5 (MDGs 4 & 5) offer all countries with targets to achieve in improving the RH status of their people. It is relevant to note the status of the MDGs in the different countries in South Asia.
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The first Meeting of South Asia Regional Network on Maternal and Neonatal Morbidity / Mortality Reduction held from 26th – 27th January 2006 at Kathmandu, Nepal under the Presidency of Prof. Sudha Sharma provided an opportunity to review the status achievements of the MDGs 4 & 5 in the SAFOG countries. The objectives of the meeting were stated as follows:
1. To create a common understanding among all the stake holders on the issues related to maternal and newborn health.
2. To clarify the role of the partners and of the network itself in the context of other similar and global networks.
3. To build a consensus on the way forward for improving maternal and newborn health in the South Asian context.
These objectives indeed provided a mechanism to establish future unified actions for improving the status of RH care for the people of South Asia. The data from the meetings of the network serve as indicators of success towards achieving the MDGs 4 & 5. All countries except Bangladesh and Sri Lanka have fallen short on their march towards achieving reductions in the Maternal Mortality Rate (MMR). Sri Lanka's reduction in the MMR is commendable. It is an island with a manageable educated population, a devolved political framework and a reasonable income level of its people. It provides education and health services without a user fee to its people with only minimal foreign assistance. Can Sri Lanka continue to provide such a facility?
Both Sri Lanka and India have data which indicate a lack of countrywide uniformity in the level of MMR. A similar status has been demonstrated in the status of the Neonatal Mortality Rates of India. Nepal and Pakistan have also shown data to highlight the lack of skilled birth attendance and the high rate of home deliveries. An additional unexpected issue noted repeatedly in the Demographic and Health Surveys in Sri Lanka (2000, 2006) is that the highest non users of any form of contraception are the highest educated in the country. This brings the family planning promotional messages to the public under scrutiny as there appears to be a serious lapse in their relevance in alleviating the fears of side effects of contraceptives and brining the non-contraceptive benefits to the fore front.
What is then the role of SAFOG and professional societies in Maternal and Newborn Health? In addressing the 2nd Network meeting to Reduce Maternal and Newborn Morbidity and Mortality in South Asia by consultation between Professional Societies and UN Agencies on 29th March 2008 in Kathmandu, Nepal, Prof A B Bhuiyan the then President Elect of SAFOG stated the high level of trust placed on professional societies by the public and governments. While stating that governments, policy makers and UN agencies should consult and involve professional societies in all aspects of developing policy and implementing health care he emphasised that the professional societies have obligations towards the people of their countries as the public has high expectations from them. The future tasks for SAFOG have to be looked at within the above context.
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SAFOG could focus on four (4) areas of activity in the future:
1. Advocacy with governments, policy makers and public on Reproductive Health
2. Human resource development for RH.
3. Enhance basic, clinical and operational research.
4. Corporate capacity building of member national societies
The advocacy role of SAFOG and member national societies would be to act as a mediator / promoter of interactions between stakeholders as actor / driver or recipient / target in the provision of RH care. The principles and protocols provided by the ICPD at 10 Advocacy Tool Kit provides the necessary guidance to all national societies for this purpose.
Human resource development for RH care in South Asia has many facets. In the first instance calculation of the number of staff of all grades can be made according to WHO criteria, requirements for EmOC etc. Such a calculation performed in Sri Lanka in 2007 projected for 2015 helped to calculate the training requirements to staff the CEmOC units and their distribution throughout the country. In a recent publication "Tracking progress towards safe motherhood: meeting the benchmark yet missing the goal? An appeal for better use of health-system output indicators with evidence from Zambia and Sri Lanka" in Tropical Medicine and International Health, Sabine Gabrysch, Philipp Zanger, Harshalal R. Seneviratne, Reuben Mbewe and Oona M. R. Campbell the benchmark systems of calculating staff requirements have been challenged.
In addition to adequacy in staff numbers quality assurance is mandatory for improvements in RH care in South Asia. At the 7th SAFOG Conference held in Dhaka, Bangladesh in March 2009 a pre-conference training workshop on the adoption of international guidelines was conducted where a panel of stakeholders would accept, modify, reject existing guideline statements and if necessary add new one based on local needs. This methodology would be an excellent and convenient way for SAFOG countries to enhance the quality of care provided in South Asia.
Task shifting especially in the provision of EmOC in the fields of Anaesthesia and Operative / Caesarean deliveries to alternative staff in relevant countries, even as a short term measure, is an issue that needs the urgent attention of SAFOG. The need for such a measure was emphasised by Prof. S. Tipu Sultan at the 2nd networking meeting when he stated that "It will take about 220 years to be self-sufficient in terms of anaesthesiologists at the present rate of production and disappearance (Export – loss)".
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The role of SAFOG national societies in the provision of care during natural disasters was clear by the role played by Society of Obstetricians and Gynaecologists of Pakistan and the Sri Lanka College of Obstetricians and Gynaecologists. Their experiences could be shared with the other societies whenever required.
Enhancing Reproductive Health Research is a task that SAFOG would look at in a focused manner. The present status of RH in South Asia provides ample opportunities for basic, clinical and operational research. The expertise and the will to do research are present amongst the members of the SAFOG national societies. It would be necessary to seek the support of the relevant agencies for the provision of financial and other resources. It would be the responsibility of SAFOG to seek the support of the profession, the governments, care providers and other stakeholders in getting research results into practice.
In Promoting Corporate Capacity Building of National Societies it is relevant to state the role of the profession. Dr. Tomris Turmen WHO (2000) states that "The Obstetrician and Gynaecologist must be a champion for all women's health, welfare and rights. It is time to move beyond the consulting room, beyond the hospital ward, to play a prominent part in the revitalization of the whole health system as a whole". Therefore what type of a professional association is needed or wanted ? At the 3rd meeting of the Network to Reduce Maternal Mortality and Morbidity in South Asia held in New Delhi, India from 6th – 8th June 2008, Dr. Harshad Sanghvi listed items to maximise the contribution of Professional Societies in reaching the challenges of MDGs 4 and 5 as:
1. Briefcase associations no more: Associations need to be organized in their functioning as a corporate body.
2. Committed and Concerned: Associations may be apprehensive about new role that will strain their essential voluntary status.
3. Coming together: Partnerships and multi-disciplinary teams can make the most compelling case when advocating and implementing an EMoC agenda.
Do our national societies and federations of societies possesses corporate capacity in terms of the ability to perform planned functions effectively, efficiently and sustainably so as to ensure the progress of the entity in its defined vision, mission and strategic goals / priorities ?
The Society of Obstetricians and Gynaecologists of Canada (2009) specifies that "In the modern context Societies / Federations require more than the acquisition of technical skills for individuals and would need to acquire the knowledge, skills and processors required to address the daily operational and strategic problems in a planned way so as to be accountable to its membership, the general public and the government". SAFOG needs to adopt such a concept and encourage its member national societies to follow these trends if the profession is to maintain its status as the leader in the provision of quality Reproductive Health Care in South Asia.
In conclusion I wish to quote that great statesman from India and South Asia, Pandit Shri Jawaharlal Nehru "Build your own house on your soil with your own ideas, but keep the windows of your mind open to the winds that blow from foreign shores".
"Sabbe saththa bhavanthu sukhithaththa" (May all beings be well and happy).
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