POLICY OCCASIONAL9 P APERS
Adolescent and Youth Reproductive Health in the Asia and Near East Region Status, Issues, Policies, and Programs
Karen Hardee Pamela Pine Lauren Taggart Wasson
January 2004
POLICY POLICY is funded by the U.S. Agency for International Development under Contract No. HRN- C-00-00-00006-00, beginning July 7, 2000. The project is implemented by Futures Group International in collaboration with Research Triangle Institute (RTI) and the Centre for Development and Population Activities (CEDPA).
ISBN 0-9605196-9-6
PO LI CY POLICY Occasional Paper #9
Adolescent and Youth Reproductive Health in the Asia and Near East Region Status, Issues, Policies, and Programs
Karen Hardee Pamela Pine Lauren Taggart Wasson
January 2004 Contents
Acknowledgments iii Executive Summary iv Abbreviations viii Introduction 1 Demographic and Social Context of Adolescent and Youth Reproductive Health 3 Demographic Profile, 2000–2020 3 Social Context 3 Education 5 Employment 6 Marriage and Childbearing 7 Adolescent and Youth Sexuality 8 Adolescent and Youth Reproductive Health Issues 9 Lack of Knowledge about Sexuality and Reproductive Health 9 Low Contraceptive Use 11 High Unmet Need for Contraception 11 Abortion 12 STIs and HIV/AIDS 12 Sexual Abuse, Exploitation, and Prostitution 14 Legal and Policy Environment for Adolescent and Youth Reproductive Health 15 Near East 15 South Asia 19 Southeast Asia 21 Adolescent and Youth Reproductive Health Programs 24 Near East 24 South Asia 27 Southeast Asia 31 Summary 34 Operational Barriers to Adolescent and Youth Reproductive Health 37 Recommendations 41 Endnotes 46 References 49 ii Acknowledgments
OLICY Occasional Papers are ◗ Ajit Pradhan and Molly Strachan Pintended to promote policy dialogue on (Nepal) family planning, reproductive health, and ◗ Aysha Khan and Pamela Pine (Pakistan) HIV/AIDS issues and to present timely ◗ Christine A. Varga and Imelda Zosa- analysis of issues that will inform policy Feranil (Philippines) decision making. The papers are ◗ W. Indralal De Silva, Aparnaa disseminated to a variety of audiences Somanathan, and Vindya Eriyagama worldwide, including public and private (Sri Lanka) sector decision makers, technical advisors, ◗ Khuat Thu Hong (Vietnam) researchers, and representatives of donor ◗ Arwa Al-Rabee’ (Yemen) organizations. An up-to-date listing of POLICY publications is available on the web Karen Hardee oversaw the project, and Lily at www.policyproject.com. Copies of these Kak and Elizabeth Schoenecker from publications are available at no charge. USAID and Ed Abel and Koki Agarwal from POLICY provided support. Karen This paper provides a synthesis of the Hardee, Pamela Pine, Lauren Taggart findings from a 13-country study of Wasson, and Nancy McGirr reviewed and adolescent and youth reproductive health edited the country reports. Felicity Young, issues, policies, and programs on behalf of Jeff Sine, and Don Levy were helpful in the Asia/Near East Bureau of the U.S. locating consultants to write the profiles. Agency for International Development Katie Abel assisted with compiling and (USAID). The reports were researched analyzing the country data. The STARH and written by: Program (Sustaining Technical ◗ Abul Barkat and Murtaza Majid Achievements in Reproductive Health), (Bangladesh) under the direction of Gary Lewis and ◗ Graham Fordham (Cambodia) Adrian Hayes from the Johns Hopkins ◗ Julia Beamish (Egypt) Center for Communication Programs, ◗ S.D. Gupta (India) supported the preparation of the Indonesia ◗ Iwu Dwisetyani Utomo (Indonesia) country report. ◗ Issa S. Almasarweh (Jordan) ◗ Julia Beamish and Lena Tazi Abderrazik Views expressed in this paper do not (Morocco) necessarily represent those of USAID.
iii Executive Summary
he POLICY Project conducted adolescent and youth reproductive health Tassessments of adolescent and youth necessitates a multisectoral approach—one reproductive health in 13 countries in the that focuses on decreasing girls’ Asia and Near East (ANE) region that vulnerability, promoting gender equity and represent diverse population sizes and schooling, and expanding life options for geographic, cultural, and socioeconomic both females and males. Each of the 13 settings. The countries include Egypt, countries needs to make more progress in Jordan, Morocco, and Yemen in the Near this regard. East; Bangladesh, India, Nepal, Pakistan, and Sri Lanka in South Asia; and Cambodia, Nonetheless, the ANE region has achieved Indonesia, the Philippines, and Vietnam in social, policy, and programmatic progress, Southeast Asia. In 2000, the 13 countries with some countries demonstrating accounted for a total of 354 million young substantially more progress than others. people ages 15 to 24 years. The purpose of Some countries’ adolescent and youth the assessments was to highlight the populations have greater knowledge of reproductive health status of adolescents and reproductive health, improved access to youth in each country within the context of information and services, and better overall the lives of young males and females. life circumstances as a result of policies and programs designed to address their Most young people in the ANE region begin reproductive health needs. Other their sexual lives within marriage, although, populations of young people, however, have as the age at marriage in the region rises, seen little progress and therefore are at an increasing number of young people are greater risk of early pregnancy, gender-based beginning to engage in sex before marriage. violence, and sexually transmitted infections While programs can and should promote (STIs), including HIV, and have limited delayed sexual initiation, young people— options for education and other life choices. regardless of when sexual activity begins— need to be adequately prepared for their The social and cultural context pertaining to sexual lives and relationships instead of young people differs considerably among the “being kept in the dark” until marriage. 13 countries, but the assessments found Programs can help prepare young people for several universal challenges in the region. sexual relationships by increasing their These challenges include the paucity of understanding of sexuality and the choices research and data on the age group, they can make to protect their reproductive particularly with regard to rural and health. Correspondingly, addressing minority adolescents and youth; insufficient iv attention to enormous gender disparities; that affect them. Youth must be actively lack of information and services available to involved in both discussing the issues facing young people (including married adolescents their generation and developing solutions and youth), often leading to unwanted that meet their needs for good pregnancy and disease; weak or nonexistent reproductive health. policies directly addressing adolescent and youth reproductive health; and small-scale 2. Inform policymakers about the needs of and generally weak programs, even where young people and advocate for policy national and other policies exist. In addition, and program change. the global environment in terms of both information (e.g., from films and television) Adolescent and youth reproductive health and resources (e.g., dependence on foreign remains a politically and socially sensitive aid) has had both positive and negative topic; policymakers are often reluctant or effects on the status of adolescent and youth unable to develop multisectoral policies reproductive health throughout the region. that address adolescent and youth reproductive health. Stakeholders need to The 13 country assessments indicate that advocate to policymakers based on an adolescent and youth reproductive health understanding of existing laws and policies. should be addressed by involving youth in Youth and adolescent reproductive health policy design and implementation; advocates should encourage development of advocating for policy and program relevant laws, policies, and guidelines to development; educating policymakers, ensure adequate protection and promotion teachers, parents, and adolescents and of adolescent and youth reproductive youth; facilitating family communication; health and attention to associated social promoting gender equity; expanding access issues, such as gender equity in education to information and services; and conducting and the economy. The support of an needed research to ensure that programs are individual, high-profile political figure can evidence-based. These challenges are not be crucial to improving a country’s new, although they take on more urgency in adolescent and youth reproductive health an era of rising prevalence of HIV/AIDS in policies and programs. This person’s the region. Nor are the challenges unique to advocacy and action can catalyze high-level the ANE region, even though the region is discussion and even effect change. home to the world’s largest group of adolescents and youth. Nevertheless, it is 3. Educate policymakers, teachers, parents, imperative that the 13 nations address the community leaders, and young people to challenges in order to improve the change public opinion about the reproductive health of today’s and future importance of meeting youth and generations of adolescents and youth. adolescent reproductive health needs.
1. Involve youth in developing policies and It is essential to reach—through the programs to meet their needs. appropriate means—village and community leaders and religious and Young people are often left out of opinion leaders so that they, in turn, can discussions about policies and programs influence community members, families,
v and parents. In most countries, the from their parents. Parents can also be appropriate message may be one strong advocates on a political level. underscoring the “healthy development of youth.” Young people should be fully One way to educate parents is through engaged in the development of messages their children’s education. Young people and the “packaging” of information for could take information home to their adolescents and youth. parents to engage their families in discussions about sexual relationships and Teachers and others who are in regular to educate their parents, who may have contact with youth and adolescents need to incomplete or inaccurate knowledge. feel both comfortable and adequate in Faith-based organizations (FBOs) can also dealing with adolescent and youth facilitate information exchange within reproductive health once they have the families. FBOs have succeeded in social platform on which to do it. Given the addressing the HIV/AIDS pandemic in conservative nature of most societies in the Africa; perhaps that model has a place for ANE region, these special gatekeepers will reaching young people in the ANE region. need assistance in acquiring appropriate skills and changing attitudes. Training can 5. Promote gender equity in all youth- be developed and conducted through related policies and programs. cooperation among governments, NGOs, and private organizations. Adolescents Promoting gender equity and positive should also have an opportunity for their gender norms around sex and reproductive voice to be heard. Communication among health, such as reducing early marriage and all stakeholders will be critical to eliminating or helping to redefine social comprehensive programming. systems (including the dowry system) that make females the chattel of males, must 4. Promote communication in families. form the foundation of comprehensive, multisectoral, and thus functional and For change to occur, the gap between successful programming. sociocultural norms and the realities of adolescent and youth reproductive health 6. Increase young people’s access to must be narrowed. Parents need to realize information and services. that social norms are changing, such that many adolescents and youth are sexually Reproductive health education in schools active. Parents also need accurate needs to be designed to make young people reproductive health information and must (and teachers) knowledgeable and become comfortable discussing reproductive comfortable with the information. The most health topics so that they can help and effective curricula are comprehensive and teach young people and support appropriate cover the biological and social aspects of policies and programs. Parents can be a reproductive health. Adequately trained great source of assistance and information peer educators can be useful additions to for their adolescent children, who want adolescent and youth reproductive health their first exposure to information on education programs. Adolescents and young sexual and reproductive health to come people should also have access to information vi through community clinics, satellite clinics, 7. Develop and promote evidence-based premarital counseling, family welfare programs. centers, schools, peer education, local youth forums, mass media, clubs, and so forth. To promote adolescent and youth reproductive health, programs should draw Service providers at all levels need to be on existing information on what works. trained in all aspects of adolescent and The resultant knowledge should be youth reproductive health. Each country disseminated widely and applied in should also examine the possibility of developing and implementing adolescent developing or strengthening links between and youth reproductive health education various services, such as between programs. Despite the availability of some clinics/pharmacies and youth activities, to information, all of the country reports achieve an integrated approach to pointed to the need for more research to adolescent and youth reproductive health. inform program efforts. Countries differ Often, NGOs have more flexibility than in the type of research needed, but, at a governments in providing information and minimum, research should focus on services to young people. Governments various segments of society, including and donors should consider providing more underserved, minority, and rural support to NGOs to undertake adolescent populations—those most at risk for poor and youth development work. reproductive health outcomes.
vii Abbreviations
AIDS Acquired immune deficiency syndrome ANE Asia and Near East A&YRH Adolescent and youth reproductive health CEDPA Centre for Development and Population Activities CMS Commercial Market Strategies (Project) FBO Faith-based organization FLE Family life education FP Family planning HIV Human immunodeficiency virus ICPD International Conference on Population and Development IEC Information, education, and communication MOH Ministry of Health NGO Nongovernmental organization RCH Reproductive and child health RH Reproductive health RTI Reproductive tract infection RTIResearch Triangle Institute STI Sexually transmitted infection UNAIDS Joint United Nations Program on HIV/AIDS UNESCO United Nations Educational, Scientific and Cultural Organization UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID U.S. Agency for International Development WHO World Health Organization
viii Introduction
dolescents and young people1 are at Despite the execution of international A the beginning of their sexual and agreements, countries’ policies and reproductive lives; they are also the next programs do not sufficiently promote or generation of parents. How they undergo provide for adolescent and youth preparation for this journey has tremendous reproductive health. To understand how implications for their own lives as well as for countries in one diverse region are national reproductive health outcomes, addressing the adolescent and youth including fertility, safe motherhood, and reproductive health, the POLICY Project sexually transmitted infections (STIs), conducted assessments of 13 countries in particularly HIV/AIDS. In the Asia and the ANE region: Egypt, Jordan, Morocco, Near East (ANE) region, as in other parts of and Yemen in the Near East; Bangladesh, the developing world, approximately one in India, Nepal, Pakistan, and Sri Lanka in four persons is between the ages of 15 and South Asia; and Cambodia, Indonesia, the 24 years. Governments throughout the Philippines, and Vietnam in Southeast Asia. region have agreed that adolescents and youth should be accorded access to good The assessments examined each country’s reproductive health through information social context and status, policies, and and service provision. The 1994 programs regarding adolescent and youth International Conference on Population and reproductive health and made Development (ICPD) Programme of Action recommendations for future action. emphasized a holistic concept of Adolescent and youth reproductive health reproductive health that included adolescent status and the sociocultural and political and youth reproductive health as an integral influences that shape it vary among the component. The Programme of Action noted countries, making it difficult to tackle that signatory “countries, with the support adolescent and youth reproductive health as of the international community, should a single ANE regional issue. However, the protect and promote the rights of assessments found several universal themes adolescents to reproductive health within the region that may be addressed to education, information, and care.”2 In improve adolescent and youth reproductive addition, United Nations member states health status throughout Asia and the Near agreed to the Millennium Development East. These challenges include the paucity Goals to reduce poverty, which include of research and data on the age group, young people’s need for gender equity, particularly with regard to rural and education, safe pregnancy, and reduction in minority adolescents and youth; insufficient the spread of STIs and HIV/AIDS.3 attention to enormous gender disparities;
1 lack of information and services available to This paper discusses the social context young people (including married that sets girls and boys in the ANE region adolescents and youth), often leading to on different life paths; the sexual, unwanted pregnancy and disease; weakness reproductive health, and STI/HIV/AIDS or absence of policies directly addressing issues facing young people; the countries’ adolescent and youth reproductive health; policies and programs; operational policy and small-scale and generally weak barriers to addressing adolescent and programs, even where national and other youth reproductive health; and policies are in place. In addition, the global recommendations for policies and environment in terms of both information programs in the region. The findings are (e.g., from films and television) and generally grouped by the subregions resources (e.g., dependence on foreign aid) within the wider ANE region, namely, the has had both positive and negative effects Near East, South Asia, and Southeast on the status of adolescent and youth Asia, with country examples illustrating reproductive health throughout the region. specific points.
