INVESTING IN OUR FUTURE A FRAMEWORK FOR ACCELERATING ACTION FOR THE SEXUAL AND REPRODUCTIVE HEALTH OF YOUNG PEOPLE
A Joint WHO /UNFPA /UNICEF Publication
WHO Library Cataloguing in Publication Data Investing in our future : a framework for accelerating action for the sexual and reproductive health of the young people. 1. Reproductive health. 2. Sexual health. 3. Adolescent. 4. Far East. 5. Pacific Islands. ISBN 92 9061 240 X (NLM Classification: WQ 200 )
© World Health Organization 2006 All rights reserved. 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 specific 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. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. 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 2476; fax: +41 22 791 4857; email: bookorders@who. int). Requests for permission to reproduce WHO publications, in part or in whole, or to translate them – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; Email: permissions@who.int). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, Fax. No. (632) 521-1036, Email: publications@wpro.who.int
Foreword
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his publication, Investing in Our Future: A Framework for Accelerating Action for the Sexual and Reproductive Health of Young People, was developed in response to World Health Assembly resolution WHA55.19, and furthers the commitment to working collaboratively first forged in 1989 by WHO, the United Nations Population Fund (UNFPA) and the United Nations Children’s Fund (UNICEF). The consultations to develop this framework involved collaboration between the WHO Western Pacific Regional Office in Manila, UNFPA Country Services Teams (CSTs) in Bangkok and Suva, and, the UNICEF East Asia and Pacific Regional Office in Bangkok. Inputs were also sought from international nongovernmental organizations, in-country government representatives, researchers and people living and working in countries serviced by these United Nations regional offices. The consultation process identified the practical components of comprehensive sexual and reproductive health programmes to target young people (10-24 year-olds), and strategies to accelerate programme success. The framework sets out the core components for young people’s sexual and reproductive health and renews the calls for action towards access, information and choice, made by United Nations agencies and other international and incountry agencies. It aims to give guidance to policy-makers and programme managers in fulfilling their obligation to provide for the health needs and protect the rights of young people, and to bring about a sustainable improvement in their sexual and reproductive health. It is hoped that this framework stimulates the review of existing efforts and promotes accelerated, sustained actions to improve the sexual and reproductive health of young people in Asia and the Pacific.
Shigeru Omi, MD, Ph.D. Regional Director WHO Western Pacific Region
Mr Sultan A. Aziz Director UNFPA Asia and the Pacific Division
Ms Anupama Rao Singh Regional Director UNICEF East Asia and the Pacific
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Acknowledgment
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cknowledgement is made to Dr Annette Robertson (UNFPA, Suva), Dr Peter Chen (UNPFA, Bangkok), Dr Stephen Atwood (UNICEF East Asia and Pacific Regional Office), Dr Pang Ruyan (WHO, Regional Office for the Western Pacific) and Dr Bernard Fabre-Teste (WHO, Regional Office for the Western Pacific) who were involved in all steps of the development of the “Framework for Accelerating Action for the Sexual and Reproductive Health of Young People”, and the accompanying “Policy and Planning Brief” including organizing the consultation meetings, drafting and revising the framework and the brief. Special thanks is given to Dr Bencha Yoddumnern-Attig (Mahidol University, Bangkok) for drafting the final draft and Dr Narimah Awin (Ministry of Health, Malaysia) for finalizing the framework. We also wish to thank the agencies, International Planned Parenthood Federation (IPPF), Japan International Cooperation Agency (JICA), Japanese Organization for International Cooperation in Family Planning (JOICFP), Program for Appropriate Technology in Health (PATH), and the Secretariat of the Pacific Community (SPC), for their valuable contribution in the development of the framework. Appreciation is also specially expressed for the governments of Cambodia, China, Japan, Malaysia, Mongolia, Vanuatu and Viet Nam for their involvement and contributions. The names of the contributors for the development of the framework are listed in Annex 1.
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Executive Summary
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n the East Asia and Pacific Region, young people make up a significant proportion of each country’s population. They are also major contributors to the labour force and thus form the backbone of each country’s economy. The ability of young people to contribute to a nation’s productivity and prosperity, however, depends to a great extent on how well they can avoid health risks, especially those associated with their sexual and reproductive health. Since the International Conference on Population and Development (ICPD) in 1994, many programmes, activities and research studies have been carried out in the Region to address the sexual and reproductive health needs of young people, and significant progress has been made in understanding those needs. However, major health threats persist, most notably: teenage pregnancy, often arising from the unmet need for contraception; sexually transmitted infections (STI), including HIV/AIDS; and sexual violence and exploitation. The benefits of combating those threats and promoting the sexual and reproductive health of young people are far-reaching. For instance, positive interventions can reduce the likelihood of teenage pregnancy and its social and economic costs. They can encourage couples to have the number of children they can afford, increase household savings and investment, and facilitate higher productivity. Delaying marriage and parenthood can allow for greater educational achievements and thus improve career and employment opportunities. The prevention and treatment of STI and HIV/AIDS also reduce social stigma and help young people remain healthy, enabling them to better care for and invest in their families, communities and countries. Consequently, one of the most important commitments a nation can make for future economic, social and political progress and stability is to address the sexual and reproductive health needs of its youth. It is a sound investment for the future. The framework presented in this document provides a set of concrete interventions or actions for policy-makers, programme managers and their partners to undertake in scaling up their responses to meet the sexual and reproductive health needs of young people. The framework has three major components that are based on the commonly accepted premise that, to practice lifestyles that lead to optimal sexual and reproductive health, young people need; (1) life-skills-based information and education; (2) access to reproductive health services that are receptive to them; and (3) a supportive and enabling environment. The importance of providing young people with accurate and up to date information about their sexual and reproductive health was endorsed at ICPD in 1994. However, although progress has been made since that time, there are still major concerns and shortcomings. The first component of the framework therefore highlights major strategies to effectively provide young people with life-skills information and education through in-school, out-ofschool (community, workplace) and media initiatives. The sexual and reproductive health of young people cannot be fully addressed without the support of health services, particularly those that are youth-friendly.
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The framework’s second component thus provides several recommended actions to improve the quality and accessibility of sexual and reproductive health services, especially in terms of improving the content of such services, their coverage and availability, their utilization and their sustainability. Many of the factors that adversely impact upon the sexual and reproductive health of young people stem from their immediate social environment, including: poverty and unemployment; restrictive social and gender norms; and the impact of social and economic changes. Hence, programmes to improve the sexual and reproductive health of young people must create an immediate social environment that fosters personal development and open communication to encourage young people to adopt healthy types of behaviour. The framework’s third component provides several recommended actions for creating a supportive and enabling environment where families, communities, the media and others can communicate positive norms and actions to promote healthy behaviour among young people and adults alike. To be successful and sustainable, actions within the three components noted above require the development, implementation and acceleration of several activities at all levels. The framework thus provides recommended actions for directing attention and resources to institutionalize, accelerate and scale up current and future programmes to improve the sexual and reproductive health of young people. These actions centre around seven cross-cutting strategies: securing political will; formulating and implementing policies and legislation; mobilizing resources to ensure sustainability; enhancing human capacitybuilding; establishing research, monitoring and evaluation mechanisms; forging partnerships; and applying lessons learnt.
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Contents Foreword Executive Summary Chapter One: Introduction The value of investing in young people Changing lives Lessons learnt Framework development Aims and users i iii 1 1 2 3 3 4 5 5 6 7 9 10 11 13 13 13 14 15 17 17 18 19 23 24 24 26 26 29
Chapter Two: Current Situation The sexual and reproductive health of young people Teenage pregnancy Unmet need for contraception among young people Sexually transmitted infections, HIV/AIDS and reproductive tract infections Sexual violence and exploitation Summary note
Chapter Three: A Framework for Accelerated Action Goal of the Framework Framework components Objectives and outcomes Summary note
Chapter Four: Promoting Healthy Behaviour through Life-SkillsBased Information and Education Issues and challenges Responses Recommended actions Summary note
Chapter Five: Ensuring Access to Reproductive Health Services for Young People Issues and Challenges Responses Recommended Actions Summary Note
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Chapter Six: Creating a Supportive and Enabling Environment Issues and challenges Responses Recommended actions Summary note
30 30 31 31 33 35 35 36 37 38 39 40 41 42 42 44
Chapter Seven: Accelerated Actions Issues and challenges Securing political will Formulating and implementing policies and legislation Mobilizing resources to ensure sustainability Building human resource capacity Establishing research, monitoring and evaluation mechanisms Forging partnerships for action Applying lessons learnt Summary note
Appendix: Characteristics of Adolescent-Friendly Health Services
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Acronyms AIDS BCC CEDAW CRC HIV ICPD IDU MDG NGO RTI STI UNFPA UNICEF WHA WHO Acquired immunodeficiency syndrome Behaviour-change communication Convention on the Elimination of All Forms of Discrimination Against Women (1979) Convention on the Rights of the Child (1990) Human Immunodeficiency Virus International Conference on Population and Development (1994) Injecting drug users Millennium Development Goals Nongovernmental organizations Reproductive tract infections Sexually transmitted infections United Nations Population Fund United Nations Children’s Fund World Health Assembly World Health Organization
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Map of East Asia and the Pacific Region
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chapter one
introduction The value of investing in young people
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he term “young people” includes girls and boys aged between 10 and 24 years, spanning the periods defined as adolescence (10 to 19 years) and youth (15 to 24 years). Young people make up a significant proportion of each country’s population and comprise about 20% of the world’s people.1 In countries within the East Asia and Pacific Region, where the diversity is enormous, the percentages range from 10.5% in Japan to over 30% in some Pacific island countries. In most, if not all countries in the East Asia and Pacific Region, young people are a significant part of the labour force and form the backbone of each country’s economy. The health of young people is thus a key element for social and economic progress. Neglecting the sexual and reproductive health of young people can lead to high social and economic costs, both immediately and in the years ahead. For example, it has been estimated that Thailand has lost an estimated 400 000 lives and over one million person-years from the labour force due to premature deaths from HIV/AIDS alone.2 Hence, the cost in human and economic terms is enormous. It is uncertain what the toll could be for other countries in the Region, but the threat is real, particularly in the face of youth unemployment and migration, which can contribute to HIV/AIDS transmission.3 The aim, therefore, is to maximize opportunities and minimize risks to facilitate growth and development. The benefits of sexual and reproductive health interventions on poverty reduction are far-reaching. For instance, improving the sexual and reproductive health of young people reduces the likelihood of teenage pregnancy and its social and economic costs. It also encourages couples and individuals to decide freely and responsibly the number, spacing and timing of their children. It enables higher household savings and investment, and facilitates higher productivity. Delayed marriage and well-timed parenthood allow for greater educational achievements and thus greater career and employment opportunities. The prevention and treatment of sexually transmitted infections (STI), including HIV/AIDS, also reduce social stigma and help young people remain healthy, so they are better able to care for and invest in their families and in their future. Healthy families can earn more and save more, spurring economic growth.4 One of the most important commitments a country can make for future economic, social, and political progress and stability, therefore, is to address the sexual and reproductive health needs of its young people. It is a sound investment for the future.
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The case for investing in young people as part of a national poverty reduction strategy. Reference notes on population and poverty reduction. Paper commissioned by UNFPA, New York, 2005. 2 UNAIDS Joint Plan of Action on HIV/AIDS in Thailand 2002-2006. Bangkok, UNAIDS, 2002. 3 Action for adolescent health. Towards a common agenda. Recommendations from a joint study WHO/UNFPA/UNICEF group. Geneva, World Health Organization, 1997. (WHO/FRH/ADH/97.9) 4 Adding it up: The benefits of investing in sexual and reproductive health care. A joint publication of the Alan Guttmacker Institute and UNFPA, New York, 2004.
