Irish Medical News – October 23 2009
By Priscilla Lynch
In the latest article in the Whatever happened? series, where we examine high profile health-related projects, reports and schemes which have stalled or been abandoned in recent years, Priscilla Lynch examines our long running failure to produce a national sexual health strategy.
Sexual health encompasses not just the absence of disease and infections, but also well-being, the ability to control fertility and to have children, and the ability to enjoy fulfilling relationships free from discrimination.
Ireland’s sexual health services lag well behind many of our European neighbours when it comes to education, prevention, accessible and prompt treatment and aftercare in the area of sexual health. While there are a number of hospital-based sexual health services, most notably based in Dublin, and GPs carry out a lot of the day-to-day sexual health-related services, there is no comprehensive, joined-up sexual health service.
Waiting lists for public sexually transmitted disease (STI) testing in the relevant hospitals are long and there is much criticism over public access to emergency contraception, in comparison to the comprehensive and crucially, free sexual health services available through the NHS in the UK, while the private sector in Ireland including entrepreneurial GPs, the Irish Family Planning Association (IFPA) and the Dublin Well Woman centres offer accessible, fast, discreet STI testing, weekend access to emergency contraception as well as family planning services, at a price, despite their efforts to increase public patient access.
STIs are a major global cause of acute illness, infertility, long-term disability and death, according to the World Health Organisation (WHO), and perhaps one of the biggest drivers for a national sexual health strategy in Ireland is the huge rise in STI rates in the past decade.
Earlier this year, the HSE admitted it was concerned at the resurgence of syphilis during the 2007-08 reporting period. In 2001-02, there was a major outbreak of syphilis in Dublin, which mostly affected men who have sex with men (MSM). The outbreak was contained and the numbers decreased between 2003-06. However, since 2007, there has been an increase in new cases of early syphilis. In 2008 alone, there was 96 new cases of early syphilis reported.
Another concern is the increase in diagnosed cases of chlamydia, which is the most common STI notified to public health departments in Ireland.
In 2008, there were 1,855 new cases diagnosed in the HSE East region alone – an increase of 35 per cent on 2007 figures. WHO figures reveal that Ireland’s chlamydia rates have exploded in the last decade, rising from 17.41 cases per 100,000 in 1998 to 86.35 cases per 100,000 in 2007.
Broken promises
Despite the aforementioned concerns, Ireland does not have a national health sexual health strategy. There have been many recommendations for a national sexual health strategy and many subsequent promises by the HSE and the Department of Health over the years, and the creation of such a strategy is included in the Programme for Government.
The 2001 National Health Strategy- Quality and Fairness stated that “measures will be taken to promote sexual health and safer sexual practice” and that “an action plan for sexual health will be developed”.
The Report of the National AIDS Strategy Committee (2000) recommended that HIV/AIDS should be dealt with in the wider context of sexual health and other STIs, and the 2001 Get-Connected Report for adolescent health recommended that a sexual health strategy be developed in each of the health boards. Since then, a number of the former health boards produced or developed their own plans
To be fair to the HSE, there have been a number of sexual health documents for various areas and minority groups published over the years, the best example of which would be the HSE’s Sexual Health Strategy for the Eastern Region, published in May 2005, after four years of detailed work.
The Strategy was devised by a working group consisting of a wide range of prominent sexual health stakeholders and included representatives from the HSE Population Health, the ICGP and the IFPA, and the Strategy document covered the areas of service delivery, access, education and prevention.
Amongst its key recommendations were that sexual health services should be based more in primary care, which could provide general medical care, screening and referral, education, advice, information and support in the area of sexual health, with formal links to hospital-based services. The Report said publicly-funded services should be provided in more satellite locations, and some out-of-hours services should be encouraged, especially for emergency contraception.
The Strategy was broadly welcomed and it was hoped it would provide a template for a national strategy; however, its key recommendations were never rolled out or translated nationally.
The HSE has claimed various times during the last few years that work was being undertaken on a national strategy. In September 2006, IMN reported that the HSE was to prepare a sexual health strategy amid renewed concern over the spread of STIs in Ireland and as the ICGP planned to develop a sexual health course in 2007.
“This strategy is currently being scoped and a position paper on the topic has been prepared. A project group will be established in the next few weeks,” the Executive told IMN in a statement in September 2006, maintaining that its Population Health Directorate was committed to developing the strategy.
The Executive said the strategy would include input from all relevant stakeholders and cover all aspects of sexual health including health promotion; prevention and surveillance of STIs; education; provision of contraceptive services; and provision of resources.
Current situation
Unfortunately, Ireland still has no national sexual health strategy and there appears to be no hurry to create one, despite the commitment in the Programme for Government and the various recommendations and indications from the HSE in recent years.
Last week, when asked about the status of the strategy by IMN, the HSE merely said its development was the responsibility of the Department of Health and that the Executive “supports the Department in developing and implementing strategy”.
“The HSE will work with the Department if and when a decision is made to develop a National Sexual Health Strategy and currently delivers sexual health services within available resources”, a HSE spokesperson told IMN, pointing to the publication of reports including the Action Plan for the Prevention of HIV and AIDS 2008, and the Irish Survey of Sexual Health and Relationships (2006).
This is a considerable U-turn from its statement in 2006, where the Executive said it was actively working on developing the strategy.
Furthermore, the Department last week said the funding and development of health awareness campaigns is the responsibility of the HSE. The Department also confirmed to IMN that developing the strategy was not a current priority, saying it has to be considered against existing and competing priorities in the Department.
Despite this, key stakeholders have not given up hope and called on the HSE and the Department to deliver a strategy as soon as possible.
“A national sexual health strategy is something we really need, and it’s something we call for every year,” commented Well Woman Chief Executive Ms Alison Begas, emphasising that every barrier to sexual health services needs to be removed, giving the example of the difficulty in accessing emergency contraception and sexual health screening services at weekends.
Dr Caitriona Henchion, Medical Director of the IFPA, said it was “very obvious” Ireland needed a sexual health strategy, pointing out that sexual health was currently delivered by a number of different agencies and services, with many aspects being ad hoc and inequitable, as well as the general public having little awareness of STI risks and subsequently the availability of STI services.
She maintained that the creation of the strategy should not be seen as a budget issue, given that existing services are just not connected and emphasised that a strategy would be very beneficial and cost effective as a significant part of any strategy would have to be about prevention. She pointed out that in the US, for every dollar spent on prevention under sexual health, $2.65 dollars was saved, something the HSE should note.