2 Demographic and Social Context of Adolescent and Youth Reproductive Health
oung people in the ANE region live in of the countries—Jordan, Nepal, Pakistan, Ya wide range of political, economic, the Philippines, and Yemen—youth social, cultural, and religious settings. populations will continue to grow through Nevertheless, the similarities in issues 2020. In Bangladesh, Cambodia, Egypt, affecting adolescent and youth reproductive India, Indonesia, and Morocco, the size of health in Asia and the Near East are greater the youth populations will start to decline than the differences. Overall economic after 2015. The size of the youth development remains weak, and the region populations in Sri Lanka and Vietnam will is characterized by wide urban-rural begin to decline before 2015. disparities with regard to health, education, and other indicators. In many of the countries, religious beliefs and practice have Social Context an overarching influence on adolescent and youth reproductive health issues, policies, Gender norms and roles. Gender and programs. Similarly, social issues socialization in the region sets girls and related to gender socialization, education, boys on separate life-time paths in terms of employment, and marriage affect the life expectations, educational attainment, region’s adolescent and youth reproductive job prospects, labor force participation, health. In addition, young people in reproduction, and duties in the household. virtually all countries are coming under the Adolescence is a crucial period of the life influence of global and national media. cycle for the socialization of gender roles regarding sexuality and reproductive health. The 13 country assessments all Demographic Profile, noted unequal gender norms regarding 2000–2020 what constitutes appropriate behavior among boys versus girls and how these In all, the 13 countries in Asia and the norms manifest themselves in the behavior Near East were home to 354 million young of young people. people in 2002. The region’s countries vary dramatically in population size, from The assessments noted the social Jordan with approximately 5 million people subordination of girls and the resultant to India with more than 1.03 billion. inequity and discrimination to which they Correspondingly, Jordan has approximately are subjected. During childhood, 1 million youth (ages 15 to 24 years) households expect girls to perform more compared with 200 million in India. In five domestic chores than boys, allowing
3 adolescent boys to enjoy more leisure time wives.”6 In Yemen, “in childhood, the male and to focus more on their studies. The child’s needs (e.g., education, care, and assessments also noted that adolescence nutrition) take precedence. The focus for marks a period in which boys enjoy the female child is on becoming a good, increased social mobility as girls’ social obedient wife and mother, which entails mobility is curtailed. Adolescent girls are early training in domestic activities and kept closer to home, especially in some agricultural work, including transporting Islamic countries that practice purdah water in rural areas.”7 norms, which separate the sexes and restrict females socially—particularly after South Asia. The India assessment noted adolescence and puberty. that differences in attitudes toward boys and girls lead to discriminatory behaviors After marriage, females’ power over that can begin at birth with prenatal sex resources and decision making within the determination and female feticide and home and family tends to be far less than continue with nutritional deprivation, that of their husbands, particularly for lower allowance for educational those living in extended families. In all of attainment, greater household work the region’s countries, females are expectations, and early marriage for girls.8 expected to be wives and mothers The situation for women in Bangladesh responsible for the domestic sphere, and Pakistan is much the same. In including childrearing. With growing Pakistan, menstruation marks a girl’s educational and career options, however, transition to womanhood. In Punjab opportunities for young women are Province, “a girl was immediately expected expanding, although females are not to observe purdah and wear a burqa [full necessarily released from traditional body covering] and would be married expectations. within two or three years.”9 In urban Nepal, “for boys...adolescence marks a Near East. In Egypt, “the movements of period of increased mobility, reduced adolescent girls are restricted and their supervision, growing interest in fashion, participation in public activities is severely and increased participation in youth limited...Women strive to be ‘marriageable’ clubs...For girls...adolescence is marked by and to fulfill the conventional vision of decreased social mobility. Within the womanhood.”4 The situation for young household, girls are expected to do more women is similar in Jordan, where “young housework than their brothers and, women’s marriageability is an important consequently, have no time for leisure.”10 consideration.”5 In Morocco, as elsewhere In Sri Lanka, adolescents “face lower levels in the region, “early on, girls discover that of gender discrimination at home and at they are second to their brothers. From a school relative to adolescents in the rest of young age, girls have to assume adult South Asia. However, despite performing responsibilities, starting with domestic as well, if not better than, their male chores, whereas boys can enjoy a more counterparts at school and university...Sri leisurely childhood. Imposing these Lankan women continue to be burdened responsibilities on girls is part of the with productive, reproductive, and social process of training them to become good expectations.”11
4 Southeast Asia. In Cambodia, “marriage adultery, to restore honor to the family. and domestic labor are viewed as the Females have little recourse against such primary goals for girls, and young girls are violence. often removed from school to care for younger siblings and help with household and agricultural tasks.”12 In Indonesia, Education “the girl children in the family have to be trained to be responsible for domestic While educational attainment is rising for chores and care giving...An Indonesian both females and males throughout the woman is taught to submit, maintain region, inequality in access to and harmony in her family, and devote her life completion of education is apparent in to domestic concerns and her family’s well- most of the countries. More female than being...”13 The Vietnam assessment noted male youth remain uneducated (see a “conflict between the modern and Figure 1), and fewer young females have traditional models of gender completed secondary and/or higher relations...While gender roles are in education. In several countries, the transition in Vietnam...many stereotypes magnitude of young females’ educational and gender values have changed little over centuries. Although what women do as Figure 1. Adolescents Ages 15 to 24 Years part of their daily tasks has changed with No Education, by Sex, in Selected ANE Countries, Various Years dramatically in recent years, the image of the ideal Vietnamese woman is still the Percent traditional one of housewife.”14 70 Near East South Asia Southeast Asia
The subordinate position of females in all 60 59.1 Male 54.3 13 countries is also manifest in gender- Female 50 45.9 based violence, noted explicitly in 45.9 Bangladesh, Cambodia, Jordan, Pakistan, 40 38.4 and the Philippines, although its extent is 31.0 unknown. The Bangladesh assessment 30 highlighted physical and sexual violence 25.1 21.5 20.0 perpetrated on girls and women, including 20 18.5 16.8 14.6
marital rape, which is not uncommon in 11.7 15 10 6.8
that country. The Cambodia assessment 5.9 4.9 4.3 3.3 2.8 2.2 1.7 1.7 1.3 1.2 noted that the rape of girls younger than 1.1 0 12 and adolescent girls is sometimes used Egypt India as a means to force marriage and that the Jordan Yemen Nepal Morocco Pakistan Vietnam 16 Sri LankaCambodiaIndonesiaPhillipines violence often continues after marriage. Bangladesh The Jordan assessment describes a “culture of silence” that results in most domestic Note: The Morocco country report did not include data on the percentage of adolescent boys with no education. 17 violence in Jordan going unreported. Sources: Demographic and Health Surveys or other national reproductive health Jordanian females may also be victims of survey, various years. Egypt (2000); Jordan (1997); Morocco (1995); Yemen DMCHS (1997); Bangladesh (2000); India NFHS (1999); Nepal (2001); honor killings, in which a male family Pakistan (1991); Sri Lanka Department of Census and Statistics (2000); member kills a female for a crime, such as Cambodia (2000); Indonesia (1997); Philippines (1998); Vietnam (1997).
5 disadvantage is remarkable. In Yemen, for Cambodia, and Morocco state, respectively, example, 54 percent of female youth has no that education is equally available to education compared with 6 percent of females and males, accessible to all, and a males. Data for Cambodia, India, Nepal, universal right. However, in reality, not all and Pakistan also indicate great gender children are able to attend school in these gaps in educational attainment. In countries. In Cambodia, for example, Cambodia, by age 15, the male school education is free, but teachers charge extra enrollment rate is 50 percent higher than fees to supplement their paltry salaries. In that of females.18 In Nepal, even though Vietnam, the government no longer the government adopted a policy in 1990 of subsidizes school fees. Therefore, in both free education for all children through the countries, many children cannot afford to seventh grade and places special emphasis attend school, and, often, girls in rural on the need to educate girls, a significant areas are pulled out of school. gap remains between educational attainment for boys and girls.19 The level of education of young women worldwide has direct relevance to The gender gap in education is not, reproductive health as well as to issues of however, as dramatic in some counties and broader gender equity. Women’s education shows exceptions to the general trends. In is related to use of family planning and Jordan, Indonesia, the Philippines, Sri reproductive health outcomes; worldwide Lanka, and Vietnam, few young people are increases in education are linked with uneducated, and the percentage of female higher contraceptive use, smaller family youth with no education is nearly identical size, and better birth outcomes. to that of male youth. In Jordan, Sri Lanka, and the Philippines, a higher proportion of female than male youth has Employment completed secondary and/or higher education. Young people of both sexes share some employment trends. Several country The country assessments also noted an assessments noted that unemployment urban-rural gap with regard to education. rates are highest among youth and thus In Indonesia, for example, after the first identified underutilization of young nine years of compulsory education for both people’s time as a concern. Many young girls and boys, the gap widens, with 60 people who work do so to help their percent of young people ages 15 to 19 years families, often without pay. In all of the no longer in school in rural areas compared countries, young females have far fewer with 33 percent in urban areas.20 employment opportunities compared with young males. In Egypt, for example, one- These gaps exist despite many countries’ half of young males and one-sixth of young education policies. Egypt, Indonesia, females work.21 Both young males and Jordan, Sri Lanka, and Yemen have females in Morocco have difficulty finding formulated and put in place policies that jobs; however, the areas in which they seek make some level of education compulsory and obtain jobs differ, with young females for males and females. Bangladesh, working in factories and young males
6 providing manual labor.22 In Bangladesh, a to cement economic relations between larger percentage of females work in families. The assessments highlighted agriculture than in manufacturing.23 In dowry as an issue in Bangladesh, Morocco, Vietnam, more females than males ages 15 and Yemen. The Bangladesh assessment to 29 years work in the state sector of characterizes dowry as providing a platform socialist enterprises.24 for economic and sexual gain for the paid groom while providing little regard and The treatment of some girls with regard to doubtful benefit for his future wife.27 In employment poses concerns. In rural areas contrast, “love marriages” are now more of Morocco, for example, girls as young as common than arranged marriages in five or six years of age are often sent to Indonesia.28 work for well-to-do families, and some experience beatings and/or sexual abuse.25 Childbearing often begins soon after A similar situation exists in Pakistan.26 marriage. The percentage of young women that has given birth by age 20 ranges from 17 percent in Jordan and Morocco to more Marriage and Childbearing than 60 percent in Bangladesh (see Figure 3). Still, just as the age at marriage The expectation and reality of marriage is universal in the ANE region, although Figure 2. Percent Married by Age 18 among young females are marrying later, on Females Ages 20 to 24 and 45 to 49 Years in Selected ANE Countries, Various Years average, than their mothers’ generation. Figure 2 shows the percentage of young Percent
females ages 20 to 24 years and older 100 Near East South Asia Southeast Asia
females ages 45 to 49 years who were 90 90 married by age 18. In all countries, except 20–24 80 78 Yemen, a smaller percentage of younger 74 45–49 70 females than older females were married 65
by age 18. Young females in South Asia 60 56 53 50 49 tend to marry earlier than do young 50 48 females in the other subregions. In 37
40 36 Bangladesh in 2000, nearly 65 percent of 30 30 young females ages 20 to 24 years were 25 20 20 19 15 married before age 18, and close to one- 15 14 12 12 half of young Indian and Yemeni females 10 were married by age 18. In comparison, in 0 Vietnam, approximately 10 percent of Egypt India Jordan Yemen young females were married by age 18. Morocco Vietnam CambodiaIndonesiaPhillipines Bangladesh Early and arranged marriage remains the Note: Only the countries for which data were available were included in this norm in a few countries, particularly those figure. in the Near East and South Asia. In some Source: Demographic and Health Surveys or other national reproductive health surveys, various years. Egypt (2000); Jordan (1997); Morocco (1995); Yemen countries, including Nepal, child marriages (1997); Bangladesh (2000); India (1999); Cambodia (2000); Indonesia (1997); are still sometimes arranged in rural areas Philippines (1998); Vietnam (1997).
7 is rising in most countries, age at first birth marriage certificate, “I give you as a bride is rising among young women compared my daughter who is still a virgin.”29 In with their mothers’ generation in all Cambodia, “adolescent girls are expected to countries except Vietnam and Yemen. uphold the virtue and honor of their family by taking care of their reputation and maintaining not only their actual virginity Adolescent and Youth but also their imputed sexual reputation.”30 Sexuality In contrast, young males are not held to Throughout the region, cultural norms and the same standard, and sex before religious beliefs dictate different attitudes marriage, while not socially condoned in all toward males and females with respect to of the countries, is more accepted. In adolescent and youth sexuality and sexual Cambodia, young males are expected to practices. For females, only sex within “seek out multiple partners both prior to marriage is considered socially acceptable; and after marriage.”31 In the Philippines, tradition continues to place a premium on young males often receive a sexual female virginity at the time of marriage. In “baptism” with a prostitute, which is Morocco, for example, the bride’s father arranged by a male family member.32 In declares to the groom, per the current general, homosexual behavior is not condoned, although it does occur in the Figure 3. Percent Who Gave Birth by Age 20 ANE countries included in this study. among Females Ages 20 to 24 and 45 to 49 Years in Selected ANE Countries, Various Years While data on the topic of adolescent and Percent youth sexual behavior are scant, in reality, 100 Near East South Southeast Asia the number of adolescents and youth in the Asia 90 ANE region engaging in premarital sex is 83 20–24 increasing as a consequence of rising ages 80 45–49 at marriage and greater exposure to 70 national and global media and changes in 61 60 traditional norms.33 This increased sexual 48 50 47 activity takes place in the context of highly 45 42 41
38 unequal gender relations and, as described 40 37
31 in the next section, limited information on 30 29 24 24 reproductive health and safer sex practices, 21 19
20 17 17 15 leading to exposure to the risk of 10 unintended pregnancy, abortion, and 0 STIs/HIV/AIDS.