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Changing lives As young people transition from childhood to adulthood, they undergo rapid physical and psychosocial changes. They gain new experiences, acquire new capacities and face many new situations and challenges. It is also a time of behavioural experimentation that shapes how they will live their future lives as men and women. Many types of behaviour that young people acquire early on during this process will last a lifetime, and will affect their own health and well-being and that of the nation’s future children. Unfortunately, this time of rapid development is also a time of great risk. Learning about sexuality and reproductive health is part of the larger development process as children become adults. During their development, young people are challenged to make many decisions and choices about their sexual and reproductive lives that can impact on their health and how they live within society. Some of those decisions can lead to an improved quality of life for the young people and their families. Others, however, can impede the achievement of their personal, social and economic goals significantly. Major sexual and reproductive health threats abound, such as unwanted pregnancies, especially among adolescents, STI and HIV/AIDS, and other related issues, such as sexual violence and exploitation. All of those threats, especially those related to teenage pregnancy, can have significant social and health impacts, including loss of educational and economic opportunities for young mothers and a high risk of mortality among infants. Threats arise when young people do not have adequate information and skills to make responsible, informed choices and take proper actions. Lack of knowledge and skills to avoid risky behaviour and lack of access to youthfriendly reproductive health information and services, along with environmental challenges related to poverty and unemployment, place young people in a position of greater vulnerability. They are also affected by the content of today’s advanced communication systems that disseminate or popularize inaccurate information, such as pornography over the Internet or violent movies. A strong need exists, therefore, to provide young people with proper information and youth-friendly health services to help them to understand their sexuality and development and to guide them in protecting themselves from significant sexual and reproductive health risks. In addition to adequate information and services that support young people to make good decisions on their own, threats to young people also require a strong response from society. Adults have a duty to protect the young and to address coercive sex, gender inequities, exploitative situations, trafficking and the like in a forceful manner. At the very least, young people need to know their rights and where to turn for assistance in times of need. Fortunately, young people are often receptive to new ideas; they are keen to make the most of their growing capacity for decision-making. It is a time when, given the opportunity, young people can channel their energies down positive and productive paths. At this early age, or even before, the opportunity exists to prevent the onset of health-damaging types of behaviour and their future consequences.
Lessons learnt Many initiatives aimed at supporting the sexual and reproductive health needs of young people have been implemented since the International Conference on Population and Development (ICPD),5 or even before. They include activities 5
International Conference on Population and Development. Cairo, 1994.
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to reach young people, both in and out of school, through various information and education approaches, as well as establishment of youth centres and clinics by both government and nongovernmental organizations (NGOs) and community-based organizations, as a means to undertake outreach activities. Early pilot initiatives have led to greater appreciation and extensive awareness of the needs of young people, and have taught us that programmes to improve their sexual and reproductive health must provide support and opportunities for young people to: • • • • • acquire accurate information; build skills for responsible decision-making, especially for those decisions dealing with risks and conflict; obtain counselling (preventive and supportive); access reproductive health services compassionate and youth-friendly; and, live in a safe and supportive environment. that are confidential,
Yet, despite what has been learnt, the challenge to provide for the sexual and reproductive health of young people continues, one that, if not met, can have a wide-ranging and potentially very serious impact on society and human development.
Framework development In view of the magnitude of young peoples’ sexual and reproductive health needs, current programmes need to be expanded and scaled up. Towards that end, this document, Investing in our future: A framework for accelerating action for the sexual and reproductive health of young people, was developed in response to World Health Assembly Resolution WHA55.19. The framework is also a concrete example of our commitment to working together, one that was forged early in 1989 by WHO, the United Nations Population Fund (UNFPA), and the United Nations Children’s Fund (UNICEF). That commitment was set forth in the joint document entitled The reproductive health of adolescents: a strategy for action and, in 1997, elaborated in the recommendations from a joint study group in the document Action for adolescent health: Towards a common agenda. The process of developing the framework presented in this document began in 2003, when financial and technical support was given to eight countries to conduct literature and project reviews on adolescent sexual and reproductive health. After that review process, governments and agencies recognized the urgent need to develop a regional strategy on adolescent sexual and reproductive health, which led to the development of a draft strategy. In January 2004, a consultative meeting was held to put together a draft framework for accelerating action to promote and improve the sexual and reproductive health of young people. Cosponsored by WHO, UNFPA and UNICEF, the meeting was attended by over 30 participants from countries, international organizations and NGOs in the Asia-Pacific Region. The participants reviewed critically and made major constructive revisions to the earlier draft strategy, which was then revised again into a draft framework for action. At a second consultative meeting, held from 27 June to 1 July 2005, a smaller working group reviewed and revised the draft framework in preparation for its finalization. Special attention was given at each consultative meeting to identifying the practical
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components of comprehensive sexual and reproductive health programmes to target young people, as well as strategies to accelerate programme success.
Aims and users This framework is intended to guide policy-makers and programme managers in scaling up responses to meet the sexual and reproductive health needs of young people in countries within the East Asia and the Pacific Region. It aims, especially, to give those stakeholders: • information on the sexual and reproductive health challenges currently facing young people, as well as the health, social and economic benefits that can arise from investing in addressing those challenges; the capacity to improve and sustain effective programmes to provide for the sexual and reproductive health needs of young people, especially those aimed at promoting healthy behaviour through lifeskills-based information and education, as well as those that aim to provide youth-friendly health services and quality care; the ability to create a supportive environment for young people that acknowledges their evolving capacity to develop positive lifetime behaviour and skills; and mechanisms for directing attention and resources to institutionalize, accelerate and scale up current and future programmes and activities in support of the sexual and reproductive health of young people.
•
•
•
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chapter two
current situation
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any programmes, activities and research studies have been carried out in the East Asia and Pacific Region to address the sexual and reproductive health of young people, and significant progress has been made in understanding their needs since the ICPD. This chapter describes the current situation and outlines the challenges that need to be addressed in order for us to fulfill our duty to protect and provide for young people’s rights to sexual and reproductive health.
The sexual and reproductive health of young people The Programme of Action adopted at the ICPD in 1994 defines reproductive health as 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.6 Promoting young people’s sexual and reproductive health thus means ensuring their physical and emotional well-being and protecting them from: unintended and unwanted pregnancy; abortion; STI, HIV/AIDS, and reproductive tract infections (RTI); maternal mortality; infertility; and all forms of sexual violence and exploitation.7 Because of changing sexual and reproductive health behaviour and exposure to rapidly changing social environments, young people are vulnerable to adopting risky types of behaviour that can lead to unfavourable health outcomes. For instance, earlier puberty and later marriage, the decreasing influence of family and culture, and rapid urbanization and migration for work – especially among young people marred by poverty, inadequate education and lack of work opportunities – extend the risks of unprotected sexual activity in unmarried adolescents in many parts of the world.8 The issues that affect young people’s sexual and reproductive health status can be complex and are often interrelated. Substance abuse, for example, increases the risk of unsafe sex, which in turn increases the risk of HIV and other STI, unintended pregnancies and complications from pregnancy and child birth.9 It can also lead to sexual violence. Such unfavourable outcomes arise when young people are not equipped with the means to make sound and responsible decisions, especially in terms of contraception and STI prevention, including preventing HIV/AIDS, as well as when no effective measures exist to prevent sexual violence and sexual exploitation. Consequently, the healthy psychosocial development of young people within an actively supportive societal environment and through their use of appropriate life skills is vital to ensuring that they develop into healthy adults. Young people are not a homogenous group but are comprised of various vulnerable groups such as young married adolescents. These vulnerable groups require special programmes to ensure basic human rights are promoted and addressed. 6
7 Reproductive health briefing cards. New York, Family Care International, 2005. 8 Op cit. Ref. 3. 9
Programme of Action adopted at the International Conference on Population and Development, Cairo, 513 September 1994.
The health of children and adolescents. Report by the Secretariat. Geneva, WHO Executive Board, 2001 (EB109/10).
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The health problems and needs surrounding the following issues are more typical of and more important for young people than adults, and therefore merit special attention.
Teenage pregnancy Three factors contribute to increasing rates of pregnancy among young people: (1) a fall in the average age of menarche; (2) rising rates of premarital, unprotected sex due to an increase in the average age at marriage and a decrease in the age of sexual initiation; and (3) the gender inequality that exists between men and women, making it difficult for girls to have a say in whether or not they have sexual relationships or to negotiate contraceptive use with their partners. Girls are particularly vulnerable to the risks of unprotected sexual relationships, unplanned pregnancy, and coerced sexual encounters. Pregnancy during the teenage years puts the mother and child at higher risk of serious health consequences. Teenage girls are more likely to experience premature labour, spontaneous abortion and stillbirth than older women. Insufficient physical maturity of the pelvis in young girls can lead to obstructed or prolonged labour, which can lead to haemorrhage or even death for the mother and child. In developing countries, maternal mortality in girls under 18 years of age is estimated to be two to five times higher than in women between 18 and 25.10 The 1996-1998 statistical data for Mongolia, moreover, show that more girls die of pregnancy-related causes than from any other cause.11 Young mothers are also at high risk of poor pregnancy outcome due to anaemia, as their iron needs - increased by growth, development and menstruation - are often not met. Globally, it has been estimated that iron deficiency anaemia contributes to 20% of all maternal deaths,12 which raises a great concern for many countries.13 In Cambodia in 2001, 57.7% of women aged 15 19 years and 57.0% of women aged 20 24 years were anaemic.14 The infants of young mothers are also at grave risk. The 1998 National Health Survey in Cambodia revealed that children born to mothers15 below the age of 18 years were 1.5 times more likely to die than children born to older mothers. Children of young mothers also have a higher risk of low birth weight, which predisposes them to higher infant morbidity and mortality.16, 17 Teenage pregnancy also has grave psychosocial and socioeconomic consequences. Young, unmarried parents, especially mothers, are often forced to drop out of school due to social ostracism and a lack of support in taking care of their newborn infants. As a result, they lose out on career opportunities and thus economic independence. Their communities and countries also lose valuable sources of production. Furthermore, when pregnancy occurs out of wedlock, fear and social stigma often drive girls to seek unsafe abortion services or to attempt self-induced abortions. 10 Briefing notes on selected adolescent health issues, Geneva, WHO, 2001. 11 The world’s youth 2000. New York, Population Reference Bureau, 2000. 12 13
Ross J, Thomas EL. Iron deficiency anemia and maternal mortality. Washington DC, Academy for Educational Development, January 31, 1996. (PROFILES 3 Working Notes Series No. 3.) The work of WHO in the Western Pacific Region, Report of the Regional Director, July 2000 to June 2001. Manila, WHO Regional Office for the Western Pacific, 2001. 14 Cambodia National Demographic and Health Survey 2000. Phnom Penh, National Institute of Statistics, 2001. 15 National Health Survey 1998. Phnom Penh, National Institute of Public Health, Ministry of Health Cambodia, 1999. 16 Teen sex and pregnancy. New York, The Alan Guttmacher Institute, 1999. 17 The reproductive health of adolescents: a strategy for action. A joint WHO/UNFPA/UNICEF statement. Geneva, World Health Organization, 1989.
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While the socioeconomic consequences of teenage pregnancy directly impact girls, it is important to recognize that boys are also affected by teenage pregnancy. Identifying and meeting the needs of teenage parents, especially teenage fathers, has been largely neglected to date.
