What is Parental and Spousal Consent?

This indicator assesses the extent to which a country’s policy environment supports youth access to FP services without parental or spousal consent.

What is Provider Authorization?

This indicator assesses the extent to which a country’s policy environment requires providers to deliver FP services to youth without discrimination or bias.

What are Age Restrictions?

This indicator assesses the extent to which a country’s policy environment supports youth access to FP services regardless of age.

What are Marital Status Restrictions?

This indicator assesses the extent to which a country’s policy environment supports youth access to FP services regardless of marital status.

What is Access to a Full Range of FP Methods?

This indicator assesses the extent to which a country’s policy environment supports youth access to a full range of contraceptive methods, including the provision of long-acting reversible contraception.

What is Comprehensive Sexuality Education?

This indicator assesses the extent to which a country’s policy environment supports comprehensive sexuality education (CSE) for all youth, in accordance with the United Nations Population Fund (UNFPA) guidelines on essential components of CSE.

What is Youth-Friendly FP Service Provision?

This indicator assesses the extent to which a country’s policy environment supports youth-friendly FP service delivery, in accordance with three service delivery core elements shown to increase youth uptake of contraception: provider training, confidentiality and privacy, and free or subsidized services.

What is Enabling Social Environment?

This indicator assesses the extent to which a country addresses the two enabling environment elements of youth-friendly contraceptive service provision: build community support and address gender norms.

Many countries have taken a protectionist approach to legislating youth access to FP services, based on a belief that young people need to be protected from harm and that parents or spouses should be able to overrule their reproductive health (RH) decisions. In practice, these laws serve as barriers that inhibit youth access to a full range of sexual and reproductive health (SRH) services, including FP. For example, an International Planned Parenthood Federation study in El Salvador reported that laws requiring parental consent for minors to access medical treatment create a direct barrier for youth to access FP. The study recommended: “Primary legislation should clearly establish young people’s right to access SRH services, independent of parental or other consent; to avoid ambiguity and the risk that informal restrictions will be applied at the discretion of service providers.”

Global health and human rights bodies stress the importance of recognizing young people’s right to freely and responsibly make decisions about their own RH and desires. The 2012 International Conference on Population and Development’s Global Youth Forum recommended that “governments must ensure that international and national laws, regulations, and policies remove obstacles and barriers—including requirements for parental & spousal notification and consent; and age of consent for sexual and reproductive services—that infringe on the sexual and reproductive health and rights of adolescents and youth.”

Laws around consent to FP services are often unclear or contradictory. The Scorecard intends to recognize countries that explicitly affirm youth’s freedom to access FP services without parental or spousal consent. Countries that have created such a policy environment have been placed in the green category, signifying the most favorable policy environment, because their definitive legal stance provides the necessary grounding from which to counteract social norms or religious customs that may restrict young people’s ability to access FP services. If a policy document mentions that youth are not subject to consent from one of the third parties—spouse or parent—but does not mention the other, the country is classified in the yellow category. Any country that requires consent from a parent and/or spouse is placed in the red category. If a country does not have a policy in place that addresses youth access to FP services without consent, it is placed in the gray category.

Providers often refuse to provide contraception to youth, particularly long-acting reversible methods, for non-medical reasons. Service providers may impose personal beliefs or apply inaccurate medical criteria when assessing youth FP needs, creating a barrier to youth contraceptive uptake. Three-quarters of Ugandan providers queried on their perspective of providing contraception to youth believed that youth should not be given contraception, and one-fifth of providers said they would prefer to advise abstinence instead of providing injectables to young women. To address this barrier, national laws and policies should reflect open access to medically advised FP services for youth, without youth being subject to providers’ personal beliefs.

Policies that explicitly underscore the obligation of providers to service youth without discrimination or bias are considered fully supportive of youth access to contraception and receive a green categorization under this indicator. Any country that generally supports the World Health Organization (WHO) medical eligibility criteria for contraceptive use but does not explicitly require providers to service youth despite personal beliefs is placed in the yellow category. Any country that supports providers’ non-medical discretion when authorizing FP services for youth is placed in the red category, indicating a legal barrier for youth to use contraception. Countries that lack any policy addressing non-medical provider authorization fall in the gray category.