Egypt Jordan Yemen Morocco Vietnam CambodiaIndonesiaPhillipines Bangladesh
Note: Only the ANE countries with available data were included in this figure. Source: Demographic and Health Surveys or other national reproductive health surveys, various years: Egypt (2000); Jordan (1997); Morocco (1995); Yemen (1997); Bangladesh (2000); India (1999); Cambodia (2000); Indonesia (1997); Philippines (1998); Vietnam (1997).
8 Adolescent and Youth Reproductive Health Issues
The reproductive health status of young current information and services that are people in the ANE region results from a available are not specific to adolescents, and number of factors that are not unique to the quality of such information and services the region but nonetheless affect young is often poor or inappropriate for this age people around the world, including group.”35 Other country assessments noted inadequate knowledge about sexuality, similar situations regarding the lack of fertility, and STIs/HIV/AIDS and early information available to and level of sexual activity without adequate knowledge among adolescents and youth protection, resulting in the risk of regarding sexuality and reproductive health. unintended pregnancy, induced abortion, Even in Sri Lanka, where adolescents and and STIs/HIV/AIDS. youth are aware of family planning, “the usual channels of information on safe sex, RH, and countering peer pressure are not Lack of Knowledge about available to adolescents”36 as a consequence Sexuality and Reproductive of the social taboo surrounding discussion of Health adolescent and youth reproductive health.
Throughout the region, young people begin For the most part, parents are sexual activity, even within marriage, with uncomfortable and socially proscribed from inadequate information to protect their discussing sex with their children. Teachers reproductive and sexual health. While and health care providers, like parents, are knowledge of family planning is high, social sometimes uncomfortable teaching conservatism makes discussion of sex adolescents and youth about sex. In sensitive, inhibited, and often taboo, addition, because many parents themselves affecting family communication and formal have had little education about sex and reproductive health education. For teachers may not have sufficient training to example, in the Philippines, “the [Catholic] teach reproductive health education Church’s primary stand is that one should properly, neither parents nor teachers not have sex before marriage. According to necessarily have good-quality information to this view, there is no point in providing convey to adolescents and youth. reproductive health services to adolescents and youth because by definition they are not Beyond issues of discomfort and social taboo, sexually active.”34 Cambodia likewise many adults do not want to discuss sex with maintains an official denial about adolescent unmarried adolescents and youth because and youth sexuality. In Bangladesh, “the they worry that providing information
9 encourages premarital sexual activity, even Egypt assessment noted that “what young though recent evaluations of sex education people do know they seem to have gathered programs worldwide have concluded that from the media.”38 The Indonesia such programs do not promote or lead to assessment pointed out the conflicting increased sexual activity.37 Some adults messages young Indonesians receive about therefore prefer maintaining the ignorance sexuality. On the one hand, the topic is of adolescents and youth, believing that they socially taboo for discussion either in public will get the information they need at the or in families; on the other hand, young proper time—at the time of marriage. people are exposed to sex-related However, married couples may remain information from various media. uninformed because sex is still a sensitive “Therefore, while young people are topic such that there are few opportunities provoked by the media about sex and for discussion or education. sexuality, they lack accurate information about sex, reproduction, and reproductive Adolescents and youth often turn to peer health.”39 Similarly, the Philippines groups or the media for information. The assessment noted that “what youth now get in terms of information is from their peers Figure 4. Ever-Use of a Modern Family and the media. And this is likely to be Planning Method among Married Females incorrect or misleading...They get Ages 15 to 19 and 20 to 24 Years in information from the wrong sources.”40 Selected ANE Countries, Various Years
Percent As a result, most adolescents and youth in
100 Near East South Asia Southeast Asia the ANE region have a paucity of 90 reproductive health knowledge. Even in 15–19 countries such as Morocco, where 80 20–24 72 contraceptive awareness is high among 70 70 urban adolescents and youth, actual 61 41
60 56 knowledge is deficient. “[Moroccan] 54 53 50 50 48 adolescents are starved for sexual and 42 41 reproductive health information.” In 40 Jordan, young married females can identify 29 30 28 an average of 2.6 modern family planning 19
18 43 17 20 16 methods, but “young couples know little 12
10 8 about sexuality and reproductive health 6 2 1 when they marry, so they embark on their 0 sexual and reproductive lives with little or Egypt India Jordan Yemen no knowledge and limited skills for Morocco Vietnam CambodiaIndonesiaPhillipines Bangladesh discussing or negotiating sexual and reproductive health preferences and Note: Only ANE countries for which data were available were included in this 44 figure. needs.” Source: Demographic and Health Surveys or other national reproductive health surveys, various years: Egypt (2000); Jordan (1997); Morocco (1995); Yemen (1997); Bangladesh (2000); India (1999); Cambodia (2000); Indonesia (1997); Knowledge about STIs and HIV/AIDS is Philippines (1998); Vietnam (1997). also scant among young people in the region, as discussed below.
10 Low Contraceptive Use among young people in the Philippines is almost nonexistent, probably because Contraceptive use tends to be low among young people associate condoms with STI young females, many of whom are and HIV/AIDS prevention rather than discouraged from using family planning with pregnancy prevention.45 Filipinos until at least the birth of their first child often consider condoms the tool of (see Figure 4). Ever-use of family planning prostitutes or promiscuous girls. The among young married females ages 15 to same holds true in Cambodia. 19 years ranges from 1 percent in Cambodia to more than 50 percent in Bangladesh and Indonesia. Use increases High Unmet Need for among young females ages 20 to 24 years Contraception compared with females ages 15 to 19 years presumably because the older group has The unmet need for contraception46 is had more children and wishes to begin generally high among young females in the either spacing or limiting childbearing. ANE region, particularly in the age groups 15 to 19 years and 20 to 24 years, ranging Incomplete or inaccurate information may affect contraceptive use. For example, Figure 5. Unmet Need for Contraception, despite high levels of modern method among Females Ages 15 to 19 and 20 to 24 knowledge, confusion exists among Years in Selected ANE Countries, Various Years Jordanian adolescents and youth because of Percent misunderstandings about Islam’s position 50 Near East South Asia Southeast Asia on modern contraception. Some Filipinos 15–19 believe that contraceptives have damaging 40 20–24 37.1 36.1 side effects, such as sterility and cancer; 36.0 35.6 33.8 33.2 32.3 some Vietnamese believe that 32.1 contraceptives are harmful to unmarried 30 29.4 27.1 females. 24.4 21.7 20.0 18.3 20 18.1
Social stigmas associated with 15.4 13.3 12.2 contraception also create barriers. Many 11.8 10.5 10.1 9.7 9.1 countries strongly pressure adolescents 10 8.6 and youth to hide their sexuality, especially from their parents. Young 0 people do not want to be caught obtaining Egypt India Jordan Yemen Nepal or possessing contraception. Furthermore, Morocco Pakistan Vietnam CambodiaIndonesia owing to the social premium placed on Bangladesh Philippines girls’ virginity, many young females want Note: Only the countries for which data were available were included in this to appear naïve with regard to sex. In figure. Vietnam, many girls do not negotiate Source: Demographic and Health Surveys or other national reproductive health surveys, various years: Egypt (2000); Jordan (1997); Morocco (1995); Yemen contraceptive use with their boyfriends so (1997); Bangladesh (2000); India (1999); Nepal (2001); Pakistan (1995); that they can maintain the impression of Cambodia (2000); Indonesia (1997); Philippines (1998); Vietnam (1997). their sexual innocence. Condom use
11 from around 9 percent in Indonesia to over percent in Egypt to 36 percent in the 35 percent in Cambodia (see Figure 5). Philippines. Pregnancies among young Unmet need for family planning among females are more likely to involve young females in union is highest in complications. Cambodia, Nepal, Pakistan, the Philippines, and Yemen. Unmet need translates into unintended pregnancies and Abortion the risk of abortion and maternal morbidity and mortality in addition to exposure to Abortion among adolescents and youth is STIs/HIV. becoming more common because of premarital pregnancies, which are While childbearing is expected to begin generally socially unacceptable. Abortion is early in marriage, not all young married most common in Southeast Asia— females intend to become pregnant when Cambodia, Indonesia, the Philippines, and they do. Figure 6 shows that, among the Vietnam. In Indonesia, one study showed young females younger than age 20, a that young unmarried females accounted significant percentage had experienced a for 40 percent of villagers seeking mistimed pregnancy, ranging from 5 abortions.47 The premarital abortion rate in Vietnam has doubled in the past 10 Figure 6. Mistimed Pregnancies among years, perhaps because increasingly Females Younger than Age 20 in Selected prevalent sexual activity among young ANE Countries, Various Years unmarried females has led to more Percent unwanted pregnancies.48,49
50 Near East South Asia Southeast Asia Abortion often has serious health effects. Given that abortion is illegal in most 40 36.6 countries, except in certain circumstances, such as when the life of the mother is
30 28.5 threatened, many abortions are clandestine 25.8 and thus may be self-induced or performed 22.9 50
19.4 by unqualified providers. Health 20 18.7
15.3 consequences for females include sepsis of 13.3 the uterus and birth canal. 10.2
10 8.8 5.1 STIs and HIV/AIDS 0
Egypt India Jordan Yemen Nepal HIV prevalence among youth in the ANE Morocco Vietnam CambodiaIndonesia Bangladesh Philippines region is low overall but rising, particularly in Cambodia, India, Nepal, Note: Only countries for which data were available were included in this figure. Source: Demographic and Health Surveys or other national reproductive health and Vietnam (see Figure 7). Most surveys, various years: Egypt (2000); Jordan (1997); Morocco (1995); Yemen countries have similar HIV prevalence (1997); Bangladesh (2000); India (1999); Nepal (2001); Pakistan (1995); Cambodia (2000); Indonesia (1997); Philippines (1998); Vietnam (1997). rates among young males and females, although Cambodia, India, and Vietnam
12 are exceptions due in part to the person could be HIV-positive, such predominant modes of transmission in knowledge is low in South Asia (under 30 these countries. Young females in percent) and Indonesia (32 percent). Cambodia and India have higher HIV prevalence because of prostitution. In Yo ung people engaging in premarital sex Vietnam, young males have higher HIV often engage in high-risk sex, increasing prevalence because most infection in the their chances of contracting STIs or HIV. country is associated with injecting drug They know little about preventing use, which is more common among boys. infection and often do not have access to condoms. Even with knowledge and STI and HIV prevalence is increasing access, however, many adolescents and among adolescents and youth as more are youth do not obtain condoms because of sexually active before marriage. For the stigma associated with condoms, example, 12 to 25 percent of STI cases in sexual activity, and, among young females, India, where STIs are the third most knowledge about safer sex. Young people prevalent communicable disease, are may also be misinformed by cultural myths limited to teenage boys.51 In Jordan, that lead them to unsafe sexual practices. adolescent and youth cases account for a For example, popular Moroccan beliefs significant proportion of reported STIs.52 In addition, STI prevalence is rising among Figure 7. HIV Prevalence Estimates among Sri Lankan adolescents and youth. Youth Ages 15 to 24 Years in Selected ANE Countries, 2001
Young people are generally uneducated Percent about STIs and HIV/AIDS, perhaps 4 South Asia Southeast Asia because the topic is so stigmatized in many Female cultures that reproductive health education Male does not adequately address it. For 3 3.00 example, more than one-half of Bangladeshi adolescents and youth could not identify a mode of STI transmission, 2 and only 13 to 14 percent were aware of gonorrhea and syphilis.53 Many countries 1.20 have made efforts to educate the public 1 0.96 about HIV/AIDS; thus, many young people 0.46 0.38 0.38 have heard of it, but their knowledge is 0.36 0.20 0.08 0.08 0.07 0.07 0.02 0.02 insufficient overall. Figure 8 shows that, 0.01 0.01 0 for the Southeast Asian countries and India, knowledge of methods of preventing India Nepal Pakistan Vietnam Cambodia IndonesiaPhilippines HIV using the ABC approach (abstaining Bangladesh from sex, being faithful to one uninfected Note: Only countries for which data were available were included in this figure. partner, and using condoms correctly and These estimates represent the “high” estimates for HIV prevalence among this consistently) is far from universal. While age group. Source: UNICEF, UNAIDS and WHO, “Young People and HIV/AIDS: Opportunities more than 60 percent of females ages 15 to in Crisis.” www.unicef.org/pubsgen/youngpeople-hivaids.pdf. Various data 24 years know that a healthy-looking sources.