Unmet need for contraception among young people With the earlier arrival of puberty and the trend towards postponing marriage and child-bearing, the period during which young people are exposed to potentially unsafe premarital sexual relations has become longer. Due to ignorance of the risks to young people on one hand, and society’s denial of pre-marital sex on the other, young people’s need for contraception is, by and large, not recognized or met in the East Asia and Pacific Region. The fertility of young people is most commonly indicated by the age-specific fertility rate (Table 1). While national statistical data may imply that teenage pregnancy in the Region is not significant, it must be remembered that the age-specific fertility rate only accounts for the number of live births and gives no indication of the extent and gravity of pregnancies that are terminated. Accurate data on abortions among young people are scarce or incomplete due to the sensitive nature of the issue. However, despite cultural and legal restrictions, young people do seek assistance in terminating unwanted pregnancies, often from unqualified practitioners. Moreover, unsafe abortion and its complications pose significant health risks for many women, especially those living in countries where abortion is illegal. Young people’s failure to obtain and use contraceptives correctly and constantly, the social stigma associated with premarital pregnancy, and the lack of appropriate counselling are thought to be the major factors leading to the high abortion rate among young people. Table 1. Age-specific fertility rates (15-19 years) and proportion of the population aged 10-24 years in selected countries in the East Asia and Pacific Regiona, b Countries Marshall Islands Lao People’s Democratic Republic Solomon Islands Papua New Guinea Kiribati Cambodia Fiji Tonga Philippines Vanuatu Mongolia Viet Nam Samoa Australia Malaysia New Zealand China Singapore Japan Republic of Korea Age-specific fertility rate (15-19 years), (Births per 1000 women) 97 81 69 64 59 45 45 42 39 38 31 27 23 18 16 14 12 6 5 4 Proportion (%) of the population aged 10-24 years 31.5 23.7 32.7 31.9 29.8 27.0 29.2 32.4 21.8 33.1 24.3 22.4 26.3 14.0 20.8 14.0 17.3 12.1 10.5 14.0
SOURCE: a US Census Bureau, International Program Center, International Data Base, Internet release date: March 22, 2004. b Demographic tables for the Western Pacific 2005-2010. Manila, WHO Regional Office for the Pacific, 2005.
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Globally, up to 4.4 million abortions are performed every year among women aged 10-24 years, most under unsafe conditions and conducted by unskilled providers.18 Unsafe abortions can result in haemorrhage, septicaemia, injuries, infertility and death. Several studies in the Region show that despite the availability of safe abortion services in countries where abortion is legal, young people, particularly those who are unmarried, seek abortions from private practitioners or from unqualified persons, especially when they seek anonymity or when they desire termination at a late stage of pregnancy.19,20 Young people often seek assistance in terminating pregnancies at a late stage because they are more likely than adults to deny that they are pregnant, to fail to recognize the signs of pregnancy, and to delay taking the decision to seek help, thus putting themselves at greater risk of complications. Where abortion is illegal, the rising incidence of abortion-related complications is a major concern. In the Philippines, abortion-related complications are a leading cause of gynaecological admissions to government hospitals.21 The problem of abortion, however, is not unique to countries where it is illegal. In Viet Nam, for example, abortion has been legal since the 1960s and is widely accessible through public health services. While the procedures are safe, repeat abortions are common, making the abortion rate in the country one of the highest in Asia and fifth in the world.22 Even in Japan, the rate of induced abortion for women below 20 years of age has almost doubled in the last decade, from 6.2 per 1000 females in 1995 to 12.1 in 2000, in contrast to the decreasing trend in the total population.23 Safe or unsafe, repeated or not, abortion puts young people at risk of physical and psychological trauma and results in adverse socioeconomic consequences for them and the societies in which they live. Therefore, maximum efforts should be made to avoid such unplanned pregnancies.
Sexually transmitted infections, HIV/AIDS and reproductive tract infections Studies documenting the early age of onset and high frequency of sexual activity among young people in the East Asia and the Pacific Region suggest that they engage in a high level of unprotected sexual activity.24,25 That situation inevitably calls for attention to be given to young people’s risk of acquiring STI, including HIV/AIDS. In general, the lack of systematically collected data on STI and HIV/AIDS among young people makes an in-depth analysis of the actual situation difficult for many countries. However, it is clear that STI rates among adolescents have risen quickly in recent years.26 In particular, the long-term effects of gonorrhoea, chlamydiosis and syphilis are substantial, and attention needs to be paid to preventing those infections in young people. The dramatic increase in STI facilitates increased HIV transmission. The current epidemiology of STI and HIV suggest that they are diseases of young people. In China, the incidence of STI among 15-19 year olds has risen by 79.45% since 1999. China is experiencing one of the most rapidly expanding 18 19
Young people and sexually transmitted diseases. Geneva, World Health Organization, 1997. (WHO Fact Sheet no. 186) Hong KT. Adolescent reproductive health in Viet Nam: Status, policies, programmes and issues. Ha Noi, Center for Social Development Studies, 2003. 20 Nham L et al. Teen-age pregnancy and abortion. 1996. 21 Philippines Population Research for Policy Initiatives, Series 2001:1. 22 Goodkind D. Abortion in Viet Nam: Measurement, puzzles and concerns. Studies in family planning 25 (6), 1994. 23 Ministry of Health, Labour and Welfare, Japan 2001 24 Adolescent reproductive health situation analysis in Kiribati. Suva, Fiji, UNFPA Office for the Pacific, 2005. 25 Adolescent reproductive health situation analysis in Solomons. Suva, Fiji, UNFPA Office for the Pacific, 2005. 26 Sexual health – A new focus for WHO. Progress in reproductive health research. Geneva, Wpr;d Health Organization, 2004. (SHR No. 67)
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HIV epidemics in the world, with a 30% annual rate of increase in reported infections. Experts fear that HIV could affect over 10 million people by 2010.27 Worldwide, young people account for nearly half of all new HIV infections. Rising HIV/AIDS rates and the young’s special vulnerability signal the need for accelerated action, especially preventive strategies targeting young people. Young women, in particular, are at great risk of infection. As of December 2003, women accounted for nearly 50% of all people living with HIV globally. In Papua New Guinea, alone, the Port Moresby General Hospital reported an increase in HIV infections among antenatal women aged 15-24 years from 0.19% in 2000 to 2.6% by 2005.28 In the Philippines, as in many countries where transmission is predominantly sexual, most HIV infections occur among women at a younger age than men. Even among those uninfected, women and girls bear the brunt of the epidemic’s impact. They are most likely to take care of sick people, to lose jobs, income and schooling as a result of illness, and to face stigma and discrimination. There is thus an urgent need to address the many factors that contribute to the vulnerability and risk experienced by women and young girls, especially gender and cultural inequalities, violence and ignorance.29 In this Region, the main mode of HIV transmission among young people is sexual, although variations exist. In Malaysia and China, for example, the HIV epidemic is closely associated with injecting drug use. However, heterosexual transmission is also increasing in China, especially in the eastern provinces, along with rising trends in the commercial sex trade and labour migration. Such a situation reflects the tendency of risk factors to cluster in young people. Injecting drug users (IDUs) are less responsible and more likely to have unprotected sex, which increases the likelihood of transmission of STI, including HIV. Adding to that risk is the fact that many commercial sex workers are IDUs, which increases the risk of their transmitting STI to their clients and further into the general population. In addition, in many countries where significant proportions of young people migrate to seek employment opportunities, the risk of STI transmission in that vulnerable group is high, further signalling the need for greater attention to be paid to the problem. Of great concern, moreover, is the discrepancy between the high level of knowledge about HIV/AIDS and the low level of condom use among young people. Also of concern is the reported high level of reproductive tract infections (RTI), which are not necessarily transmitted sexually, in young people. For instance, a recent study among asymptomatic women in Vanuatu reported high levels of trichomoniasis in young women aged 15-24 years attending antenatal clinics.30 Furthermore, pelvic inflammatory disease is a relatively common problem in some countries and will contribute to problems with fertility later in life. Early sexual activity and high number of sexual partners are also risk factors for cervical cancer.
Sexual violence and exploitation While increasing numbers of young people are engaging voluntarily in sexual relations at an early age, some young people are victims of non-consensual or coerced sex. In Thailand, for example, 41% of young women (15-24 years) in one study reported that they had been forced to have sexual relations during 27
Ministry of Health, China and the United Nations Theme Group on HIV/AIDS in China. A joint assessment of HIV/AIDS prevention, treatment and care in China. Beijing, Ministry of Health, December 1, 2003. 28 HIV incidence in the antenatal clinic at Port Moresby General Hospital. Papua New Guinea, Ministry of Health, 2005. 29 2004 report on the global AIDS epidemic. Geneva, UNAIDS, June 2004. 30 Antenatal clinic STI survey, Port Vila, Vanuatu. Manila, World Health Organization Western Pacific Regional Office, Manila, 2001.
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their first encounter.31 In Malaysia in 1998, there were 1489 reported cases of rape, over half of which involved girls under the age of 16 years.32 The circumstances under which rape occurs vary, but often the perpetrators are people that the victims know, such as boyfriends, colleagues, relatives or immediate family members. In Solomon Islands and Papua New Guinea, date rape and gang rape are major concerns.33 In most cases of sexual violence, the victims are powerless to negotiate for safe sex, which places them at risk of unwanted pregnancy, STI and HIV/AIDS. Furthermore, studies report that alcohol consumption in all age groups, including young people, increases the likelihood of sexual violence.34 Although most countries have laws to protect victims of sexual abuse and to deter perpetrators of sexual violence, victims often suffer physical and psychological trauma, societal discrimination and rejection, even from their families. Such an unfortunate situation is antagonized even further when rape victims do not receive medical treatment, emergency contraceptives, counselling and support. Today, at least 12.3 million people are victims of forced labour worldwide; 2.45 million as a result of trafficking. Most people are trafficked for commercial sexual exploitation (43%) or for economic exploitation (32%), and the remainder for mixed or undetermined reasons.35 Most victims come from poor families and do not possess the knowledge and skills to prevent their exploitation without outside intervention. Their sexual and reproductive rights and their ability to seek necessary health care are severely compromised due to physical and/or financial bondage, illegal status and language barriers, as well as the shame and guilt associated with the nature of the work in which they are forced to engage. This is further exacerbated by gender inequity and lack of negotiating power of women.
Summary note While substantial improvements have begun in this Region, there still remains an urgent need to address the sexual and reproductive threats to young people, especially vulnerable to teenage pregnancies, sexual violence and exploitation, and who are at the centre of the STI and HIV/AIDS epidemic. Without access to adequate information, skills, services and a safe and supportive environment, they face serious health risks. By investing in young people and implementing strategies for accelerated action to improve adolescent sexual and reproductive health, as outlined in this framework, countries can begin to make significant progress in promoting their overall socioeconomic development, improving the well-being of their people, and meeting the rights of women, men and young people in the Region. Investment in reproductive health and the rights of young people is crucial for the achievement of the MDGs and the ICPD+5 Plan of Action by reducing poverty, improving maternal and child health, curbing the spread of HIV/AIDS, and providing for gender equity and sustainable economic development.
31
Im-Em W. et al. Sexual coercion among ever-partnered women in Thailand. In: Jejeebhoy S, Shah I, Thepe S (eds.) Non-consensual sexual experiences of young people in developing countries. Zed book. (Forthcoming). 32 Awin N. Malaysia’s experience in capacity building in adolescent health (including reproductive health). Paper presented at the 7th National Congress of Perinasia and International Symposium on “Adolescent’s Reproductive and Perinatal Health Towards the Third Millennium,” Semerang, Indonesia, 18th - 21st November 2000. 33 Op cit. Ref. 25. 34 Op cit. Ref. 31 35 A global alliance against forced labour. Geneva, International Labour Organization, 2005.
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chapter three
a framework for accelerated action
I
n accelerating actions to promote the sexual and reproductive health and rights of young people, it is important to follow a framework that links the various necessary components for ensuring their health and well-being. That framework should be based on an overall goal and should identify the strategies and actions to meet that goal. The framework that follows is one that is commonly used to guide comprehensive sexual and reproductive health programming for young people, and it can be used as a starting point for establishing or improving upon such programmes.
Goal of the Framework The broad goal of this framework is to improve the sexual and reproductive health of young people in the East Asia and Pacific Region. To achieve that goal, programmes should promote healthy and responsible sexual and reproductive health behaviour, aimed particularly at reducing the following risks for young people: • • • • pregnancy before maturity; unmet need for contraception in young people; STI, HIV/AIDS and RTI; and sexual violence and exploitation
Framework components The framework has three major components that are based on the commonly accepted premise that to practise lifestyles that lead to optimal sexual and reproductive health, young people need:36,37,38 • • • life-skills-based information and education; access to reproductive health services for young people; and a supportive and enabling environment.