13 hold that females harbor STIs and that Sexual Abuse, Exploitation, HIV is most common among females as a and Prostitution result of their debauchery.54 Consequently, Moroccan males seem to be exempt from Young females and males in the region STI prevention responsibilities.55 are too frequently the victims of sexual abuse and exploitation. While only a few Adolescents and youth face significant country assessments pointed to the issue, barriers to health-seeking behavior for STIs the problem may in fact be more and HIV infection. With STIs and HIV/AIDS widespread. In Pakistan, child sexual highly stigmatized in ANE countries, young abuse is prevalent within homes and people hesitate to seek advice or care when communities and may be rooted in the they may have been infected. In addition, culture, reflecting an encouraged child- many adolescents and youth do not have adult power imbalance.56 Bachabazi— access to reproductive health services. older males providing adolescent boys with education, clothing, and care in Figure 8. Knowledge of Prevention exchange for sex—is a frequent practice Methods among Youth Ages 15 to 24 Years in Pakistan’s North-West Frontier in Selected ANE Countries, 2001 Province. Percent
100 South Asia Southeast Asia Adolescent prostitution is a problem in Abstinence most countries; only the Egypt and Yemen 90 One partner assessments did not specifically address it. 80 Condom use 71
70 In Cambodia, adolescent girls are 70 64 64 63 sometimes sold into prostitution by their 60 59 57
60 55
54 families or boyfriends or are pressured to 50 become prostitutes because of financial and
40 57 40 social obligations to the family. It seems 34 that many prostitutes in the countries 30 23 included in the study begin work during 20 adolescence. In India, for example, two out 10 of five prostitutes are younger than 1858 0 and have had limited education about India Cambodia Indonesia Philippines Vietnam contraception and disease prevention. Prostitutes are often not able to negotiate Note: Only the countries for which data were available were included in this figure. safer sex with their clients. In addition, Source: UNICEF, UNAIDS and WHO, “Young People and HIV/AIDS: Opportunities young prostitutes are often victims of in Crisis.” www.unicef.org/pubsgen/youngpeople-hivaids.pdf. Various data sources. sexual violence.
14 Legal and Policy Environment for Adolescent and Youth Reproductive Health
hile all 13 countries included in Near East W the ANE regional assessment have put in place policies that affect young Egypt. The interrelationship of religious people, some countries, such as India and teachings and prevailing attitudes and Jordan, have set forth several policies even culture with regard to sexuality is an as others, such as Yemen, have adopted just important consideration in many countries, a few policies. Only India and the including Egypt. A significant breakthrough Philippines have promulgated specific occurred in 2001 with the development adolescent and youth reproductive health of a document by the Ministry of Health policies. and Population Reproductive Health/Information, Education, and In addition, the policies address Communication (RH/IEC) Project that adolescent and youth reproductive health provides a foundation for a national issues with different degrees of fortitude adolescent and youth strategy. The and are implemented with variable rigor. document assesses the health, well-being, The mere existence of policies does not and status of adolescents and youth, offers necessarily translate into adequate recommendations for addressing their needs, protection or services. Some governments and provides examples of ways to address have made headway in developing such needs. It also provides background for awareness about adolescent and youth a yet-to-be developed national adolescent reproductive health and have publicly and youth strategy. Supporters refer to the underlined its importance to young strategy document, noting the importance of people in particular and to society in eliminating gender discrimination and girls’ general. However, politics, culture, and illiteracy, increasing the age at marriage for religion still pose major barriers to girls to 18, providing specific reproductive ensuring good adolescent and youth health services for young females, reproductive health. implementing the new law that bans female genital cutting, and increasing the role of Table 1 summarizes the legal and policy NGOs in addressing the needs of girls and environments for adolescent and youth young females. reproductive health in the 13 countries by subregion. More details for each country To this point, however, Egyptian policies are presented below. have delivered a mixed message regarding
15 Table 1. Policy Environment for Providing Adolescents and Youth with Services in 13 ANE Countries, 2002–2003
Region/Country Status Near East Egypt Recent political interest in ensuring a healthy transition to adulthood. Public sector services targeted to married females. Jordan Policies and programs for adolescents and youth are limited in scope. Public sector services are targeted to married females. The government is promoting cross-generational communication on reproductive health. Morocco Marriage is the only setting in which sexual activity is allowed. Reticence to serve adolescents and youth. Yemen Extremely difficult for unmarried and not-in-school youth to obtain services. South Asia Bangladesh MOH recently listed adolescent and youth reproductive health as a priority. Still difficult for unmarried youth to obtain services in the public sector. India Some policies explicitly address adolescent and youth repro- ductive health. No clear definition of a strategic approach and activities to provide adolescent and youth health care. Nepal Recent law specifies that unmarried youth can receive services. Pakistan Public sector services are targeted to married females. Sri Lanka Cultural taboos limit opportunities to address adolescent and youth reproductive health. Policy goal is to make young people responsible for their behavior. Southeast Asia Cambodia No legal barriers, but lack of services; denial of youth sex. Indonesia Government recognizes needs of adolescents and youth, but topic remains politically sensitive. Services are geared toward married females. Philippines Policy to provide services to the unmarried is limited in scope. Vietnam For decades, nothing done; no specific policies addressing adolescent and youth reproductive health; the unmarried remain ignored. Source: Data from Soubbotina, Tatyana P. and Katherine Sheram. 2000. Beyond Economic Growth: Meeting the Challenges of Global Development. Washington, D.C.: World Bank.
adolescent and youth reproductive health. have a clear or consistent definition of While numerous ministries and their adolescence. In addition, Egypt’s policies address issues pertinent to population policy focuses explicitly on adolescents and youth, Egypt does not yet young female adults’ need for health care
16 before marriage, including premarital National Reproductive Health and Life examinations and counseling. The Planning Youth Communication Strategy, country’s prevalent attitude is that the best which covers the period 2000 to 2005. The way to protect children and young adults strategy is introducing innovative from engaging in unacceptable behaviors, approaches to cross-generational such as premarital sex, is not to provide communication by targeting two important them with any information on these audiences: primary audiences, consisting of practices. While Ministry of Health and married and unmarried youth ages 15 to 24 Population services and university clinics years, and secondary audiences, consisting and hospitals are available to people of all of parents and family members, educators ages and school health programming is and school social workers, government prevalent in Egypt (preventive health care, officials and decision makers, and religious including check-ups, vaccinations, and leaders.63 The policy on the age at curative and rehabilitation services are marriage was successfully changed in 2001 provided through the School Health from 15 and 16 years for girls and boys, Insurance System), the range of services respectively, to 18 years for both (except in does not include reproductive health care. specific cases that are left to a judge to In addition, no scheme comparable to the decide). Various other policies, particularly School Health Insurance System covers out- those developed in recent years, focus on of-school youth, although, as of 1998, the health and well-being of society in several ministries were discussing ways to general. They include Public Health Act provide health insurance to these young No. 21 of 1972, which obligates the people.59 The limited reproductive and Ministry of Health to do everything in its sexual health education received by young power to safeguard the health of citizens; a people has been and continues to be the 2001 royal decree establishing the National responsibility of families.60 Laws and Council for Family Affairs; successive policies do exist that address specific issues, national socioeconomic development plans, such as motherhood and abortion, the right such as the 1999–2003 plan stressing to maternity leave,61 and protection improvements in health with specific “against unsafe abortion”;62 however, the objectives in all health areas, including exact parameters of the abortion issue, for maternal and child health;64 and the Labor example, are not entirely clear. The next Law and Civil Service By-law, which few years should provide a clearer picture of entitles working females to fully paid Egypt’s commitment to adolescent and maternity leave and time for breastfeeding youth reproductive health. for one year.65 Their Majesties King Abdullah and Queen Rania are according Jordan. Important policies address high priority to these and other areas adolescents and youth, and four ministries, affecting adolescent and reproductive a specialized committee for youth within health, such as family violence, thereby the Parliament, and two specialized providing hope for improvements in councils are responsible for responding to adolescent and youth reproductive health. the needs of Jordan’s adolescents and youth. The Jordanian National Population Nonetheless, Jordan lacks a clear or Commission has also developed the first consistent definition of adolescence; thus,
17 developing a specific policy on adolescent providing services in a manner that is and youth reproductive health in Jordan friendly and acceptable to youth. In remains difficult. Existing policies may general, the condemnation, prohibition, also be inadequate. For example, the and denial of unmarried adolescents’ country lacks specific provisions for first- sexuality is a major impediment to time or adolescent mothers (even though improving the sexual and reproductive working females are entitled to maternity health and even the opportunities and leave). In addition, while Jordan’s National lives of this large and growing segment of Population Strategy explicitly addresses the population.68 young people’s need for reproductive health education, reproductive and sexual Yemen. Yemen’s Population Policy health education is minimal in schools and explicitly addresses young adults through often nonexistent within families owing to its provisions for reproductive health prevailing attitudes and a focus on familial education and services, including antenatal protection. care, immunization, and family planning services.69 However, the policy lacks clear Morocco. In Morocco, as in other and consistent definitions with regard to predominately Muslim countries such as adolescents and youth and related policy Pakistan, marriage is the only setting in direction even while other policies address which sexual activity is allowed under adolescents and youth and the numerous Islam and in which pregnancy and ministries involved with their issues. As a childbearing are legally legitimate.66 result, programming remains limited. Therefore, religious customs affect the legal and political response to adolescent The government has attempted to address and youth reproductive health despite the issues related to adolescent and youth reality that premarital sexual relationships reproductive health by, for example, issuing typically occur long before marriage.67 the 1991 Presidential Decree that While IEC programming has been established the National Council for increasingly available, the current situation Childhood and Motherhood; devoting an with regard to adolescent and youth entire chapter of the current five-year plan reproductive health policies and laws in (2001–2005) to motherhood and childhood; Morocco is described as follows: enacting Civil Service Law No. 19 (1991), which entitles working women to maternity [It] impedes investigating the issues in- leave and reduced work days while pregnant depth to gain a real understanding of the and breastfeeding; and issuing the 1999 situation. It constrains educating youth decree (No. 59) establishing the General to enable them to develop healthy attitudes Strategy for Youth, Adolescents, and Sport about sexuality and reproduction and to (2000–2004), which aims to provide a avoid high-risk sexual behaviors. It planned and scientific base for ensuring the precludes designing and funding infrastructure necessary to make headway reproductive health and related programs on youth-oriented issues. In addition, to target the large and ever-growing Yemen has committed itself to the National population of adolescents and unmarried Strategy for Integrating Youth into young adults in Morocco. It rules out Development (1998). The strategy presents
18 an analysis of issues, provides health problems as priorities, including recommendations for addressing the needs nutritional deficiency, early and unwanted of adolescents and youth, identifies pregnancy, maternal mortality related to strategic actions, and supports the early and risky pregnancy, lack of development of subcommittees to information and services, and problems coordinate and follow up on activities. The attributable to unsafe abortion, accidents, strategy also stresses the importance of and violence. For the first time, he providing information to decision makers. suggested relevant information and service In addition, a youth strategy helps provide a delivery for young people at various tiers of basis for action on issues defined in the the public health system. The promising ICPD. Other policies on adolescent and steps taken since that time include youth reproductive health in Yemen address provision of health education materials for the legal age at marriage, which is 15 years. adolescents and youth on general health and reproductive health; IEC on adolescent and youth reproductive health for South Asia guardians, teachers, and social leaders; distribution of vitamins to adolescents; Bangladesh. The Constitution of medication for dysmennorrhea; provision of Bangladesh stipulates equal rights for men consultation and treatment for adolescent and women irrespective of caste, creed, and and youth reproductive health problems; color. The country has set forth and and provision of counseling for young enacted numerous policies and acts that people’s physical and mental health address various aspects of issues pertinent problems. to adolescent and youth reproductive health (e.g., the Dowry Prohibition Act of India. Since the early 1990s, India’s 1980, the Cruelty of Women Act, the Child national government has developed 12 bills, Marriage Restraint Act, and the Penal plans, or policies that deal with children, the Code, which permits capital punishment girl child, labor, population, and youth. In for causing grievous injuries or acid addition, some Indian states have developed throwing). However, the government often their own population policies and policies on does not enforce the limited laws, women, with some state governments regulations, or ordinances that are emphasizing concerns about adolescent and specifically designed to protect adolescents youth health and development. At the time and youth, particularly young females, from the India report was written, India’s exploitation and violence. Thus, the National Health Policy of 2000 was numerous current laws, rules, regulations, undergoing final preparation. It highlights and ordinances that might positively affect adolescent and youth health as a strategic various aspects of young people’s lives do focus in achieving sociodemographic goals. not de facto ensure the rights or health of The policy aims to ensure that young adolescents and youth. people’s need for information, counseling, population education, and accessible and In January 2001, the Director General of affordable contraceptive services is met; the Directorate of Family Planning that food supplements and nutrition services declared a number of adolescent and youth are available; and that the legislation on
19 restraint of child marriage is enforced. The the mid-1990s, reproductive health has population policy also stresses that received a boost from the creation of the reproductive health services for adolescent ministries of Population and Environment girls and boys are especially needed in rural and Women, Children, and Social Welfare. areas, where adolescent marriage and The existing population policy focuses on pregnancy are most prevalent. The policy gender equity and population management underscores the need for programs that through good governance and on the need encourage delayed marriage and to address demand for family planning childbearing as well as the need for among couples. It also articulates the need education about the risks of unprotected to alleviate poverty, accelerate economic sex.70 development, decentralize, and develop public/private partnerships. The National India’s earlier focus on adolescents and Reproductive Health Strategy, adopted in youth was important in the development of 1998, identifies adolescent and youth current policies and programs. For reproductive health as a central component example, the National Youth Policy (1986) of integrated health services. The National placed adolescent health as a subsection Adolescent Health and Development under the health sector and recognized Strategy, adopted in 2000, aims to improve youth empowerment and gender justice as the health and socioeconomic status of major thrusts of the policy. Various acts also adolescents through access to information have helped safeguard the health and social and services; the steps the government welfare of children (e.g., the Immoral Traffic takes to implement the strategy warrant (Prevention) Act (1956), the Child Marriage attention. In addition, the National IEC Restraint Act (1976), and the Child Labor Strategy includes an adolescent component Act (1986)). In addition, other sectors have while the National Safe Motherhood Plan, helped focus attention and services on which targets a 15-year period beginning in adolescents and youth. The National 2002, emphasizes improved access to and Education Policy (1974) recognized the right use of services for women during pregnancy, to education for all segments of the childbirth, and postpartum in order to population and made elementary education prevent maternal death. The latter focuses for all children compulsory, helping lead the on developing basic and essential obstetric way to more equitable conditions. care throughout the country by working in tandem with community facilities. Further, Nepal. As in many countries, support and abortion may soon become legal in certain numerous initiatives along with barriers circumstances. Unmarried adolescents and sum up the status of adolescent and youth youth had been legally prohibited from reproductive health in Nepal. However, the receiving FP/RH care until the recent country has made progress over the past passage of a policy by the National decade with regard to policy. The Prime Reproductive Health Program Steering Minister formulates and monitors all Committee that allows unmarried development programs, including the adolescents and youth to obtain family reproductive health program; as a result, planning services. The policy changes the the issue commands the highest level of requirement for service providers to government involvement. In addition, since ascertain whether a client is married. To
20 ensure equity, policy also needs to address combat child sexual abuse/exploitation or girls’ empowerment issues. trafficking by addressing its underlying causes. The Hudood Ordinances of 1979 Pakistan. As in other predominantly continue to help create an unsafe Muslim countries, religious beliefs and environment where, for example, if a traditions in Pakistan have an intricate victim charges rape and cannot prove it, he relationship with state structures and or she can be charged with illegal sex institutions, although other geopolitical outside of marriage and receive the and cultural influences also affect maximum punishment. adolescent and youth reproductive health. Policy planners are only just beginning to Sri Lanka. Sri Lanka needs to devote conceptualize adolescence in Pakistan, and more attention to policy and legal matters, research is in the preliminary stages. With although it has clearly made some an official refusal to inform the public progress. After the 1994 ICPD, the about sexual issues, only a small number of government of Sri Lanka appointed an NGOs or health practitioners make intersectoral task force charged with reproductive health information available formulating a national population and and only by means of limited outreach. The reproductive health policy and an action National Health Policy, developed nearly a plan. In 1997, the National Health Council decade ago, states that reproductive health and the Cabinet Ministers approved the and health education will be among the Population and Reproductive Health Policy. MOH’s priority programs; however, the The policy stipulated eight goals to be policy includes no reference to providing achieved within 10 years, with a focus on information about sexuality. Progress on several issues, including reducing fertility, both the provision of health education and ensuring safe motherhood, achieving sexuality has been stalled since that time. gender equity, increasing public awareness of population and reproductive health Sexual exploitation is a significant issues, promoting responsible adolescent adolescent and youth reproductive health and youth behavior, and improving problem, but policies do not adequately population planning. In addition, over the address it. No law specifically prohibits past decade, Sri Lanka has strengthened its child sexual abuse. In addition, while policies addressing the protection of sodomy is punishable by up to 10 years in mothers, children, and adolescents and prison, vaginal or oral penetration or any youth and has devoted greater attention to other sexual violence to a child is the protection of the girl child. However, punishable by only up to two years.71 the country has yet to deal at all or Weaknesses in the law, such as the lack of a adequately with numerous issues. clear definition of child, arguably facilitate child prostitution. Child trafficking is a well-known problem in South Asia, but Southeast Asia recommendations made by the Working Group on Youth Development in Cambodia. Cambodia has no explicit preparation for the Ninth Five-Year Plan adolescent and youth reproductive health (1998–2003) do not mention the need to policies in place, but it addresses
21 adolescent and youth reproductive health Indonesia. Policymakers in Indonesia have activities in other policy areas. The recently begun to discuss mainstreaming country’s pronatalist policies of the 1980s gender concepts in the school curriculum,75 were reversed in the early 1990s under a a practice that could have a profound maternal health rationale. Policies and impact on knowledge, understanding, and, laws enacted within the last decade include ultimately, the behaviors of young people the National Safe Motherhood Policy with regard to unsafe sex, marital relations (1997), a fairly liberal abortion law (1997), and responsibilities, and societal attitudes and the Birth Spacing Policy (1995), and behaviors. However, Indonesia will need resulting in widespread dissemination of to undertake a review of its laws if it decides contraceptives and contraceptive to implement policies and programs on information.72 Correspondingly, knowledge adolescent and youth reproductive health. of family planning is high in Cambodia—92 While a number of laws already address percent of all women and 96 percent of adolescent and youth reproductive health, married women know of a contraceptive they do not address the issues whose method—and contraceptives are used for resolution would directly and adequately both birth spacing and limiting.73 improve adolescent and youth reproductive health. For example, Law No. 2/1979 makes Cambodia imposes no legal barriers to the nine years of education compulsory for all; implementation of adolescent and youth however, it does not address the importance reproductive health activities; however, of teaching about reproductive health or substantial infrastructure barriers and a gender issues. Another example is Law No. vast gulf between policy and 1/1974, the Marriage Law, which identifies implementation, particularly in rural the minimum age at marriage for girls as areas, limit the delivery of needed services. 16. The law needs to update the minimum The focus on curative rather than age for girls to 18 or older so that girls and preventive health continues in their families can focus on education. Due Cambodia,74 and, given that Cambodia’s to sociocultural, religious, and political MOH and other relevant ministries do not reasons, programming for adolescent and yet recognize the need for an adolescent youth reproductive health, while available, and youth reproductive health policy, does not fall under the rubric of a national adolescent and youth reproductive health adolescent and youth reproductive health activities remain the province of other program, thereby curtailing the strength of policy areas (e.g., maternal and child the programs’ focus and reach. health policy, population/birth spacing policies, gender equity, and equality Philippines. The Philippines set forth a policies). The problem of HIV/AIDS in number of direct (e.g., those specifically Cambodia and the perilous state of designed to influence population, health and maternal and child health mean that reproductive health, adolescent and youth policy has focused on these areas. reproductive health, and HIV/AIDS) and Cambodia needs to adopt a clear focus on indirect policies (e.g., those focusing on adolescence if it is to address adequately educational policies). The 1987 the problems of adolescents and youth, Constitution states that it is the “right and maternal and child health, and HIV/AIDS. duty” of parents to ensure the welfare of
22 and instill proper moral development in recognized the shortcomings of its approach. their children.76 It also specifies that the state has an obligation to help parents in The government has provided support for this endeavor. Such emphasis has set the and approved the development of a tone and focus for much of the policy and National Strategy on Reproductive Health programming targeted to adolescent and for 2001–2010, with adolescent and youth youth reproductive health in the Philippines, reproductive health identified as the which has been described as “indirect and second among seven outstanding problems cautious.”77 Some positive developments are that the new reproductive health program underway. For example, the Adolescent and must address. The strategy is intended to Youth Health Policy (2000) recognizes improve adolescent and youth reproductive adolescents and youth ages 10 to 24 years as health through education, counseling, and the priority population in terms of pressing provision of reproductive health services. health needs. The policy provides guidance It includes a focus on providing for youth-friendly health service center information on healthy sexuality. The development, stipulates the availability of strategy supports the provision of contraceptive services and supplies, and information through the schools and supports the integration of the Adolescent underscores the importance of providing and Youth Health Development Program counseling and medical assistance to into the health care system with a focus on adolescents and youth, including IEC, advocacy, technical capacity, services, contraceptive methods, safe abortions, and partnerships, and improved data collection. treatment of reproductive tract infections Another important development was the (RTIs), and of paying particular attention National Family Planning Policy, which to the needs of rural and remote areas. earned the approval of the Department of Related policies that exist or are in Health in 2000 and stresses the importance development include the safe motherhood of family planning as a health and poverty master plan integrating adolescent and reduction intervention. youth reproductive health components; the strategy for healthy living and life skills Vietnam. In Vietnam, sexual activity among education for children, adolescents, and adolescents and youth has increased along youth (through capacity building for with a reported rise in gender-based teachers and others and the development violence. In the past, Vietnam did little to of partnerships between various societal address adolescent and youth reproductive sectors); and support for local NGOs health in population and family planning working with adolescent and youth policies—no development of national reproductive health education and service adolescent and youth reproductive health provision. Nonetheless, the lack of impact programs and no institutionalization of and monitoring and evaluation indicators programming despite the lack of substantial for adolescent and youth reproductive legal barriers. More recently, though, in health will present difficulties for planning what was an important step in policy and and implementing programs and assessing program development, Vietnam publicly progress.
23 Adolescent and Youth Reproductive Health Programs
he record of adolescent and youth prevention. The Ministry of Education and Treproductive health programming for other ministries, such as the Ministry of the ANE region is mixed; overall, countries Youth, are also involved in adolescent and lack concrete and comprehensive programs. youth reproductive health activities. For Some countries in the region have moved more than two decades, the Ministry of ahead steadfastly in implementing Education has ensured that primary and programs that are aimed at young people; secondary school curricula cover some others have made timid progress. information on physiology and family Generally, most countries’ policies and planning, and science curricula now include programs do not support provision of HIV/AIDS information (although only girls services to unmarried youth; in fact, some are privy to some of the education). programs are reluctant to provide family However, among the uneducated, levels of planning to young women until after they knowledge about HIV/AIDS remain low have had at least one child. while other fundamental knowledge is lacking.79
Near East Even though NGOs are highly regulated by the Egyptian government, some carry out Egypt. The 1994 ICPD helped mobilize important work with adolescent and youth Egypt’s government institutions, whose reproductive health. For example, the New influence has continued to affect attitudes Horizons Project is proving successful in and programming with regard to adolescent breaching the reproductive health and youth reproductive health. One result information gap among adolescents and is a renewed focus on female education youth and may be a model for other accompanied by a reduction in employment programs in Egypt and elsewhere. New inequities.78 In addition, an effort worth Horizons is a “non-formal education noting is a national media campaign run by program designed to demystify and the State Information Service of the communicate essential information in the Ministry of Information, in collaboration areas of basic life skills and reproductive with the Ministry of Health and Population. health” to girls and young women. The The campaign focuses on the mass media community-based and demand-driven promotion of excellence in reproductive project is designed to address the specific health services for young women. Other needs articulated by its target population: important initiatives include telephone illiterate girls and young women in villages. hotlines and peer education for HIV/AIDS Most are ages nine to 20 years; however,
24 New Horizons now also involves young young men and women. The Ingaz youth women and mothers as old as 25. It is also economic opportunities program, originally targeting boys. Thus far, 16,000 girls have sponsored by Save the Children Fund, completed the thorough, 100-hour USAID, and the private sector, aims to program. The project is active in all the enhance the leadership skills, networking, governorates/provinces of Upper Egypt and volunteerism, and employability of is expanding into Lower Egypt. It is low- Jordanian youth.81 The MOH launched a cost and proving sustainable, with local hotline in 2001 to provide young persons organizations taking the initiative to with medical information and counseling request training, participate in educator on HIV/AIDS and other reproductive training, and subsequently carry out the health issues. The MOH also conducts program. A project evaluation is home visits. In addition, school-based undergoing completion.80 In general, more health education contributes a great deal leeway for programming is needed if the to the dissemination of reproductive health NGO sector is to be successful. information through the curricula, although the quality of education has come Jordan. To date, few public programs in under criticism. While Jordanian youth are Jordan address adolescent and youth not often involved in clubs, a few reproductive health; as a result, unmarried community-based interventions are making youth do not receive reproductive health inroads in terms of providing important services from the public sector. However, reproductive health information to youth the 1994 ICPD was a catalyst for action on (e.g., Festivals of Innovative Youth). The reproductive health such that NGOs in Jordan Association for Family Planning and Jordan have become active since that time. Protection and the Ministry of Youth and Jordan has broadened the nation’s strategy Sports are collaborating on a project for achieving its population objectives by, funded by the Netherlands Fund. Called for example, involving governmental and Youth to Youth for Safe Reproductive nongovernmental organizations in Health, the project focuses on awareness supporting the expanded availability of raising. With regard to clinical services, reproductive health information to the public and private sectors together adolescents and youth. To reduce the provide approximately two-thirds of gender gap, the strategy also stresses Jordan’s clinical availability (NGOs provide female education and calls for increased the other one-third), with the private employment opportunities for women. sector carrying most of the burden. The Commercial Market Strategy (CMS) In addition, many programs involving the Project is showing great promise for private sector, NGOs, donors, and reaching a sizable number of youth with cooperating agencies, currently focus on health services. USAID has funded CMS in adolescent and youth reproductive health Jordan since 1999. in Jordan. The Shabab 21 campaign is a noteworthy national media campaign run Beyond the health sector, groups such as by the National Population Commission the Higher Council for Youth (leadership that promotes reproductive health program), the Ministry of Education information and life planning skills for (involvement in productive activities for
25 girls and boys), and the Jordan University program reached more than 100,000 youth of Science and Technology (awareness- in 1997–1998 alone. In association with the raising workshops on various topics, Association Marocaine de Planification including women’s issues) are undertaking Familiale (AMPF), the Ministry of Youth programmatic initiatives. and Sports provides information through 340 public sector youth houses around the Morocco. Although Morocco adopted a country and supports endeavors that assist focus on reproductive health education in enhancing discussion and nearly three decades ago following the 1974 communication on adolescent and youth international population conference in reproductive health. The Ministry of Youth Bucharest, reproductive health programs and Sports is also involved in IEC specifically targeting adolescents and youth campaigns specifically designed for still consist primarily of population and Moroccan youth through youth festivals health education efforts. A population and the Internet. The Ministry of Public education coordinating body has been Health is also active in programming. For operating since the mid-1970s and brings example, it organized a Week on together the Moroccan Family Planning Reproductive Health in 2000 that reached Association and the ministries of the 1.2 million youth with health messages and Interior, Public Health, Employment and is now planning to focus on young adults by Social Affairs, Youth and Sports, and instituting peer and other education efforts Education. The Ministry of Youth and to influence sexual behaviors.83 With Sports and the Ministry of Education carry acknowledgment from the Ministry of out formal health education, and other Yo uth and Sports that Moroccan youth are ministries provide informal health now typically sexually active long before education.82 The Ministry of Youth and marriage, governmental agencies recognize Sports’s programming includes the need for additional programs that reproductive and sexual health education address reproductive health.84 through summer camps, sports clubs, youth centers in poorer neighborhoods, and other Morocco was the first country in the Near institutions. One component of the East region to introduce population education into the national high school science curriculum, and Moroccan schools continue to provide information on human reproduction, contraception, and STIs,85 although through a number of standard school subjects rather than as freestanding subjects. The information, however, is not satisfying young people’s need for information.86 The possibility of implementing sex education in the schools ran into opposition, and topics such as STIs and HIV/AIDS were cut back while the Ministry of Education started slowly to implement a newer curriculum.