These three components are the mechanisms by which the sexual and reproductive health needs of young people can be met. To begin, the response of societies and governments should be based on giving young people appropriate information, education and life skills that will help them to make responsible decisions about their sexual and reproductive health behaviour as early as possible. Moreover, youth-friendly health services should be made available to young people to help them understand and deal with their sexuality and protect them from unwanted pregnancies, STI and HIV/AIDS, as well as the subsequent risk of infertility. In addition, social norms regarding sexual activity and sexual expression have changed, and the onset of pubertal changes has been getting earlier. However, the environment to support 36 Op cit. Ref. 17. 37
The second decade: Improving adolescent health and development. Geneva, World Health Organization, 1998. (WHO/FRH/ADH/98.18) 38 Op cit. Ref. 3.
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adolescents in facing those changes has not changed. Many governments still need to put in place institutionalized mechanisms (policies, legislation and services) and sources of funding to address the sexual and reproductive health issues of young people. Moreover, families and communities need to be prepared to provide them with accurate information and appropriate services. All three components above represent strategic areas for action. The following chapters in this document discuss each of those components in detail in terms of prevailing issues and challenges, responses and recommended actions. These components require accelerated action to develop and implement coherent policies and legislation that protect, promote and maintain young people’s health.
Objectives and outcomes Based on this framework, a comprehensive programme to improve the sexual and reproductive health of young people should be guided by clear, timebound and contextually appropriate objectives. Those objectives can be considered as target outcomes that a programme will aim to achieve within a specified timeframe. The table below is illustrative of the types of objectives, indicators and timeframes that can be used, although they will vary by country. Each country will need to identify indicators and targets appropriate to them. In addition, each country also will need to engage monitoring and evaluation specialists to help them quantify objectives appropriate to the situation. Table 2. Objectives Objective 1. To reduce pregnancy before maturity of young people aged 15-19 by 20% between 1990 and 2015.
Indicatorsa 1. Average age at marriage 2. Percentage of young people who have ever had sexual intercourse by sex. 3. Percentage of young people who have ever been pregnant or caused a pregnancy. 4. Percentage of young females who have dropped out of school because of pregnancy. 5. Fertility rate among young females aged 1519 years.
Objective 2. To reduce the unmet need for contraception among young people aged 15-24 by 30% between 1990 and 2015.
1. Percentage of sexually active young people who have ever used modern contraception by sex and method. 2. Percentage of young people who report condom use at last high risk sex 3. Percentage of sexually active young people who are currently using contraception by sex and method. 4. Percentage of young females who have ever terminated a pregnancy.
Objective 3. To reduce the STI/ HIV infection rate among young people aged 15-24 by 25% between 1990 and 2015.
1. Percentage of young people who report specific STI/HIV symptoms by sex. 2. Prevalence rate of STI among young people by type and sex. 3. Percentage of young men and women aged 15-24 who have access to STI/HIV prevention methods. 4. HIV prevalence among 15-24 year-old pregnant women.
Objective 4. To reduce sexual violence and exploitation of young people aged 15-24 by 25% between 1990 and 2015. 36
1. Percentage of young females and males who report having been victims of sexual abuse. 2. Percentage of young females and males who have ever been forced to have sex.
Adamchak S et al. A guide to monitoring and evaluating adolescent reproductive health programs. Focus on young adults. Tool Series 5, June 2000.
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Summary note The framework outlined above and discussed in the following chapters provides a set of concrete interventions or actions for governments and their partners to undertake to achieve the goal of improving young people’s sexual and reproductive health. The institutionalization and scaling up of sexual and reproductive health programming for young people require an approach that is both rigorous and attractive to young people themselves. It requires planning to ensure sustainability and the creation of effective social networking. This comprehensive framework can be used in a manner and to the extent appropriate and feasible for each country to fill gaps in programming. Some countries may have begun to take action in some of these areas already, while others may just be starting. According to each country’s situation, it may be appropriate to start by taking only a few selected actions, or it may be more effective if several coordinated actions are taken simultaneously. Some action areas are not new, but a decade of experience has taught us that further strengthening and scaling up is necessary. It should also be noted that this framework is only a guide, and countries may feel they require to take measures beyond those recommended in order to effectively reach the goal noted above.
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chapter four
promoting healthy behaviour through life-skills-based information and education Issues and challenges
A
cquiring adequate and accurate information helps young people to arrive at informed and responsible decisions. There is increasing recognition that the introduction of sexual and reproductive health education as early as the pre-school level is most effective in developing positive types of behaviour in young people. However, it has been well documented that information alone is not sufficient for informed decision-making. Surveys in the Region such as “SAVY”39 and in many countries show that young people have the knowledge, but often lack the ability to translate that knowledge into healthy sexual behaviour. This limits their ability to meet challenges and respond appropriately in a variety of circumstances and situations. To address that issue, the life-skills approach is a major initiative being undertaken in the Region in both in-school and out-of-school settings. Lifeskills-based education is designed to facilitate the practice and reinforcement of psychosocial skills in a culturally and developmentally appropriate way. It contributes to the promotion of personal and social development, the prevention of health and social problems, and the protection of human rights. A life-skills approach equips young people with information and relevant skills for responsible decision-making, so they can learn to function as independent adults capable of making healthy decisions. The life-skills approach focuses on giving young people a structured, interactive environment for understanding and practising such skills. In sexuality education, participants learn to negotiate relationships in a healthy way. Although the content can vary, it typically includes areas such as values clarification, relationships, decisionmaking and negotiation skills, planning for the future, and assessing credible sources of sexual and reproductive health information and services, including legal and support services in response to coercive or abusive situations. It includes skills for those who choose to delay first sex, refuse sex or practice safe sex. It also focuses on helping the individual to understand his or her own morals and plans for the future, in order to make appropriate and healthy choices for his or her own life.40 In most countries, however, no clear guideline or policy exists regarding sexual and reproductive health education for young people, including life-skills training. Consequently, information and education programmes and projects vary as regards what is taught, at what age, in what setting, by whom, and in what manner.41 Together with a lack of clarity in programme focus, this has 39
Survey Assessment of Vietnamese Youth. 2005. Ministry of Health, General Statistics Office, UNICEF, WHO. Hanoi, Vietnam 40 Adapted from: Life planning skills: A curriculum for young people. Washington D.C., Program for Appropriate Technology in Health (PATH), 2003. 41 HIV and sexual health education in primary and secondary schools. Findings from selected Asia Pacific countries. National Centre in HIV Social Research, Faculty of Arts and Social Sciences, The University of New South Wales, Australia, October 2000.
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led to the establishment of various programmes, both in-school and out-ofschool, that are planned and coordinated inadequately, thus exposing them to the risks of duplication and inefficient use of resources. Experiences illustrate that information and education programmes have covered only a small proportion of the young population, given the limited resources and the relatively short history of sexual and reproductive health interventions for young people in the Region. Progress towards long-term institutionalization of programmes for sustainability purposes has also been limited. Many programmes have been implemented on an ad hoc basis as pilot initiatives that have not been well evaluated. However, despite the relatively small scale of interventions and the implementation challenges of introducing new programmes, progress and early achievements include creating greater community awareness; securing support from national leaders, teachers, and parents; and creating an environment that is receptive to and supportive of sexual and reproductive health education for young people. One of the challenges for such programmes, however, is that the concept of sex education is often misinterpreted by parents and community leaders, largely due to misunderstandings about the goal and the content. Such a situation can lead to resistance and reduce the receptiveness of such programmes at the community level. Parental and community support is key to the success of educational interventions. It is necessary to raise awareness among adults that sexual and reproductive health education does not lead to promiscuity, but promotes positive sexual and reproductive health behaviour.42
Responses Responding to the Programme of Action adopted at the ICPD and the Convention on the Rights of the Child,43 many governments and nongovernmental organizations have made substantial efforts to initiate sexual and reproductive health information and education interventions for young people through both in-school and out-of-school programmes. The major aim has been to ensure access to accurate, timely, age-appropriate and gender-sensitive sexual and reproductive health information for all young people. Some successful strategies have been intersectoral, managed by the combined efforts of health, education, employment, family services and other sectors. Partner agencies have developed comprehensive education and training programmes and have worked to develop and implement multifaceted approaches using the lessons learnt from local and regional experiences.
Recommended actions To facilitate the development of a comprehensive life-skills-based information/ education sexuality and reproductive health education programme, several approaches need to be considered. One set of approaches is based on situations or contexts that affect the lives of young people, while the other is based on linkages to services. In the contextual setting, programmes need to address the development of young people from a broad perspective and to take into consideration the different situations and backgrounds in which they live, their different needs at different stages of development, the impact of gender on sexual and reproductive health, and the importance of involving families, communities and influential leaders. 42 43
Grunseit A et al. Sexuality education and young people’s sexual behaviour: a review of studies, Journal of adolescent research, 1997, 12(4): 421-453. Convention on the Rights of the Child. Adopted by the United Nations General Assembly, 1990.
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In linking to services, it is important that programmes take into consideration the relevance of youth participation; the linkages between sexual and reproductive health and other issues affecting young people; promotion of youth-friendly environments; establishment of linkages to adolescent reproductive health services; the role of multisectoral participation and networking; the importance of multi intervention strategies; the crucial importance of establishing effective coordinating systems; and establishment of monitoring and evaluation mechanisms.
In-school programmes Ministries of Health and Ministries of Education need to collaborate closely to ensure that life skills and sexual reproductive health is included in school curricula. Well designed in-school information/education programmes provide a sustainable means of reaching a large captive audience to promote healthy practices making it one of the most cost-effective investments in the youth of any nation.44 The school system is a strategic setting in which reliable sexual and reproductive health knowledge and support can be provided to young people. Information/education programmes should adopt a life-skills approach to deliver both knowledge and skills that help young people use information to make responsible choices and decisions. The advantages of in-school programmes are that they can be formalized into the school curriculum, and can be delivered or taught in an age-appropriate manner so that the content of learning is in line with the maturity of the students. Moreover, when introduced at the primary school level, the structured school environment allows information to be reinforced throughout the development stages of students, from primary-to secondary-school levels. In-school programmes can integrate or introduce sexual and reproductive health into formal school systems, either as part of an existing school subject, such as is done in Myanmar and Thailand, or as a separate subject, as in Fiji. Making the subject compulsory and introducing it at the primary-school level have added benefits. Building on the joint WHO and multi-agencies Skills for Health45 recommendations, approaches to delivering a well structured, school based information/education programmes include the following: (1) Core content areas of sexual and reproductive health education should be developed in a sexual and reproductive health curriculum to help young people understand the relationship of sexuality and reproduction to other key aspects of their development and lives.46 (2) Teachers need to be trained and equipped with skills to deliver sex education in an age appropriate, gender sensitive and youth-friendly manner. (3) Sexual and reproductive health issues can be integrated into school subjects as student research activities or debate topics linked to other health/social topics. Such ‘normalization’ of sexual and reproductive health issues will help minimize the possible sensitivity of the subject and associated stigma and myths, while the process will facilitate the acquisition of knowledge and skills, as well as build confidence among young people. (4) The establishment of school-based counselling provides an opportunity for students to access one-on-one counselling in the 44 World Bank. World development report 1993: Investing in health. Oxford University Press, New York. 45 World Health Organization. Information Series on School Health.Document 9. 2002: WHO, Geneva 46
Senderowitz J. A review of programme approaches to adolescent reproductive health. Poptech Assignment Number 2000, 176, 2000.