26 The nongovernmental sector has more Family Planning, and international liberty than the public sector to act on agencies, such as the European Project, adolescent and youth reproductive health.87 fund reproductive health and sexual health The Association de Lutte Contre le SIDA, a education in schools. As it stands, however, well-respected, Casablanca-based few young women receive information organization, has been bringing topics such about family planning. Only 30 percent of as STIs and HIV/AIDS, high-risk sexual women ages 15 to 19 years had recalled behaviors, sex work, and other sensitive but receiving family planning information pressing issues to the attention of through the media in 1997, and that policymakers and the public through number is only slightly higher among awareness-raising and advocacy efforts. women ages 20 to 24 years at 34.2 The Institution Nationale de Solidarité avec percent.90 The overall lack of awareness les Femmes en Detresse helps single and information possessed by Yemeni mothers and their children by providing an women as well as by members of other in-depth adult education curriculum in societal segments is part of what stalls reproductive health. The PASA Project of progress on programs in Yemen. Association Marocaine de Solidarité et le Développement has an exemplary community-based, needs-driven social South Asia development program similar to the New Horizons Project in Egypt88 (see Egypt Bangladesh. The government of above); it provides in-depth adult education Bangladesh identified adolescent and youth on reproductive health to communities health and education as both a priority and after first working to gain their trust. a challenge; to face the challenge, it Other NGO initiatives are also underway or incorporated adolescent and youth health planned, including a large, comprehensive and education into its Health and program that could effectively begin to fill Population Sector Program. With a focus in sexual and reproductive health services on providing more services, the and information gaps in the national family government expects an overall increase in planning and education sectors. The focus the quantity and quality of information and of the plan is on the integration of women services available through a network of in development; it concentrates on clinics at the community, thana (upazilla), reproductive health, with provision for and district levels. However, without reproductive health counseling and youth additional efforts from other agencies, the programming. improvements to be delivered through the Health and Population Sector Program are Yemen. In Yemen, programming is scarce, unlikely to make significant contributions but progress is evident. The government to achieving results in the area of has begun to institute programs to educate adolescent and youth reproductive health youth about risky behaviors.89 The during the life of the program (1998–2003). National Council for Childhood and Motherhood of the Ministry of Youth is Fortunately, government and NGO involved in awareness-raising efforts. collaboration is filling some of the gaps. NGOs, such as the Yemeni Association of Nearly 200 NGOs work with adolescents
27 and youth in some capacity.91 Their policies and regulations that address activities include vocational training for adolescent and youth reproductive health. skill development, microcredit programs, However, India needs to scale up the efforts leadership training, family life education in order to produce a greater impact. The (FLE), sex education, reproductive health government programs addressing services, personal hygiene education, and adolescent and youth reproductive health legal assistance in cases of violence and include the Reproductive and Child Health abuse against women. Many NGOs are (RCH) Services Program; the Integrated developing and most are disseminating Child Development Services Scheme; the materials. Adolescent Girls Scheme; and the State Plans of Action for the Girl Child Scheme. In addition, other sectors have become The government launched the RCH involved in adolescent and youth Services Program in 1996 to provide reproductive health. Work in the education holistic RCH care through the existing, sector continues to narrow the gender gap vast network of the primary health care in education. The secondary school system. It encompasses provisions for all education curriculum has incorporated aspects of safe motherhood and child adolescent and youth reproductive health survival interventions, including an and includes education on population, emphasis on increased access to reproductive health, and family life contraceptives, safe management of issues.92 Various other sectors are involved unwanted pregnancies, enhanced nutrition, through ministries and NGOs, focusing on prevention and management of RTIs and issues such as income generation and STIs, availability of reproductive health justice. services to adolescents and youth, and educational outreach. The RCH program India. Both regionally and internationally also focuses on providing services for supported governmental and gynecological problem management and nongovernmental organizations have cancer screening for women. The initiated programs as part of India’s Integrated Child Development Services strategy to implement the various existing Scheme, which covers almost 85 percent of the “blocks” in India, offers an integrated package of early childhood care services that include supplementary feeding, immunization, health checkups, referral services for children up to six years of age and expectant and nursing mothers, and nutrition and health education for mothers.93 The Adolescent Girls Scheme, which was started 1991, targets girls ages 11 to 18 years and aims to meet adolescent girls’ special nutrition, education, and skills development needs. The scheme also envisages imparting skills and encouraging the involvement of girls in useful economic
28 activities later in life. This scheme has to translate into important adolescent and been extended to 3.9 million adolescent youth reproductive health programs in girls throughout the country. Nepal. In 2000, the government developed and adopted the National Adolescent Several NGO and other sector programs Health and Development Policy and are also addressing adolescent and youth Strategy. In addition, the National issues, including the Department of Reproductive Health Program Steering Education, Scouts and Guides Committee passed a policy that allows organizations, Ministry of Labor, and unmarried adolescents and youth to obtain Ministry of Social Justice and family planning services, and the MOH Empowerment. The Department of developed the National Health Education Education program, for example, focuses Information Communication Center. These on achieving universal coverage of primary various actions have all catalyzed progress. education through decentralized planning For example, the National Health and management, decentralized target Education Information Communication setting, community mobilization, and Center has launched an adolescent and district- and population-specific planning. youth program in 55 districts through its The numerous foreign and indigenous health post staff to address adolescent and NGOs working in the country, such as the youth reproductive health issues among Population Council, the Health Institute school students. Various educational for Mother and Child in New Delhi, the curricula and IEC programming for Healthy Adolescents Project in India, the adolescents and youth are being International Center for Research on implemented through schools and with Women, the Society for Social Uplift distributed materials. Lower- and through Rural Action, Planned Parenthood secondary-level students (those in the levels Federation, and CEDPA, are all working on six through 10) are targeted as well. Topics various aspects of adolescent and youth covered include FLE, quality of life, safe health issues as well. The Society for motherhood, community health, and so Social Uplift through Rural Action, based forth. Radio and television programs, such in Jagjit Nagar, Himachal Pradesh, for as “Jana Swasthya Karyakram,” have also example, regularly undertakes training provided information on adolescent and programs, seminars, workshops, and youth reproductive health. courses for capacity building among women’s groups, local governing councils, NGOs are active at the grassroots level. and adolescent and youth girls’ groups. The Family Planning Association of Nepal, Activities are geared toward imparting a one of the largest NGOs in Nepal, is broad understanding of reproductive engaged in advocacy, IEC, and providing health. services to young people. It integrates adolescent and youth reproductive health Nepal. The progress made during the last services with other reproductive health decade in policy and strategy development services that are provided through the with respect to reproductive health association’s clinics. Other NGOs, generally and on adolescent and youth including the Ama Milan Kendra, focus on reproductive health specifically is beginning issues such as male involvement and
29 working with young females to make furthered by the Behbud Welfare informed decisions regarding social, Association. UNAIDS, UNICEF, and economic, and health needs and rights. UNFPA are including education and PHECT-Nepal provides safe motherhood, awareness about STIs and HIV/AIDS in family planning, and STI services to their programs, and UNICEF aims to train adolescents and youth in one municipality. nongovernmental and health workers in Sunaulo Pariwar Nepal, a local NGO prevention and counseling techniques.95 In affiliated with Marie Stopes International, addition, a few small, local NGOs have provides youth-friendly services through taken up the challenge to raise awareness one of its clinics in the far western region about HIV/AIDS to a broad population, of Nepal and is extending similar services including, to a limited extent, adolescents to other parts of the country through its and youth. clinics. Various NGOs have undertaken Pakistan. Relative to other countries of community-based interventions that are the ANE and other regions in the addressing child sexual abuse. Sahil is an developing world, Pakistan has done little NGO devoted to handling crisis cases and with regard to adolescent and youth raising awareness about child sexual abuse reproductive health programming, in great through research, seminars, and part because of policy and legal barriers. educational materials. Aangan tackles child Public sector adolescent and youth sexual abuse through the press, seminars, reproductive health programs include and counseling. War Against Rape handles limited school health education, which does individual cases of child sexual abuse and not even provide a basic introduction to conducts research and awareness-raising “the facts of life,” as well as an attempt by activities. Aahung, an AIDS awareness program in Karachi, to develop a coeducational Sri Lanka. Achievements in the health sexuality and reproductive health sector in Sri Lanka have been impressive, education curriculum for secondary schools. although the country has devoted little attention to the health of young people, The NGO sector is addressing some particularly with regard to sexual and adolescent and youth reproductive health reproductive health. It has yet to institute issues. The Family Planning Association of an organized program for providing Pakistan has targeted young people and is information to adolescents and youth. currently preparing the groundwork for an initiative aimed at addressing the The existing adolescent and youth knowledge and attitudes of young adults reproductive health programs are toward reproductive and sexual health in implemented through the Department of order to influence their behavior in favor of Health, the Department of Education, the the small family norm and responsible National Youth Service Council, and parenthood.94 Treatment for postabortion NGOs, which, collectively, have complications has been pioneered by Marie undertaken a number of important Stopes Society, which also provides initiatives. A project initiated by the traditional family planning services, and Family Planning Association of Sri Lanka
30 and funded by the European reproductive health components. As a Commission/United Nations Population part of that project, the Health Education Fund (EC/UNFPA) was launched in 1998 Bureau of the Ministry of Health to provide reproductive health established 1,074 school health clubs in information, counseling, and health care 10 high-risk districts and provided services to adolescents and youth.96 The training for teachers. A number of NGOs project covered 13 districts and increased also are working on adolescent- and community awareness and involvement. youth-related issues. Several are working Implemented by seven NGOs, the project with UNFPA on a project to distribute succeeded in reaching more than 575,000 condom vending machines island-wide, adolescents and youth through counseling focusing on vulnerable groups. The and service delivery points, many in International Rotary Society, in schools. Another project, a partnership collaboration with UNFPA, is involved in between the Department of Health and important advocacy and awareness-raising the University of Colombo, produced work on reproductive health issues among recommendations for promoting adolescents and youth in school. adolescent and youth health and information in higher-level schools. In addition, the Department of Health’s Southeast Asia Family Health Bureau has incorporated adolescent and youth health into its Cambodia. In the absence of strong training programs for the public health barriers to adolescent and youth sector staff. The National Youth reproductive health programming in Campaign, established in 1970, undertook Cambodia, several types of organizations the Reproductive Health Information have taken on the challenge of developing Project in 1997 with support from programs. School curricula have recently UNFPA. The project’s objective was to undergone revision to incorporate provide leadership training for youth and reproductive health and HIV/AIDS peer groups. The training covered issues information into the science and social such as HIV/AIDS and STIs, drugs, family studies curricula. However, teachers need planning, and empowerment of women.97 The project reached thousands of out-of- school youth—its primary target group. The Family Planning Association of Sri Lanka has launched a hotline service to provide medical information on reproductive health issues. While the line does not specifically target adolescents and youth, it regularly receives calls from those groups. Another important project undertaken by the National Institute of Education in 1993 with UNFPA funding focuses on school health, including selected
31 additional training to ensure that they efficacy, as they are not implemented present the material properly. In addition, nationally. Sectors providing programming many students do not benefit from the include the National Family Planning materials provided in later grades because Coordinating Board, the Department of numerous years of schooling are still the Health, the Department of Social Welfare, exception rather than the rule. Various the Department of Religion, and the local and international NGOs are working Department of National Education. nearly unconstrained on the provision of Existing programming is limited to schools. information and services, some focusing In Jakarta, West Java, and Yogyakarta, some directly on adolescent and youth schools have provided adolescent and youth reproductive health and others working on reproductive health education.98 Such areas related to it. Some NGOs have even schools integrate adolescent and youth incorporated “adolescent- and youth- reproductive health education into other friendly” services, with separate waiting subjects, such as biology, social studies, and rooms for young people. Innovative religion, which address topics of marriage informational programming is not unusual; and sexuality. Teachers who received radio phone-in programs and question-and- training in counseling deliver the courses. answer newspaper and journal columns are seen regularly. In 2000, Ibu Khofifah Indar Parawansa, the former Minister of Women’s Indonesia. Adolescent and youth Empowerment and Head of the National reproductive health in Indonesia continues Family Planning Board, initiated both a to center around education, largely to the new Adolescent and Reproductive Rights neglect of addressing the need for services. Protection Directorate within the National While programming in reproductive health Family Planning Coordinating Board and has been available for many years and a a division responsible for adolescent and number of adolescent and youth youth reproductive health within the state reproductive health-related programs are Ministry of Women’s Empowerment. In identifiable, there is some question as to addition, she advocated for allowing the extent of their reach, services, and pregnant students to finish their schooling and for providing “emergency contraceptives” in certain circumstances.99 Her proposals met with considerable dissent; however, in large part due to Indar Parawansa’s persistence, policymakers in the health and education departments held discussions on the need to emphasize the importance of including reproductive health education in the school curriculum. Impetus for programming seems to be growing, with the MOH having developed and implemented peer education programs and the Department of Religious Affairs