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convenient and familiar school environment. While school teachers may be able to provide counselling, counselling services to address different aspects of sexual and reproductive health and youth development are better delivered by trained school counsellors or school nurses. (5) Linking school programmes with health facilities and other supportive services (e.g. legal, mental health, social protection and welfare) ensures that the needs of young people are attended to in a more holistic manner. An established network between schools and health facilities (government, NGO and private) also allows for back-stopping support, referrals and shared care to be available and accessible to young people. (6) School based peer education is an approach that some schools may wish to implement. It provides an opportunity to use the school environment to empower student leaders, prefects and other skillful students to take on the extracurricular responsibility of helping other students and promoting healthy behaviour. Such an approach can be especially effective when young people nominate those they consider to be credible spokespersons. Sexual and reproductive health education in that context can be linked to school-based substance abuse prevention strategies. Peer education has a greater likelihood of improved coordination, supervision and support if recognized and integrated into the school system. It is also less costly than community-based peer education. The challenges of establishing and implementing an in-school programme revolve around the development of an appropriate curriculum that includes the core areas of sexual and reproductive health, incorporates a life-skills approach, engages interactive and participatory student learning, and aims to deliver compulsory classes. Developing teacher capacity, in terms of knowledge, attitudes and skills, is crucial in the successful delivery of inschool educational programmes on sexuality and reproductive health. A monitoring system structured to the programme provides an opportunity for strengthening and improving the programme on an ongoing basis. Scaling up and expanding early in-school initiatives also requires resources and effective coordinated partnerships with the Ministry of Education and schools. Institutionalizing sexuality and reproductive health education as a compulsory subject in schools is a long-term goal that can bring about many benefits and ensure sustainability. However, it is a challenging approach and a long process, and is bound to face resistance in many settings. Given the long-term benefits, success stories and lessons learnt from other countries should be shared so that the strategy can be adapted and replicated in the Region.
Out-of-school programmes Because a large proportion of youth no longer attend school, there is a need to reach those out-of-school with behaviour change communication (BCC) interventions to provide them with equal opportunities to make healthy choices and decisions. In addition, there are groups of neglected or more vulnerable young people who need more attention, such as those who live in remote rural areas, street children, same-sex-attracted youth, young people with substance abuse problems, those with disabilities, migrant youth and minorities. Out-of-school programmes and BCC interventions include peer education
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programmes, community-based education through training workshops, lifeskills training, youth leadership training activities, community outreach using drama and entertainment, and work based outreach programmes. All of those programmes can support or strengthen existing community-based health promotion and education programmes that provide accurate information to children, young people, parents and other adults. Support should be given to efforts that supply consistent information across multiple generations, encourage parents or other adults to talk with young people about sexual and reproductive health, and integrate a life-skills approach into communitybased programmes. Approaches to delivering out-of-school information/education programmes include those conducted within the community and at the workplace, as well as those that use the media.
The community • Experience indicates that community-based peer education should be considered a rational strategy if adequate evidence exists that peer educators provide accurate information and contribute to positive behaviour. Peer education programmes with a well-structured training component that accommodates the rapid turnover of peer educators are generally more successful. Such programmes with adequate support and monitoring systems may be more cost-efficient. The challenges of peer education programmes, both in-school and outof-school, include substantial operational costs, the rapid turnover of young people trained as peer educators, the need to have a continuous training programme in place due to that rapid turnover, selection of unsuitable young people to join the programme, and weak supervision and support mechanisms. Additional challenges include maintaining quality control of interventions and messages across educators and ensuring good quality evaluations to determine the cost-effectiveness of the programme. Many countries have invested in life-skills and skills-based health education programmes for communities that pay special attention to gender-sensitive issues. Various sectors have been mobilized to varying degrees to assist young mothers and fathers in accessing and actively participating in educational or professional training services that support their right to better career opportunities. Youth and communities are being made aware of young people’s reproductive rights, including the right to protection from sexual harassment, discrimination, violence and sexual coercion, and to clear referrals to appropriate legal services. In some countries, parents and communities are fully supported, in terms of resources and capacity-building, in their role as primary sexual health educators where appropriate. However, this is an area that requires accelerated action. Parent-child communication education has been initiated and supported in some communities to strengthen the role of parents as primary teachers of children and to enhance positive parent-child relationships from an early age. A range of community-based leadership and action training programmes are being conducted. Training sessions and courses, as
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well as interactive forums, are good ways of raising awareness, as are seminars, workshops, debates and discussion groups. Drama and art can be both entertaining and educational and an effective way of engaging young people and the community. Workplace settings provide a channel for provision of sexual and reproductive health information, education and services. Findings from a project in Cambodia to reduce barriers to sexual health services among young garment factory workers revealed their concerns about health, costs and confidentiality in seeking care. It also uncovered inaccurate reproductive health knowledge, as well as negative views about condoms in established relationships.47
Media and behaviour change communication (BCC) interventions for youths. Innovative behaviour-change communication (BCC) interventions and approaches can be implemented through multimedia and entertainment channels. Radio, television, newspapers, the Internet and other media resources can be utilized as powerful tools with the potential to reach a broad audience and repeatedly provide accurate information from multiple channels. In the Philippines, for example, a multimedia campaign targeted young people through an advertised telephone hotline (Dial-a-Friend) linking them with counselling and health services. Dial-a-Friend received 8000 calls in its first seven months. Evaluation findings indicate that 51% of callers said it had influenced their behaviour.48 In developing BCC initiatives, and given the fact that evidence based data on behaviour change in Asia and the Pacific are very poor, empirical research is needed to support programming. Targeting young people through behaviour-change communication interventions and approaches Behaviour-change communication (BCC) interventions are critical to improving the health outcomes of adolescents and young people. They include those related to family planning/reproductive health and HIV/ AIDS prevention and stigma reduction. However, promoting positive sexual behaviour among young people is a complex process that requires an understanding of culture as well as behavioural science. Presenting facts alone does not necessarily ensure behaviour change. BCC interventions have to be integrated into health programmes right from the start, rather than as add-on components in the middle of a project. They have to be designed to accommodate the stages of behaviour adoption of an individual or group, and to cultivate the skills needed to enable and sustain change. A good BCC intervention uses various communication methods and tools, including training, face-to-face communication, counselling and other forms of communication, to develop the skills and capabilities of target audiences (adolescents and youths) to promote and manage their own health and development. It fosters positive changes in behaviour, as well as in the knowledge and attitudes of the target audience.
Overall, out-of-school information/education approaches are generally more challenging because of the difficulty of reaching out-of-school young people in large numbers on a regular basis. Different settings, the wide age range, and varying socioeconomic backgrounds and lifestyles pose challenges in implementing, monitoring and sustaining out-of-school programmes. However, if well planned and coordinated, they can become effective means of providing the much-needed information and life skills that young people require, particularly those who no longer attend school.
47 48
Maclean A. Serving a better future. A report of discussions with young garment factory workers about life, work and sexual health. CARE International in Cambodia, August 1999. Rimon II JG et al. Promoting sexual responsibility in the Philippines through music: An enter-educate approach. Baltimore, Center for Communication Programs/Johns Hopkins School of Public Health, 1994. (Occasional Paper Series No. 3).
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Summary note The importance of providing accurate and up-to-date information about sexual and reproductive health for young people has been endorsed since ICPD 1994. Although progress has been made, there are shortcomings in creating effective approaches to educating young people on how to make informed and responsible decisions. This chapter highlights major ways to provide young people with life-skills information and education through inschool, out-of-school (community, workplace) and communication initiatives. Under those major areas, several concrete strategies are recommended to promote healthy behaviour among young people.
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chapter five
ensuring access to reproductive health services for young people Issues and challenges
I
mproving young people’s sexual and reproductive health will not be effective unless both information and services are available. For example, even if information and knowledge about contraceptive use is widely disseminated and accepted, the number of unwanted pregnancies will not be reduced if access to contraceptives is denied to young people. Health care services have the potential to play an important role for young people in preventing health problems, promoting sexual and reproductive health and well being, and shaping positive types of sexual and reproductive health behaviour. Such positive types of behaviour will, in turn, lead to a reduction in the incidence of early, unwanted pregnancy, as well as complications during pregnancy and child birth; improvement in fetal outcomes; increased use of post-partum contraception; a reduction in HIV transmission through improved STI treatment; and decreased use of alcohol/tobacco and other psychoactive substances.49,50 However, several challenges can limit the extent to which health services are effective in shaping the sexual and reproductive health behaviour of young people.
Quality While a broad range of approaches have been implemented, most initiatives have experienced difficulties in improving the quality of reproductive health services, ensuring they are youth-friendly and broadening community-based initiatives. One major obstacle is that most countries have not fully integrated sexual and reproductive health services for young people, especially the unmarried, into their formal health and educational sectors and their policies. The services that are provided to young people, moreover, must have the necessary commodities, such as condoms and other contraceptives, adequate staffing and proper financial support. Without them, the services will face difficulties in terms of cost-recovery and sustainability.
Involvement of young people Creating youth-friendly health services does not necessarily ensure increased service utilization, however.51 Even when services are available, they are often perceived by young people as inaccessible, judgmental and unaffordable. Consequently, they tend to be underutilized, largely because reproductive health programmes suffer from a lack of involvement by young people in the planning, implementation and evaluation of reproductive health services. Young people may feel, therefore, that health services are not addressing their needs. Reaching those with special needs and those who are most vulnerable is another area in need of attention. Above all, young people should be perceived not only as receivers of services. 49 Briefing notes on selected adolescent health issues. Geneva, World Health Organization, 2001. 50 Better services can reduce abortion risks. Network 2000. (20)3: 16-20. Family Health International. 51
Global Consultation on Adolescent Friendly Health Services: a consensus statement. Geneva, WHO Department of Child and Adolescent Health and Development, 2001( WHO/FCH/CAH/02.18).
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They also have the right to be involved in the planning, design, monitoring and evaluation of those services, since they are the ones who will determine ultimately whether or not the services are used.
Increased utilization and targeting Most countries in the Region do not have programmes that are designed well enough to address specifically the issue of increasing utilization and improving accessibility of services for all young people, especially those with diverse needs. For example, it is very difficult for marginalized young people, as well as those living in rural and remote areas, to access good quality health services.52 Clinics with convenient working hours and which operate in youthfriendly settings, such as multipurpose youth centres, and with youth-friendly staff are lacking in many countries. It is well recognized, moreover, that young people often do not utilize the preventive services offered at health clinics, such as family planning and birth spacing, especially if they are unmarried. They usually visit clinics only when they have health problems. Adequate behavioural research that involves young people in identifying factors for promoting preventive health-seeking behaviour and increasing utilization of clinic services is lacking in the Region.
Training of health personnel Sensitizing personnel to the sexual and reproductive health needs of young people and building the capacity of service providers, in pre-service and in-service training programmes, is vital in ensuring youth-friendly services. They must have the knowledge and skills to provide appropriate reproductive health information and services to young people in a compassionate manner, respecting confidentiality and young people’s rights. Unfortunately, however, health service providers often lack the skills required for sensitive, interpersonal counselling and communication on issues related to sexual and reproductive health. For instance, they may use technical terms and information that are neither appropriate nor understandable to young people. They may even impose their own values and biases on young people while providing services. Hence, the quality of services for young people is low, making them unfriendly and underutilized.
Research, monitoring and evaluation Health service initiatives for young people that incorporate rigorous research design, monitoring and evaluation components are rare in this Region. Consequently, little is known about the actual effectiveness of such programmes. Record keeping, report writing, documentation and dissemination of programme outcomes, whether successful or not, are also insufficient, which blocks the meaningful sharing of information and hinders the learning process between different organizations, both nationally and regionally.
Specified outcomes Some projects do not have specific outcomes. For instance, while some countries have experienced success in obtaining commodities for communitybased distribution, particularly contraceptives and condoms for the prevention of STI/HIV/AIDS, those commodities are not used by young people because there are no institutionalized distribution mechanisms or ways of scaling up or otherwise sustaining efforts. 52
Adolescent friendly health services: An agenda for change. Geneva, World Health Organization, 2002 (WHO/FCH/ CAH/02.14).