32 having focused on efforts to develop incidence of early marriage and teenage reproductive health education for religious pregnancy, among other issues; and a schools.100 In addition, owing in part to program conducted by the Family Planning the progress that government offices are Association of the Philippines that making, NGO programming has been able stipulates that all individuals of to “take off” to a larger degree; NGOs are reproductive age (specified as persons ages less constrained by government policies 15 to 44 years) have the right to and regulations and tend to be more information, counseling, physical adolescent- and youth-friendly, although examinations, and contraceptive supplies, they need better documentation and specifically condoms or contraceptive pills. evaluation procedures. Vietnam. Since the early 1990s, Vietnam Philippines. The Philippines Local has developed and implemented some Government Code mandates that local adolescent and youth reproductive health government units provide family planning programs and activities, including school- and health programs. The Philippines has and community-based efforts, in different put in place a number of programs that areas of the country. However, most of these have tried to focus attention on both programs and activities have focused increasing the understanding of the RH primarily on IEC and have not extended to needs of adolescents and youth and the provision of contraceptives or other delivering services for young people. The reproductive services. Since 1988, with programs need additional management support from UNFPA and the United capability, technical skills, and resources if Nations Educational, Scientific and they are to serve a broad population Cultural Organization (UNESCO), the effectively. In addition, key informants school curriculum has included family life expressed concern about the willingness of and sexuality education and population government workers to provide adolescent education, which are usually integrated into and youth reproductive health services. biology or other subjects and have been According to one informant, the reality is available primarily for students in grades 10 that unmarried teens asking for through 12. Unfortunately, teachers have contraceptive services or information from a clinic will receive services at the moral discretion of the health care provider. Noteworthy are the National HIV/AIDS Prevention and Control Program, which targets several age groups; Population Awareness and Sex Education, which is a population and sexuality education program specifically targeted at out-of- school youth; Commission on Population of the Adolescent and Reproductive Health (ARH) Program, which identifies adolescence as one of its five programmatic areas and focuses on reducing the
33 been uncomfortable with the subject matter young people, whether NGOs are active in and thus have often delivered the adolescent and youth reproductive health information in the form of moralistic activities, and whether programs are lectures that can quickly lose young multisectoral and gender-focused. people’s interest. The most recent programming in schools has been more Adolescent and youth reproductive health successful, such as the National Education issues remain politically sensitive in all and Training Program on Reproductive countries, primarily because governments Health and Population Development, which do not want to be perceived as encouraging included a training component for teachers. young people to engage in sex before marriage. That sensitivity manifests itself, Community-based programmatic efforts however, as a mismatch between the supported by various internal and external information needs of young people and donors are furthering the adolescent and general population education programs, youth reproductive health effort through FLE programs, and family discussions that clubs and counseling centers (e.g., Vietnam do not directly address sexuality and family Youth Union), mobile teams, and planning. In some of the countries, campaigns, such as the 1998 UNFPA- STI/HIV/AIDS topics are slowly finding supported national campaign to raise their way into school-based FLE programs. awareness of the benefits of postponing In other countries, such as Indonesia, the sexual activity and to motivate those who government recognizes the need for making were already sexually active to practice available more specific information; safer sex. Coordination is also underway however, it lacks the political will to do so. by large organizations, such as the Vietnam Nonetheless, the political will to address Women’s Union and the Vietnam Red adolescent and youth reproductive health is Cross, which are providing IEC materials emerging in Southeast Asia, which accounts and methods. It is expected that the for fewer legal and policy barriers to development of new reproductive health reaching young people. At the same time, policies will mean further and important governments in the Near East and South gains in programming in the relatively near Asia remain conservative in dealing with future. adolescent and youth reproductive health, although some surprising policy developments have occurred; for example, Summary in Nepal, unmarried adolescents and youth are no longer prohibited from receiving Table 2 provides a snapshot of the strength services (although substantial operational of policies and programs related to policy barriers exist for young people adolescent and youth reproductive health actually receiving the services). in the 13 countries of the ANE region, including the extent to which political Information programs for young people commitment to adolescent and youth cover a range of topics, but again tend to reproductive health exists, the presence of consist of general messages about school-based FLE programs and other responsible parenthood. Parents are information programs and services for considered the most appropriate conduit for
34 Table 2. Status of Political Commitment and Adolescent and Youth Reproductive Health Programsi,ii in 13 ANE Countries: 2002–2003
NGOs Multi- Political Family Life Working in sectoral Gender Country Commitmentiii Educationiv Information Services A&YRHv focus Focus Near East Egypt *** *** ** ** Small/ *** *** Growing Growing Jordan ** *** ** ** Small/ *** — Active Morocco * *** *** ** Small/ ** *** FLE/ Starting to Active Population include Education HIV Focus Yemen ** — * * Small *** — Recent South Asia Bangladesh **** *** *** *** Active *** *** Growing NGO-driven India *** ** ** ** Small/ *** *** Active Nepal ** *** ** ** Small/ *** ** FLE/ Population Education Focus Pakistan * *** * * Small/ — — FLE/ Active Population Education Focus Sri Lanka *** *** ** ** Small/ *** *** Active Southeast Asia Cambodia ** *** *** ** Small/ *** — Emerging New Including HIV Active Indonesia ** ** ** ** Small/ ** ** Emerging Recognize Active Need Philippines *** *** ** ** Small/ *** — Mixed Including HIV Active Vietnam ** *** ** ** Small/ *** *** Emerging Including HIV Active
i Key: *** Exists; ** Limited; * Very limited ii The table does not include information on resources because all country reports listed resources as inadequate. iii All countries have policies that at least indirectly (e.g., those focusing on educational policies) relate to adolescent and youth reproductive health. iv FLE refers to school-based education programs. No country has a strong, nationwide program that deals with sexual and reproductive health, including STI/HIV/AIDS. v NGOs have more flexibility in working on adolescent and youth reproductive health issues, but they do not have wide coverage of information and services.
35 delivering information about sexuality and governments of all the countries of the reproductive health to their adolescents and ANE region. Reducing the education gap teens but generally do so only at the time of between males and females is important to marriage; in reality, though, parents some but not all governments. Providing provide little information. Typically livelihoods for young people as they reach operated by NGOs, some regular and peer adulthood is also a priority. Programs such counseling programs provide young people as New Horizons in Egypt are seeking to with more detailed information on sexual provide young women with a broader range and reproductive health. Married of life choices than only early marriage and adolescents and youth can receive services childbearing. Eight of the 13 countries in all countries; however, in many places, have recognized that gender inequities young women are discouraged or not between young women and young men allowed to receive family planning until must be addressed as part of youth they have had at least one child. With the development and reproductive health growing awareness of STIs/HIV/AIDS, the programs. In particular, NGO programs topic of infection is slowly being introduced are addressing gender inequities, including to young people, again mostly by NGOs. gender-based violence.
Nearly all countries are addressing In all, the ANE countries are increasingly adolescent and youth reproductive health aware of the reproductive health issues in the broader context of youth facing young people; however, putting development or life skills enhancement. knowledge into practice through policies Education is a high priority for the and programs remains a challenge.
36 Operational Barriers to Adolescent and Youth Reproductive Health
ational policies directly influence (e.g., in India, the Philippines, and Noperational policies—the “rules, Vietnam). Resources, both human and regulations, guidelines, operating monetary, for support of adolescent and procedures, and administrative norms that youth reproductive health programming governments use to translate national laws are also often inadequate or altogether and policies into programs and services.”101 absent. Access to services that do exist is Operational polices in turn shape public yet another problem, along with the quality sector regulations, which in their turn help of services. shape health systems management. Ultimately, this chain of events affects An obvious problem exists where national reproductive health service delivery. Thus, policies that directly address adolescent when a break in the chain occurs, as is and youth reproductive health are common in the ANE region, problems arise nonexistent. Informational barriers in the effort to develop or implement contribute to the policy vacuum. Often, adolescent and youth reproductive health governments have not yet tackled even the programs. definition of adolescence, as is the case in Yemen. The ANE region evidences a Operational barriers to adolescent and general lack of research on adolescent and youth reproductive health programming youth reproductive health and the needs of abound. Lack of understanding of the adolescents and youth, particularly among gravity of the issue or unwillingness to underserved and minority groups. Several address the issue on the part of reports, including those of Nepal, the policymakers, the public, and young people Philippines, Sri Lanka, and Yemen, themselves is often a problem. Policies are mention the paucity of research. The Sri often weak and indirect, and some Lanka assessment notes that the country countries’ policies do not address certain lacks data on teenage pregnancies, aspects of adolescent and youth abortions, contraceptive use, child abuse, reproductive health at all. While some and gender-based violence. These are adolescent and youth reproductive health sensitive issues but, as noted in the Sri program design and implementation is Lanka assessment, “as long as data are excellent, other programming is weak. scarce and the severity of adolescent and Programs often operate with poorly defined youth RH issues is not made known to the objectives and lack clearly outlined plans, public, political commitment for a coherent fail to coordinate with other organizations, policy initiative will be hard to achieve. In and lack project monitoring guidelines the long run, this could prove to be the
37 greatest operational barrier to adolescent government approval for action. In the and youth RH.”102 Social barriers often Philippines, for example, central foster operational policy barriers. government officials do not yet consider Traditional or religious values and norms decentralized authority legitimate. may impede discussion of adolescent and Coordination between public and NGO youth reproductive health issues and limit groups is also often lacking in the ANE support for policy development. countries, limiting the learning that could Policymakers, stakeholders, including be available to others and preventing the parents, and society at large are often integration of reproductive health, family uncomfortable with or not interested in planning, and treatment of STIs and HIV. changing mores; they either have difficulty At the same time, NGOs often experience addressing or refuse to address the difficulty in obtaining commodities such as pressing problems of adolescent and youth condoms. Finally, the ANE region relies reproductive health, believing that such heavily on foreign aid, which could, in the problems are best dealt with by the family short and long terms, put overall alone or not at all. Some leaders maintain programming, which is already in jeopardy, a stance of “official denial.”103 at further risk.
Even where policies are in place, barriers Table 3 lists operational policy barriers to at other points in the chain often providing adolescents and youth with undermine good adolescent and youth reproductive health information and reproductive health. Resources— services. In most counties, young people informational, human, operational, and have limited access to services and commodities—are a problem throughout information on reproductive health. the ANE region. The lack of sustained support means that both government and The lack of information and education is a NGO programs are implemented for only barrier in and of itself. It prevents young a limited time and that lessons learned are people’s understanding of what is rarely shared. In countries such as Yemen, happening to them, the changes they will a scarcity of Arabic-language materials encounter as they enter their adult years, and other objective references with regard and how best to care for themselves and to adolescent and youth reproductive future generations. The information health obviously poses a barrier. In young people do receive tends to be of a addition, training of service workers and general nature, often because parents and counselors is relatively rare in the region. community leaders fear that sex education The issue of abortion services is difficult to will promote sexual behavior at an early address in most nations, and where age. Young people throughout the region, services exist, providers may think that however, indicate that they would prefer to counseling is an unnecessary or receive more specific information on nonessential component.104 Bureaucrats sexual and reproductive health. As for often oppose moves toward decentralized segments of populations with low literacy authority and thus inhibit timely decisions, levels—a common situation throughout appropriate action, and the provision of the region—many adolescents and youth services during the wait for central may not be able to access available
38 Table 3. Operational Policy Barriers to Serving Adolescents and Youth in 13 ANE Countries, 2002–2003
Near East Egypt Difficult to obtain contraceptives before first birth; limited information. Jordan Family planning available only after the first birth; lack of knowledge before marriage and first birth. Morocco Sex out of marriage not recognized. Yemen Physical access limited, quality-of-care issues; limited information available to adolescents and youth. South Asia Bangladesh Physical access limited, quality-of-care issues. India Lack of services on a large scale; difficult for young people to obtain information. Nepal Policies sufficient, difficult for young people to obtain information and access services. Pakistan Official refusal to inform the public, particularly adolescents and youth, about sexual issues. Social and physical access limited; mobility restricted. Sri Lanka Lack of access to services; lack of information for vulnerable groups.
Southeast Asia Cambodia Substantial infrastructure barriers. Indonesia Lack of policy implementation and enforcement due to sensitivity over adolescent and youth reproductive health. Philippines Lack of access to reproductive health services for unmarried adolescents and youth; limited information and supplies. Vietnam Lack of resources generally for reproductive health; limited information and services available. reproductive health information, thus Most countries fail to provide services that pointing to the need to develop basic either include adolescents and youth or are infrastructure and education in order to directed specifically at them. In no country address adolescent and youth reproductive are unmarried youth particularly welcome health in the region. However, where in public sector clinics, and some countries education is the norm rather than the either maintain the illegality of providing exception, as is the case in certain reproductive health services to unmarried countries or segments of the population, adolescents or make access extremely problems with school administrators, difficult. Where private clinics exist, teachers, or others in positions to reach services are often unaffordable and adolescents and youth are not uncommon inaccessible to the average person—and as the educational systems resist the certainly to the average young person.105 teaching of reproductive health, as is the This is the case even in countries such as case in Jordan. Morocco, Sri Lanka, and Vietnam, where
39 sexual mores continue to change. Where skills often make the critical period of services are available for young people, contact with adolescents and youth difficult quality barriers may exist. For example, and uncomfortable and can deter young clinics may lack privacy and confidentiality people from seeking services. In many ANE for adolescents and youth. They may also countries, NGOs have tried to overcome lack professional staff, resulting in poor these barriers by implementing programs treatment of young people. Insensitive that meet the needs of sexually active interview questions or poor counseling unmarried youth.