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Scale Many programmes are small scale pilot projects run by nongovernmental organizations that rely heavily on donor support. Often, this adversely affects programme sustainability and the scaling up of successful models, since activities are discontinued after the project ends.
Responses Many countries in the Region have implemented programmes aimed at meeting the reproductive health service needs of young people. These include initiatives to make health services youth friendly, to establish youth centres, to strengthen linkages with schools and workplaces, and to involve the private sector and NGOs, either in individual projects or as a comprehensive approach. As noted above, however, reproductive health services for young people are not always accessible, acceptable, appropriate, comprehensive, effective, efficient and equitable, which highlights the need for accelerated action.
Recommended actions Content of sexual and reproductive health services Comprehensive sexual and reproductive health services for young people should include the following elements: • • • • • • provision of a full range of contraceptive information and supplies, including emergency contraceptives; counselling and information services on family planning, pregnancy and the prevention and treatment of STI, HIV/AIDS and RTI; basic equipment for provision of reproductive health services (e.g. family planning, antenatal care, laboratory testing for STI/RTI); services that cater for interrelated issues, such as mental health, nutrition, sexual abuse and substance abuse; capacity to accommodate the needs of young people with special needs; and a referral system.
A more extensive list of the characteristics of adolescent-friendly reproductive health services is included in Annex 2. It is also important to note that a comprehensive adolescent sexual and reproductive health clinic should include all the items listed above. However, in settings with resource constraints, some (such as a laboratory for STI diagnosis) could be provided through referral.
Coverage and availability Mechanisms to improve the coverage and availability of sexual and reproductive health services for young people include the following: • Integrate youth-friendly services into suitable existing facilities. The suitability of existing facilities can be identified through mapping and assessment of service delivery points including, but not limited to, primary health care facilities, NGO clinics, private practitioners, community-based organizations and pharmacies. Young people must be involved in the process so that they can assist in identifying
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those facilities that are most youth-friendly and thus those that have the greatest likelihood of being used. • Develop or review clear policies, guidelines and protocols to guide health workers’ options for actions in providing youth-friendly services (e.g. obtaining parental consent, partner notification). Review the staffing and time management procedures of health facilities to allow service providers to spend sufficient time on counselling (not preaching) on specific topics related to the services sought by young people. Update knowledge, skills and attitudes of service providers. Increase coverage by integrating sexual and reproductive health services within schools or through mobile services. Create innovative ways to deliver services, including social franchising, by involving young people. Develop the necessary guidelines and standards for unconventional service delivery points. Establish or reinforce a referral network between service delivery points and information providers, as well as other organizations working on issues concerning young people, including substance abuse and youth development. One well trained service provider who can connect young clients to the services they need in a confidential manner can make a great difference. Equip all service delivery points well, with adequate commodities and supplies and sufficient information materials for both service providers and users of the services.
•
• • •
•
•
Service utilization Mechanisms for increasing the use of sexual and reproductive health services by young people include the following: • Standardize clinical guidelines and practices in the diagnosis, treatment and management of young people’s sexual and reproductive health problems, as well as reviewing and updating guidelines as often as necessary. Integrate adolescent sexual and reproductive health and the provision of youth-friendly services into the pre-service and in service training programmes of service providers, with particular emphasis on interpersonal communication skills, respect for privacy, ethics, and the delivery of confidential services. Train counsellors effectively in both communication skills and the important issues that currently affect young people so that they can respond actively to such critical concerns as stress management, nutrition, sexual abuse and substance abuse.
•
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•
Design service delivery points to take into account convenience, affordability, confidentiality and the privacy of young people, as reflected in such aspects as service hours, location, service menu, service fees, service procedures and policies. Consult young people in determining their requirements. Pay special attention to privacy and confidentiality, particularly in small communities. Sensitization of the entire community may be necessary to make services accessible to young people, especially those who are not married. Utilize existing non-health facilities frequented by young people as service delivery points, such as youth clubs, student hostels, night clubs and marketplaces. Provide general counselling services using non-clinical facilities when young people are not utilizing health care services. Such services might include outreach, telephone, Internet or e-mail communications. Establish collaborative partnerships with law enforcement and social welfare authorities to provide for the sexual and reproductive health needs of vulnerable groups, including victims of sexual abuse, sex workers and drug users. Establish links with other service delivery points and schools. Ensure application and practice of the philosophy of providing youth-friendly services.
•
•
•
•
• •
Service sustainability The following will promote the sustainability of sexual and reproductive health services for young people: • Establish a system to assess realistically and provide regularly for commodity demands - procurement and distribution – in order to meet the needs of young people sufficiently. Ensure a reliable supply of reproductive health materials, including a wide range of contraceptives, pregnancy test kits and antimicrobials, as well as information brochures. Conduct a cost-benefit analysis to demonstrate the benefit of preventive reproductive health services for young people. Adopt sectorwide approaches to gain and optimize utilization of financial resources from other sectors. Assess the feasibility of charging fees for services provided. Strengthen information systems to collect age - and genderdisaggregated data on young people’s reproductive health issues, including those related to pregnancy outcomes; STI, HIV/AIDS, and RTI; contraceptive use; and sexual abuse.
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• • • •
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• •
Strengthen documentation for monitoring and evaluation, as well as scaling up of successful models. Develop professional requirements and qualifications for the delivery of reproductive health services, including counselling, that are recognized by a registering body. Work with existing professional bodies and NGOs to integrate and institutionalize adolescent sexual and reproductive health services within and outside the health sector.
•
Summary note The sexual and reproductive health of young people cannot be addressed fully without the support of health services. Providing health services to young people is a right defended by the CRC, the ICPD Programme of Action, the Platform for Action (Fourth World Conference on Women), The Lisbon Declaration on Youth Policies and Programmes (World Conference of Youth Ministers), and other international agreements.53,54 Meeting young people’s needs and rights in sexual and reproductive health will require wider efforts from society, far beyond the realm of health services: the legal framework, social policy, the safety of communities and education. However, within an integrated approach linking other key services with communities where young people live, health services can play a crucial role and become part of a supportive structure that protects and guides young people’s development into healthy adults.
53 United Nations Fourth World Conference on Women, Beijing, 1995. 54
Lisbon Declaration on Youth Policies and Programmes. United Nations Educational, Scientific and Cultural Organization, 1998.
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chapter six
creating a supportive and enabling environment Issues and challenges
P
roviding information and health services to young people are no doubt two of the most essential factors necessary to improve their sexual and reproductive health. However, creating and implementing an enabling environment for young people that acknowledges their evolving capacity to develop positive lifetime behaviour and skills and allows them to access information and services without embarrassment is also of great importance. Young people may engage in sexual behaviour before the years of reproduction; sexual exploration and expression during adolescence is common and a normal part of attaining their overall development. The refinement of those skills is informed by parents and carers, peers and the media, and they are influenced by cultural and spiritual values as well as survival practices. Creating such an enabling environment is challenging, since complex social, economic and political forces influence the vulnerability of young people to sexual and reproductive health risks. Poverty and inequitable access to education, information and services are associated with poor sexual and reproductive health outcomes among young people, especially those who live on the fringes of society. Poverty can push young people into situations that jeopardize their sexual and reproductive health, such as migration and early entrance into the labour force, trafficking and commercial sex work. Empirical evidence shows that poverty reduction programmes for young people, not only reduce poverty, but also improve their health.55 At a normative level, the practice of early marriage and child-bearing for girls still prevails in several countries. The norm of not mentioning sexual matters openly hinders their discussion within families and schools, and sometimes between health care providers and their young clients. It also affects the extent to which sex education initiatives are viable for pre-adolescents. Moreover, such a lack of communication often effectively blocks access to appropriate sexual and reproductive health information and services by unmarried young people, especially girls. Gender inequalities further place young girls at a disadvantage in terms of access to resources and services, as well as limiting their decision-making power, choices and opportunities. It is equally important to note, however, that while male youths may be beneficiaries of such domination, they are also at risk. Society’s expectations of behaviour, roles, access to resources, and prospects for development vary for young boys and girls.56 For boys, they may include social expectations regarding alcohol, tobacco and drug use, aggressive behaviour, multiple sex partners, etc., all of which increase their vulnerability to the risk of contracting STI and HIV/AIDS.57,58
55 Op cit. Ref. 18. 56 Op cit. Ref. 3. 57
Khan SI. Male sexuality and masculinity: Implications for STI, HIV and sexual health interventions in Bangladesh. Edith Cowan University, Perth, Western Australia, 2004. Unpublished Ph.D. dissertation. 58 Sirirasamee B et al. Gender perspectives in reproductive health practices in Thailand: A synthesis of research findings. Institute for Population and Social Research, Mahidol University, 2003 (IPSR Publication No. 274).
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Responses After the ICPD in 1994, and even before, many programmes for reproductive health education, training and life skills were begun in the Region. The experiences and lessons learnt from various programmes have repeatedly emphasized the importance of forging a supportive, enabling and receptive environment at both the policy and community levels to facilitate programme implementation and minimize the risk of unwarranted reactions, apprehension or opposition due to the potential sensitivity surrounding adolescent sexual and reproductive health matters in most communities. Key partners in creating an enabling environment include individuals and organizations in both the public and commercial sectors, such as young people, their families and their peers; schools; community agencies; spiritual institutions; businesses; politicians; nongovernmental organizations; health services and other sectors; and media that do not promote the dissemination of inaccurate information. Experiences also show that the supportive environment can be divided strategically into two major domains: the immediate supportive environment surrounding young people (e.g. parents, peers, teachers, community, health providers, mass media) and the broader supportive environment encompassing policies and legislation. Although the two domains overlap and are equally important, for the sake of practicality and clarity, this chapter provides strategies and recommended actions for the immediate supportive environment only. The broader supportive environment will be discussed in the following chapter on accelerated actions.
Recommended actions Approaches to create a safe and supportive immediate environment that helps to prevent unsafe sex and early child bearing include the following:59 (1) Work within societal norms and bridge the gender gap. Informing young people about their sexual and reproductive health and providing them with needed services is often a sensitive area, both socially and culturally. Rather than overtly confronting prevailing social norms, including those associated with gender, work to create positive conditions for changing them and improving the sexual and reproductive health of young girls and boys, such as the following: • Where necessary, promote abstinence and delayed marriage and child-bearing. Where early marriage is the norm in the local culture, there is a need for legislation, community action and media campaigns to prevent marriage below the age of 18. Information on the risks of early pregnancy and its impact on a family’s livelihood and future need to be targeted at young males as much as girls and can be a good starting point for developing a persuasive campaign. Expand access to education and training. Young women who have completed their schooling and have also acquired income-earning skills are less likely to have unwanted pregnancies and to engage in unsafe sex. It is also important for young girls to be permitted to return to school and receive training after pregnancy. Orient parents and the community to become reliable and accurate sources of information and guidance for young people on sensitive issues relating to sexual and reproductive health. The success of such orientation programmes can be heightened if the
•
•
59
Op cit. Ref. 37.
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fears and needs of parents and community members are addressed appropriately. These ‘gatekeepers’ often need to be ‘desensitized’ about sexuality, trained in communication skills, and given tools, such as information materials, that they can use to communicate with their children. If parents are still apprehensive about discussing sexual and reproductive health issues with their children, give them appropriate information about who they and their children can turn to for advice and guidance, such as counselling services, as well as out-of-school and community outreach programmes. • Support young people’s rights to access contraceptives, including condoms, especially girls and unmarried young people, and advocate the benefits of their doing so. Ensure equal access to information, education, services and other opportunities for girls and boys in urban and rural areas. Promote and support comprehensive community-based gender equality programmes that meet the diverse needs of girls and boys, with inputs from local sectors including education, labour, sports and recreation, NGOs and youth-led organizations. Create safe public spaces, especially where real or perceived vulnerability to violence inhibits girls’ social participation.
• •
•
(2) Forge partnerships through the following mechanisms: • Reach out to parents and the community. Successful programmes encourage parents to have discussions with their children on the larger issues of their relationships, goals and aspirations.60 Studies indicate that where adults are reliable and accurate sources of information and guidance, young people have low rates of abortion, STI and unplanned pregnancy.61 Ensure the involvement of youth in all phases of the design, implementation and evaluation of sexual and reproductive health programmes. It is also very important to disseminate information on laws and policies to young people to ensure that they can advocate for and receive the same quality of service, regardless of martial status. Form alliances with influential religious and political leaders and other role models of prominent standing.62 Promote the inclusion of adolescent sexual and reproductive health in the curricula of health training institutions. Work with community leaders to ensure local enforcement of policies and legislation supportive of young people, including efforts to combat sexual violence and exploitation at the community level. Community leaders are also important when working within the context of prevailing social and cultural norms is challenging. Develop networks with NGOs and other civil society groups. Engage the private sector, including pharmacies and other outlets, to ensure wide availability of services in venues where young people are comfortable. 36
•
• • •
• •
60 Op cit. Ref. 49. 61
Sex and America’s teenager. New York and Washington, DC, Alan Guttmacher Institute, 1995. In: Hughes J, McClauley A. Improving the fit: Adolescents’ needs and future programs for sexual and reproductive health in developing countries. Studies in family planning, June 1998 (29)2: 233-245. 62 Before it’s too late. Pacific experiences addressing adolescent reproductive health. Suva, Fiji, UNFPA Office of the Pacific, 2005.
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•
Influence the media to provide positive role models and accurate information on sexual and reproductive health issues to young people and the public at large.
(3) Support and promote research, especially community-based needs assessments and the identification of effective community programmes for raising awareness, advocacy and affecting positively community norms to support the sexual and reproductive health of young people. (4) Support and promote community-based poverty alleviation efforts and income earning opportunities that seek to provide educational and economic opportunities for young people as a means to protect their health. Empowering young women with income-earning opportunities, for example, enables them to participate more equally in decision-making within the family and the community. They are also less likely to be sexually exploited and abused.
Summary note Many of the factors that impact adversely upon the sexual and reproductive health of young people stem from their immediate social environment, including poverty and unemployment; restrictive social and gender norms, especially those that reduce equitable access to information and services; and the impact of social and economic changes. While programmes to improve the sexual and reproductive health of young people cannot focus directly on inequities and injustices in society, they must create an immediate social environment that fosters personal development and open communication to encourage young people to adopt healthy types of behaviour. Families, communities, the media and others can communicate positive norms and actions to promote healthy behaviour among young people and adults alike. Some ways by which this can be done are described above. However, it must be remembered that programme efforts need to take into account the fact that young people are not all alike and that interventions and the ways in which they are delivered will vary according to the differing needs and circumstances surrounding young people’s lives. For this reason, it is imperative that young people themselves also play an active role in improving their immediate environment and thus the conditions that affect their sexual and reproductive health.
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chapter seven
accelerated actions Issues and challenges
S
everal actions have been presented in this framework in the three key strategic areas of: promoting healthy behaviour through life-skills-based information and education; ensuring the provision of appropriate sexual and reproductive health services for young people; and creating a supportive and enabling environment. This chapter describes seven cross-cutting strategies to direct attention and resources towards institutionalizing, accelerating and scaling up current and future programmes and activities. These seven strategies are: (1) securing political will; (2) formulating and implementing policies and legislation; (3) mobilizing resources to ensure sustainability; (4) building human resource capacity; (5) establishing research, monitoring and evaluation mechanisms; (6) forging partnerships; and (7) applying lessons learnt.
Securing political will Lack of political will and support is a major obstacle in taking action towards improving the sexual and reproductive health of young people. There are several reasons for this, such as a lack of knowledge or misunderstanding about young people’s sexual and reproductive health, a tendency to ignore uncomfortable realities, or strong pressure from opposing political, religious or community groups. Such factors may result in a lack of legislation and policy, as well as a lack of financial support, both of which may negatively affect young people’s sexual and reproductive health and rights. Consequently, building political will and support in all related sectors is essential for ensuring that the actions recommended in this framework can be undertaken effectively.
Recommended actions: (1) Advocate for the rights of young people to health information and services by mobilizing media support and communicating influential and reliable messages that reach a wide audience. (2) Raise awareness and move adolescent sexual and reproductive health up the political agenda by communicating the benefits of improved sexual and reproductive health for young people effectively, including the benefits for local and national development.
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(3) Guide the development of policy, advocacy activities, community education, service protocols, pilot interventions and research. (4) Engage policy-makers and community, religious and political leaders to participate as champions of young people’s sexual and reproductive health. Gain greater cooperation by positioning young people’s sexual and reproductive health as a public health issue, rather than a moral or social one. (5) Collaborate with partner agencies on pertinent, cross cutting issues that affect young people’s sexual and reproductive health, such as education, nutrition, employment, labour migration, sexual violence and trafficking.
Formulating and implementing policies and legislation Experiences from several countries indicate that young people’s sexual and reproductive health is always placed low on the political agenda. This is due mainly to a lack of political will and commitment by any one sector; to competing priorities that may appear more pressing to address (such as youth employment, education or taxation); and to a lack of national consensus on how to approach such a sensitive issue. Even in countries with clear policies and political will, however, translating them into actual programmes and activities has been challenging. Moreover, special care must be taken, since the existence of some laws, such as pregnancy termination, may affect young people’s lives in a negative way, and may not cover the needs of special groups. Policies and legislation are therefore crucial: • as a framework for political action to declare youth development and the provision of sexual and reproductive health to young people as priorities; for providing realistic guidelines to ensure strong coordination among organizations serving young people and to enhance service delivery; for accommodating the diversity of the young population and responding to the specific needs of young people who are marginalized and disadvantaged; and as a blueprint of rights and responsibilities, to maximize the participation of young people.63
• •
•
A review of national youth policy formulation experiences in the Region, including those dealing with sexual and reproductive health, emphasizes the importance of five key elements: (1) identifying the needs of young women and men; (2) using a participatory process; (3) creating an appropriate policy development vehicle; (4) adopting the policy at the highest political level; and (5) involving key stakeholders.64 These major elements can be translated into recommended actions as follows.
Recommended actions: (1) Review existing policies and identify policy gaps in addressing young people’s sexual and reproductive health and their needs. 63 64
Youth policy formulation manual. United Nations Economic and Social Commission for Asia and the Pacific. 1999. Ibid.
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(2) Establish a mechanism and include the participation of members from different government agencies, nongovernmental organizations, the private sector and civil society (i.e. young people, families and communities) in the process of policy formulation. Governments should take the lead role in such a mechanism. (3) Formulate policies and interventions aimed at strengthening the capacities of families, communities and enforcement officials to protect young people and support their healthy development by ensuring an environment that enhances protective factors, such as encouraging and sustaining positive behaviour, as well as reducing the risk and diminishing the effects of negative health outcomes.65 (4) Incorporate policies and interventions into appropriate documents, such as the national public health strategic plan and provincial business plans, to ensure the visibility of young people’s health at different levels. (5) Endorse and disseminate policies and legislation, and prepare guidelines for implementation within government and nongovernmental sectors. (6) Collaborate with partner agencies, nongovernmental organizations and the private sector to implement policies and legislation, as well as evaluate and disseminate information about ongoing sexual and reproductive health programmes for young people. Developing, facilitating and sustaining partnerships require identified coordinators, an appropriate budget, respected relationships and mechanisms created for working together complementarily. The motivation of partners to collaborate should be maintained through regular feedback on their joint efforts and wide recognition of their positive achievements.66
Mobilizing resources to ensure sustainability Ensuring sustainability is a major difficulty faced by most adolescent sexual and reproductive health programmes in this Region in scaling up and institutionalization. Insufficient governmental engagement and commitment is another barrier. Consequently, government leadership and involvement should be motivated and enhanced in all aspects of programming to ensure sustained support for initiatives to improve young people’s sexual and reproductive health. Once institutionalized, the programmes will be able to mobilize resources from the entire national resource base. Although United Nations agencies will assist, governments themselves need to provide the funding to support implementation. Governments may consider financing options, such as taxes, insurance and pre-payment, user fees and community support. Feedback to partners on programme progress and outcomes is also essential for accountability and to reinforce their commitment.
Recommended actions: (1) Establish the cost of implementing a sexual and reproductive health programme for young people, as well as the cost of failing to act.67 65 66
Broadening the horizon: Balancing protection and risk for adolescents. Geneva, World Health Organization, 2002. A healthy start in life. Report of the Global Consultation on Child and Adolescent Health and Development. Stockholm, 2002. (WHO/FCH/CAH/02.15). 67 State of the world’s population 2003. Making 1 billion count: Investing in adolescents’ health and rights. United Nations Population Fund, 2003.
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(2) Estimate the contributions needed from the government and United Nations agencies to fund the implementation plan. (3) Identify key sources of funding and the roles and responsibilities of funding agencies. Different components of the sexual and reproductive health programme will have different resource bases. • The private sector is an important player, as private facilities rely on direct payments and should be included as part of the resource base. The nongovernmental sector often provides services that are not otherwise available. The public sector will need to take the lead in public health and data collection, which cannot easily be delegated to the private or nongovernmental sectors.
• •
(4) Advocate for sexual and reproductive health resource allocations from communities and the government by presenting statistics, evidence of positive outcomes of practical models, testimonials from young people about their experiences in accessing youth friendly services, and the estimated rate of return, through a cost benefit analysis.68 (5) Consolidate the efforts of United Nations agencies to: • press the need for young people’s sexual and reproductive health strategies with government representatives at international forums; provide or auspice conferences and workshops on young people’s sexual and reproductive health in direct ways.
•
Building human resource capacity Knowledge, skills and attitudes of service providers are the essence of capacity building to ensure the provision of youth friendly sexual and reproductive health services. Human resource and capacity building in relation to improved sexual and reproductive health for young people involves taking actions in the provision of information and education, counselling services, clinical services and programme management, including monitoring and evaluation. Effective advocacy also requires certain skills, and capacity building in that area needs further development. Unfortunately, health professionals, teachers, social workers, peer educators, parents and religious leaders often do not have a correct understanding of young people’s sexual knowledge, attitudes and practices to guide them in how to provide the services young people require.69 Consequently, specific actions are needed to improve their knowledge and attitudes, especially in terms of giving health providers effective skills in counselling and behaviourchange communication (BCC). There is also a need to develop and disseminate broadly appropriate BCC and training materials to help in building and supporting the knowledge and skills of young people and health providers alike. Detailed recommendations regarding human capacity building are presented in Chapters Four and Five.
68 Op cit. Ref. 4. 69
Op cit. Ref. 51.
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Establishing research, monitoring and evaluation mechanisms One weakness of past programmes was that monitoring and evaluation components were not incorporated into programme design, making systematic assessment of their relevance, adequacy, effectiveness, efficiency and impact difficult. Good monitoring and evaluation will not only ensure that programmes are made accountable to all stakeholders, but will also provide important feedback that can help programmes to be reoriented strategically so as to enhance potentially effective interventions.70 Unfortunately, however, programme managers often lack knowledge and skills in using monitoring and evaluation methods, including process, outcome and impact evaluation, as well as in translating evaluation findings into actions for programme improvement. In addition, indicators (both quantitative and qualitative) to evaluate young people’s sexual and reproductive health status are not well established, and data collection and reporting systems rarely exist. Furthermore, there is a need for partnership and dialogue between donors, programme managers and experts in technical organizations in the development, definition and use of such indicators. There are still areas in need of in-depth study, especially those designed to determine priority areas, identify effective interventions for particular target groups, assess the impact of youth participation, and explore the very nature of and underlying factors contributing to young people’s behaviour.