40 Recommendations
ountries throughout the ANE region era of rising HIV/AIDS prevalence in the Care increasingly aware of adolescent region. Nor are the challenges unique to and youth reproductive health as a topic of the ANE region, although the region is concern that requires attention. The 13 home to the world’s largest group of countries that have undergone assessment adolescents and youth. Nevertheless, the have all created various plans, policies, and challenges must be addressed to improve programs to address adolescent and youth the reproductive health of this and future reproductive health and the factors generations of adolescents and youth. affecting it. Governments, to different degrees, have committed to reducing or 1. Involve youth in developing policies and eliminating gender discrimination, closing programs to meet their needs. gender gaps in education and employment, and making reproductive health education Since the 1994 ICPD, programs have and services available. increasingly included a range of stakeholders to articulate and design Adolescent and youth reproductive health policies and programs to meet client needs. in the ANE region is influenced in great Yet, young people are often excluded from part by the traditional cultural and discussions about policies and programs religious norms and values that pervade that affect them. Youth must be actively and dictate both family communication involved in both discussing the issues facing and national policymaking. In this their generation and developing solutions context, the 13 country assessments that meet their needs for good suggest that adolescent and youth reproductive health. reproductive health should be addressed by advocating for policy and program 2. Inform policymakers about the needs of development; involving youth in policy young people and advocate for policy design and implementation; educating and program change. policymakers, teachers, parents, and adolescents and youth; facilitating family Policymakers, lawmakers, and stakeholders communication; promoting gender equity; are too often inadequately informed about expanding access to information and the conditions and specific and special services; and conducting needed research needs of young people and the to ensure that programs are evidence- consequences of not addressing them. based. These challenges are not new, Adolescent and youth reproductive health although they take on more urgency in an remains a politically and socially sensitive
41 topic; policymakers are often reluctant or General public opinion must change to unable to develop multisectoral policies enhance adolescent and youth reproductive that address adolescent and youth health. It is essential to reach village and reproductive health. Stakeholders need to community leaders and religious and advocate to policymakers based on an opinion leaders so that they, in turn, can understanding of existing laws and policies. influence community members, families, Advocacy must be premised on human and parents. Parents need a better rights principles and take into account understanding of adolescent and youth various social, economic, and religious reproductive health issues if they are to points of view. Youth and adolescent communicate effectively with their children reproductive health advocates should and support conditions that will improve encourage development of relevant laws, their health. Careful thought needs to be policies, and guidelines to ensure adequate put into the appropriate means for protection and promotion of adolescent and reaching these constituencies. In most youth reproductive health and attention to countries, the appropriate message may be associated social issues, such as gender one underscoring the “healthy development equity in education and the economy. of youth.” Young people should be fully Training is also needed so that key engaged in the development of messages individuals can adequately motivate and and the “packaging” of information for lead their constituencies and assist in adolescents and youth. disseminating policy information to other relevant groups, such as community leaders Teachers and others who are in regular and service providers. contact with youth and adolescents need to feel both comfortable and adequate in The support of an individual, high-profile dealing with adolescent and youth political figure can be crucial to improving reproductive health once they have the a country’s adolescent and youth social platform on which to do it. Given reproductive health policies and programs. the conservative nature of most societies in This person’s advocacy and action can the ANE region, these special gatekeepers catalyze high-level discussion and even will need assistance in acquiring attitudinal change. Ibu Khofifah Indar Parawansa, the and skill changes. Training can be former Minister of Women’s Empowerment developed and conducted through and Head of the National Family Planning cooperation among governments, NGOs, Board in Indonesia, First Lady Suzanne and private organizations. Adolescents Mubarak in Egypt, and Princess Lalla should also have an opportunity for their Fatima Zohra in Morocco have all voice to be heard. Communication among addressed sensitive topics related to all stakeholders will be critical to adolescent and youth reproductive health. comprehensive programming.
3. Educate policymakers, teachers, parents, 4. Promote communication in families. community leaders, and young people to change public opinion about the As policymakers and teachers receive importance of meeting youth and information and training, parents cannot adolescent reproductive health needs. be forgotten. For change to occur, the gap
42 between sociocultural norms and the ANE region. Given that religion has a realities of adolescent and youth strong influence in many ANE countries, reproductive health must be narrowed. people might feel comfortable with a Because premarital sex is inappropriate religious context for discussions about according to many countries’ cultures or adolescent and youth reproductive health. religions, families often do not realize or While some religions may not support the choose not to acknowledge that young discussion of certain topics, religious people are increasingly sexually active and institutions may be open to facilitating that, as the age of marriage rises, young dialogue about some aspects of adolescent people find themselves increasingly and youth reproductive health, such as exposed to premarital sexual activity. The relationships, gender equity, gender-based lack of acknowledgment hinders policy and violence, and sexual abuse. programmatic responses to addressing adolescent and youth reproductive health. 5. Promote gender equity in all youth- related policies and programs. Parents need to realize that social norms are changing, such that many adolescents Promoting gender equity and positive and youth are sexually active. They also gender norms around sex and reproductive need accurate reproductive health health, such as reducing early marriage information and must be comfortable and eliminating or helping to redefine discussing relevant topics so that they can social systems (including the dowry system) help and teach young people and support that make females the chattel of males, appropriate policies and programs. must underlie comprehensive, Parents can be a great source of assistance multisectoral, and thus functional and and information for their adolescent successful programming. children, who generally want their first exposure to information on sexual and 6. Increase young people’s access to reproductive health to come from their information and services. parents. Parents can also be strong advocates on a political level. Adolescents and youth in all countries need increased access to accurate and complete One way to educate parents is through information. Reproductive health their children’s education. Young people education in schools needs to be designed could take information home to their to make young people (and teachers) parents to engage their families in knowledgeable and comfortable with the discussions about sexual relationships and information. The most effective curricula to educate their parents, who may have are comprehensive and cover the biological incomplete or inaccurate knowledge. and social aspects of reproductive health. Adequately trained peer educators can be Faith-based organizations (FBOs) can also useful additions to adolescent and youth facilitate exchanges in families. FBOs reproductive health education programs. have had success addressing the HIV/AIDS Adolescents and young people should also pandemic in Africa and perhaps can offer a have access to information through model for reaching young people in the community clinics, satellite clinics,
43 premarital counseling, family welfare most programs. In addition, few programs centers, schools, peer education, local youth have sufficiently wide scope to reach a forums, mass media, clubs, and so forth. great number of young people. For example, many programs are concentrated Yo ung people who are sexually active, in urban areas or schools, neglecting rural including newly married couples, need or out-of-school adolescents and youth. access to condoms for disease protection as Many are small-scale projects or pilot well as to contraceptives for reducing projects that work with small groups of unintended pregnancy. Providers often pose young people for short periods of time. the greatest barrier faced by young people in seeking access to services. Additional Often, NGOs have more flexibility in support is needed to increase providers’ providing information and services to young knowledge and catalyze attitudinal and people. In addition, NGO staff tend to be behavior change with regard to adolescent more youth-friendly than government health and youth reproductive health. Service care providers. Yet, NGOs often cover only providers at all levels need to be trained in small areas of a country. Governments and all aspects of adolescent and youth donors should consider providing more reproductive health. Female doctors need support to NGOs to undertake adolescent to be deployed to provide services to young and youth development work. Programs females. Counseling services for male and with limited potential for scaling up should female adolescents and youth are needed not be initiated. and should address the realities of respective country conditions. For example, 7. Develop and promote evidence-based reference to marriage as “the” protective programs. agent for HIV/AIDS should be modified. Marriage is not necessarily a protective To promote adolescent and youth factor; both men and women can bring HIV reproductive health, programs should draw to a marriage either initially or later. Each on existing information on what works. For country should also examine the possibility example, the evidence shows that sex of developing or strengthening links education does not increase sexual activity between various services, such as between and that young people want to know more clinics/pharmacies and youth activities, to about abstinence, safer sexual practices, achieve an integrated approach to and other aspects of reproductive health. adolescent and youth reproductive health. Such knowledge should be disseminated widely and applied in developing and Existing policies and programs are often implementing adolescent and youth limited by lack of sustainability, narrow reproductive health education programs, scope, and short time frames. While time- especially as the age of marriage rises and bound efforts can be advantageous in the likelihood of premarital sex increases. forcing policymakers and stakeholders to revisit and revise policies and programs Furthermore, taking a youth development frequently and regularly, shorter time approach can be more culturally appropriate frames can also prove a liability to than focusing solely on reproductive health. sustainability. Funding shortages plague In addition, addressing a range of issues
44 facing adolescents and young people will indicated that more research is needed to likely be more acceptable to young people. inform program efforts. Countries differ Often, young people themselves are often in the type of research needed, but, at a more concerned about education and jobs minimum, research should focus on than about reproductive health. various segments of society, including underserved, minority, and rural While there is some available information populations—those most at risk for poor to draw on, all of the country reports reproductive health outcomes.
45 Endnotes
1. The World Health Organization (WHO) 9. Khan and Pine, 2003, p. 8. defines adolescents as persons 10 to 19 10. Pradhan and Strachan, 2003, p. 4. years of age, youth as persons 15 to 24 11. De Silva et al., 2003, p. 4. years of age, and young people as 10 to 12. Fordham, 2003, p. 5. 24 years. The 13 assessment reports, 13. Utomo, 2003, p. 4. however, have used varying definitions 14. Hong, 2003, p. 4. of adolescents and young people: the 15. Barkat and Ahmed, 2001, cited in Bangladesh, Indonesia, Morocco, Barkat and Majid, 2003. Philippines, and Vietnam reports refer 16. LICHARDO, 2001, cited in Fordham, to persons 15 to 24 years of age (a 2003. category also sometimes termed “young 17. Nassar et al., 1998, cited in people”); the Egypt, India, Sri Lanka, Almasarweh, 2003. and Yemen reports refer to persons 10 18. Beaufils, 2000; and Ministry of to 19 years of age; and the Cambodia, Education, Youth, and Sports Jordan, Nepal, and Pakistan reports [Cambodia], 1998, cited in Fordham, refer to persons 10 to 19 years of age as 2003. “adolescents” and persons 15 to 24 years 19. MOH [Nepal] et al., 2002, cited in of age as “young people.” These Pradhan and Strachan, 2003. disparities preclude precise comparisons 20. CBS [Indonesia], 1998, cited in Utomo, of age-related research (of which there 2003. is little), but important similarities and 21. Ibrahim et al., 1999, cited in Beamish, comparisons still can be examined. 2003. 2. ICPD Programme of Action, Chapter VII, 22. Beamish and Tazi Abderrazik, 2003. Section E. 23. MOHFW [Bangladesh], 1998, cited in www.un.org/ecosocdev/geninfo/populati Barkat and Majid, 2003. n/icpd.htm 24. GSO [Vietnam], 2000, cited in Hong, 3. www.developmentgoals.org 2003. 4. Beamish, 2003, p. 3. 25. Guessous, 2000, cited in Beamish and 5. Almasarweh, 2003, p. 3. Tazi Abderrazik, 2003. 6. Beamish and Tazi Abderrazik, 2003, p. 4. 26. Khan and Pine, 2003. 7. Al-Rabee’, 2003, p. 3. 27. Barkat and Majid, 2003. 8. Registrar General and Census 28. Hull, 2002; Jones, 1994; and Hull and Commissioner [India], 2001; IIPS, 2000; Hull, 1984, cited in Utomo, 2003. and Government of Rajasthan, 1995, 29. Ech-Channa, 2000, p. 145, cited in cited in Gupta, 2003. Beamish and Tazi Abderrazik, 2003, p. 4.
46 30. Fordham, 2003, p. 5. 51. Ramasubban, 1995, cited in Gupta, 2003. 31. Fordham, 2003, p. 5. 52. JAFPP, 2001, cited in Almasarweh, 2003. 32. Varga and Zosa-Feranil, 2003. 53. Barkat et al., 2000, cited in Barkat and 33. Pachauri and Santhya, 2002. Majad, 2003. 34. Respondent, cited in Varga and Zosa- 54. Dialmy, 2000; and AMPF/Experdata, Feranil, 2003. 1995, cited in Beamish and Tazi 35. Barkat and Majid, 2003, p. 8. Abderrazik, 2003. 36. De Silva et al., 2003, p. 16. 55. MSP [Morocco] and AIDSCAP, 1997, 37. Kirby, 2001; and Grunseit et al., 1997. cited in Beamish and Tazi Abderrazik, These two exhaustive reviews of studies 2003. on school-based programs concluded 56. Sahil, n.d., cited in Khan and Pine, 2003. that sex education programs do not 57. See CARAM, 1999, and Greenwood, promote or lead to an increase in sexual 2000, cited in Fordham, 2003. activity among young people with regard 58. Gupta, 2003. to either the initiation or frequency of 59. Ibrahim et al., 1999; Shafey, 1998; and sex. A U.S. study found that HIV UNFPA/MOHP, 2001, cited in Beamish, programs were more likely to result in a 2003. decrease in the number of sex partners 60. Shafey, 1998, cited in Beamish, 2003. and an increase in condom use. 61. Shafey, 1998, cited in Beamish, 2003. 38. Beamish, 2003, p. 9. 62. Al-Bindari, 2001, cited in Beamish, 2003. 39. Utomo, 2003, p. 9. 63. JNPC/GS, 2001, cited in Almasarweh, 40. Respondent, cited in Varga and Zosa- 2003. Feranil, 2003, p. 6. 64. MOP [Jordan], 1999, cited in 41. AMPF/Experdata, 1995, cited in Almasarweh, 2003. Beamish and Tazi Abderrazik, 2003. 65. Labor Law No. 8, 1996; and Civil 42. Beamish and Tazi Abderrazik, 2003, p. 23. Service By-law for 1996, cited in 43. DOS [Jordan] and Macro International, Almasarweh, 2003. Inc., 1997, cited in Almasarweh, 2003. 66. Dialmy, 2000; Ech-Channa, 2000; and 44. Almasarweh, 2003, p. 16. Joutei, 2001, cited in Beamish and Tazi 45. Respondent, cited in Varga and Zosa- Abderrazik, 2003. Feranil, 2003. 67. Mounabih, 2001; and Reynolds, 1999, 46. The data represent sexually active cited in Beamish and Tazi Abderrazik, young women in union who wish either 2003. to postpone childbearing by at least two 68. Beamish and Tazi Abderrazik, 2003, p. 13. years or to have no more children and 69. National Program of ARH and FP and yet are not using contraception. Child Health (2001–2005), NPC 47. Marcus study cited in Wilopo et al., [Yemen]; and. NPC [Yemen], 2001, 1999, cited in Utomo, 2003. cited in Al-Rabee’, 2003. 48. MOH [Vietnam], 2001, cited in Hong, 70. Government of India, 2000, cited in 2003. Gupta, 2003. 49. Goodkind, 1994, cited in Hong, 2003. 71. Sahil, n.d., cited in Khan and Pine, 2003. 50. Government of Bangladesh and 72. Chhuan et al., 1997; and MOH UNICEF, 2000, cited in Barkat and [Cambodia], 1998, cited in Fordham, Majid, 2003. 2003.
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