Recommended actions: (1) Enhance the capacity of country programmes to undertake monitoring and evaluation for better programme performance:71 • Advocate for the value of monitoring and evaluation, and secure funding to finance data collection and analysis, the design of information systems and technical assistance, or the hiring of staff with expertise in monitoring and evaluation. Incorporate a monitoring and evaluation plan into the programme design, based on a clear programme goal, objectives, time-frame, baseline data requirements and data collection methods.
•
(2) Strengthen the health information system for young people, with age- and gender-disaggregated data management and utilization, and establish mechanisms for regular reviews to help identify priority health problems, develop appropriate interventions, monitor and report on the effectiveness of those interventions, and make improvements. (3) Support and build capacity in research and development: • Give priority to stimulating and conducting research and development activities that will inform policy, lead to new technologies, improve delivery strategies relevant to identified needs of young people, and solve problems in programme implementation.72
76
Programming for adolescent health and development: Report of a WHO/UNFPA/UNICEF Study Group on Programming for Adolescent Health. Geneva, World Health Organization, 1999. 77 Ibid. 78 Op cit. Ref. 37.
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• •
Optimize the use of national research organizations. Train individuals and organizations on the methodology and skills necessary to conduct research, and provide avenues to support them financially. Translate the research results into programmes and actions.
•
Forging partnerships for action The overall reproductive health and development of young people is complex and subject to a number of determinants, such as gender and power relations, access to information and services, life skills, opportunities in life, and a supportive environment. Minimizing the risks and maximizing the benefits for young people requires an energetic coalition from various sectors to build on existing systems and reach beyond the clinic to where young people actually spend their time. Partnerships are crucial in formulating health policy, creating supportive conditions and environments, and empowering youth, as well as the community at large. Partnerships will also provide a wide range of inputs (expertise), maximize the use of available resources, and help to avoid duplication of efforts.
Recommended actions: (1) Map capacity and articulate the roles and responsibilities of government, the private sector, the international donor community, nongovernmental partners, and technical support organizations in the delivery of a comprehensive, integrated young people’s sexual and reproductive health strategy within countries. (2) Increase horizontal and vertical partnerships between groups in order to advocate more strongly around issues of critical importance to young people’s sexual and reproductive health. (3) Invest in collaborative approaches and develop innovative pilot or demonstration projects with diverse partners in order to provide space for special needs groups, and to ensure that they become nationally significant where possible. (4) Gain support from the media to raise awareness among leaders and the general population. The media has an important role to play, particularly through the communication and sharing of innovative approaches, case studies and best practices. (5) Mobilize support from multilateral, bilateral and private foundations, as well as the business sector, in order to increase the resources for sexual and reproductive health programmes for young people. Private sector businesses, for instance, can often be mobilized to pay for programmes for their young employees (e.g. factory-based programmes) when they realize the cost savings of protecting workers, even just in a decrease in absenteeism. (6) Create a platform to facilitate and promote partnership between young people and adults to allow them to work in full partnership in envisioning, developing, implementing and evaluating programmes.
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Applying lessons learnt Numerous studies, research projects and pilot programmes have been undertaken in the last decade, providing valuable experience and information on what works and what does not. Use should be made of such accumulated knowledge to scale up and/or institutionalize sexual and reproductive health programmes for young people as part of a country’s goal of achieving sustainable development.
Recommended actions: (1) Identify successful programmes that have been implemented to address the sexual and reproductive health needs of young people. Documenting the ‘key process elements’ and the concepts that contribute to programme success should be encouraged, supported and shared as much as possible. (2) Encourage critical analysis and document the key elements of the failures and difficulties of programmes – not necessarily the successes – and treat them as lessons learnt and challenges for others to overcome. (3) Encourage governments to disseminate information, about both successes and challenges, and replicate successful programmes throughout the Region where appropriate.
Summary note This chapter is an essential pillar in making the recommended actions identified in previous chapters possible, as well as in achieving the institutionalization of sustainable sexual and reproductive health programmes for young people. The aim is to guide policy makers and programme managers to address and respond to the reproductive health needs of young people in the East Asia and the Pacific Region. The seven strategic areas for accelerated action presented in this chapter cut across all levels and stakeholders, such as individuals, the community and service facilities, as well as government, nongovernmental and international organizations. This chapter also conveys two major messages: • Success in improving the sexual and reproductive health of young people does not come easily – nor does it take place by chance. It is the result of integrated and collaborative efforts, with the government taking the lead through strong and continuous commitment, coordination and resource allocation, so that programmes become institutionalized and sustainable. Improving the sexual and reproductive health of young people is not restricted to “health” alone. It is also a means to ensure social and economic well-being. Young people account for a substantial proportion of the population in low and middle income countries.
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Consequently, investing in programmes to improve their sexual and reproductive health offers a high rate of return, not only for the young people themselves, but also for the communities and countries in which they live.
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ANNEX 1 LIST OF CONTRIBUTORS January 2004 Consultation
Temporary advisers Dr Atsuko Aoyama, Professor, Department of International Health, Nagoya University School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan Ms Aurora Silayan Go, President, Foundation for Adolescent Development, Inc., 1037 R. Hidalgo Street, Quiapo, Manila, Philippines Mr Gu Baochang, Deputy Executive Director, China Family Planning Association, Building 35, Shaoyaoju, Chaoyang District, Beijing 100029, China Dr Ji Chengye, Director, Institute of Child and Adolescent Health, Peking University Health Science Center, Beijing 100083, China Mr Joseph Lagoiala, Project Officer, Vanuatu Family Health Association, Private Mail Bag 075, Port Vila, Vanuatu Dr Lam Phirun, Senior Coordinator, National Reproductive Health Programme, National Maternal and Child Health Centre, Sangkat Sras, Daun Penh, Phnom Penh, Cambodia Dr Rufina Latu, Adviser, Adolescent Reproductive Health, Secretariat of the Pacific Community, Private Mail Bag, Suva, Fiji Mrs Nguyen Thi Bich Hang, Country Representative, Marie Stopes International Viet Nam, Room 104, 521 Kim Ma Road, Ha Noi, Viet Nam Dr Nik Rubiah Nik Rashid, Principal Assistant Director, Adolescent and School Health Unit, Family Health Development Division, Ministry of Health, Jalan Cenderasari, Kuala Lumpur 50590, Malaysia Dr Bayar Oyun, Adviser, Adolescent Reproductive Health Projects, United Nations Population Fund, Jamyan Gunii Street-7, Ulaanbaatar48, Mongolia
Resource person Ms Kerry Arabena, Executive Director, Sexual Health and Family Planning ACT, P.O. Box 1317, Canberra ACT 2600, Australia
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Observers/Representatives International Planned Parenthood Federaton (IPPF) Ms Naomi Imani, Programme Manager (Adolescent and Youth), No. 246 Jalan Ampang, 50450 Kuala Lumpur, Malaysia Japanese Organization for International Cooperation in Family Planning (JOICPF) Ms Ryoko Nishida, Director, International Program,), Shinjuku-ku, Tokyo 162-0843, Japan Ms Kei Yoshidome, Hoken Kaikan Shinkan Bldg., 1-10 Ichigaya Tamachi, Shinjuku-ku, Tokyo 162-0843, Japan Ms Rosalinda Mendoza, Field Operations Adviser, Philippines Program for Appropriate Technology in Health (PATH) Ms Joan Haffey, Director, Adolescent Health Programs, 1800 K Street, N.W. Suite 800, Washington, D.C. 20006, United States of America Dr Carmina Aquino, Executive Vice-President, PATH Philippines, 26/F Yuchengco Tower, 6819 Ayala Ave cor Sen Gil Puyat Ave, Makati City, Philippines
June 2005 Consultation
Temporary advisers Dr Narimah Awin, Director, Division of Family Health Development, Ministry of Health, Block E, Jalan Dungun, Damansara Heights 50490, Kuala Lumpur 50590, Malaysia Mr Gu Baochang, Deputy Executive Director, China Family Planning Association, Building, 35 Shaoyaoju, Chaoyang District, Beijing 100029, China Ms Naomi Imani, Programme Manager (Adolescent and Youth), International Planned Parenthood Federation - East and South East Asia and Oceania Region (IPPF-ESEAOR), No. 246 Jalan Ampang, 50450 Kuala Lumpur, Malaysia Dr Rufina Latu, Adviser, Adolescent Reproductive Health, Secretariat of the Pacific Community, Private Mail Bag, Suva, Fiji Dr Bayar Oyun, Adviser, Adolescent Reproductive Health Projects, United Nations Population Fund, Jamyan Gunii Street-7, Ulaanbaatar-48, Mongolia
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Consultant Dr Bencha Yoddumnern-Attig, Institute for Population and Social Research, Mahidol University, Salaya, Phutthamonthon, Nakhon Pathom 73170, Thailand
Representatives Dr Annette Sachs Robertson, CST Advisor, Reproductive Health, United Nations Population Fund, Private Mail Bag, Suva, Fiji Dr Peter Chen, Advisor on Adolescent Reproductive Health, UNFPA/CST Bangkok, UN Building, Rajdamnern Nok Avenue, Bangkok 10200, Thailand Ms Joan Haffey, Director, Adolescent Health Programs, Appropriate Technology in Health (PATH), 1800 K. Street, N.S. Suite 800, Washington, D.C. 20006, United States of America Miss Qian (Chi-en) Geng, Senior Program Officer, Appropriate Technology in Health (PATH), 1800 K. Street, N.S. Suite 800, Washington, D.C. 20006, United States of America
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ANNEX 2 Characteristics of adolescent-friendly health services TThese characteristics are based on the WHO Global Consultation on Adolescent Friendly Health Services, held in Stockholm, Sweden, in 2001, and discussions at a WHO expert advisory group, held in WHO Headquarters in 2002. Adolescent-friendly health services require: (1) Adolescent-friendly policies that: • fulfill the rights of adolescents, as outlined in the United Nations Convention on the Rights of the Child and other instruments and declarations; take into account the special needs of different sectors of the population, including vulnerable and underserved groups; do not restrict the provision of health services on grounds of gender, disability, ethnic origin, religion or (unless strictly appropriate) age; pay special attention to gender factors; guarantee privacy and confidentiality and promote autonomy, so that adolescents can consent to their own treatment and care; and ensure that services are either free or affordable to adolescents.
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(2) Adolescent-friendly procedures to facilitate: • • • easy and confidential registration of patients, and retrieval and storage of records; short waiting times and (where necessary) swift referral; and consultation with or without an appointment.
(3) Adolescent-friendly health care providers who: • are technically competent in adolescent-specific areas and offer health promotion, prevention, treatment and care relevant to each client’s maturation and social circumstances; have interpersonal and communication skills; are motivated and supported; are non-judgmental and considerate, easy to relate to and trustworthy; devote adequate time to clients or patients; act in the best interest of their clients; treat all clients with equal care and respect; and provide information and support to enable each adolescent to make the right free choices for his or her unique needs.
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(4) Adolescent-friendly support staff who are: • • understanding and considerate, treating each adolescent client with equal care and respect; and competent, motivated and well supported.
(5) Adolescent-friendly health facilities that: • • • • provide a safe environment at a convenient location with an appealing ambience; have convenient working hours; offer privacy and avoid stigma; and provide information and educational material.
(6) Adolescents’ involvement, so that they are: • • • well informed about services and their rights; encouraged to respect the rights of others; and involved in service assessment and provision.
(7) Community involvement and dialogue to • • promote the value of health services; and encourage parental and community support.
(8) Community-based, outreach and peer-to-peer services that increase coverage and accessibility. (9) Appropriate and comprehensive services that: • • • address each adolescent’s physical, social and psychological health and development needs; provide a comprehensive package of health care and referral to other relevant services; and do not carry out unnecessary procedures.
(10) Effective health services for adolescents that: • • • are guided by evidence-based protocols and guidelines; have the equipment, supplies and basic services necessary to deliver the essential care package; and have a process of quality improvement to create and maintain a culture of staff support.
(11) Efficient services which have: • • a management information system, including information on cost of resources; and a system to make use of that information.
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