Youth seeking contraceptives continue to face barriers to accessing services because of their age. For example, a study in Kenya and Zambia found that less than two-thirds of nurse-midwives agreed that girls in school should have access to FP.

In 2010, a WHO expert panel concluded that “the existence of laws and policies that improve adolescents’ access to contraceptive information and services, irrespective of marital status and age, can contribute to preventing unwanted pregnancies among this group.” The 2012 International Conference on Population and Development’s Global Youth Forum recommended that governments ensure that their policy landscape removes obstacles to sexual and reproductive health and rights of young people, including age of consent for FP services.”

Countries that explicitly include a provision in their laws or policies that support youth access to FP regardless of age are considered to have a supportive policy environment and are placed in the green category. Countries that restrict youth access to FP by defining an age of consent for sexual and RH services are considered to have a restrictive policy environment and are placed in the red category. Countries that do not have a policy that supports youth access to FP regardless of age are placed in the gray category.

A 2014 systematic review identified laws and policies restricting unmarried youth from accessing contraception as an impediment to youth uptake of contraception. In the absence of a legal stance on marital status, health workers can justify refusal to provide contraception to unmarried youth. Thus, strong policies providing equal access to FP services for married and unmarried youth are necessary to promote uptake of contraceptive services among all young people.

Countries are determined to have the most supportive policy environment (green category) for this indicator if they explicitly include a provision in their laws or policies for youth to access FP services regardless of marital status. If a country recognizes an individual’s legal right to access FP services regardless of marital status but includes policy language that emphasizes married couples’ right to FP, it is considered to have a promising yet inadequate policy environment and classified in the yellow category, because the policy leaves room for interpretation. A country is placed in the red category if its policies restrict youth from accessing FP services based on marital status. Finally, if a country has no policy supporting access to FP services regardless of marital status, it is placed in the gray category.  

Youth seeking contraception, particularly long-acting reversible contraceptives (LARCs), frequently face scrutiny or denial from their provider based on their age, marital status, or parity (the number of times a woman has given birth). The WHO medical eligibility criteria for contraceptive use, however, explicitly state that age and parity are not contraindications for short-acting or long-acting reversible contraception.

Provision of LARCs as part of an expanded method mix is particularly effective in increasing youth uptake of contraception. In one study, implants were offered as an alternative contraceptive option to young women seeking short-acting contraceptives at a clinic in Kenya. Twenty-four percent of the women opted to use an implant, and their rate of discontinuation was significantly lower than those using short-acting methods. Of the 22 unintended pregnancies that occurred, all were among women using short-acting methods. Another study  trained providers working in youth-friendly services to offer a full range of contraceptive methods, which resulted in an increased adoption of LARCs among sexually active women, including those who planned to delay their first pregnancy. However, many young people around the world do not know about LARCs, and if they do, they may be confused about their use and potential side effects, hesitant to use them due to social norms, or face refusal from providers.

The “Global Consensus Statement for Expanding Contraceptive Choice for Adolescents and Youth to Include Long-Acting Reversible Contraception” calls upon all youth SRH and rights programs to ensure that youth have access to a full range of contraceptive methods by:

• Providing access to the widest available contraceptive options, including long-acting reversible contraceptives (LARCS, i.e., contraceptive implants and intrauterine contraceptive devices) to all sexually active adolescents and youth (from menarche to age 24), regardless of marital status and parity.
• Ensuring that LARCs are offered and available among the essential contraceptive options during contraceptive education, counseling, and services.
• Providing evidence-based information to policy makers, ministry representatives, program managers, service providers, communities, family members, and adolescents and youth on the safety, effectiveness, reversibility, cost-effectiveness, acceptability, continuation rates, and the health and non-health benefits of contraceptive options, including LARCs, for sexually active adolescents and youth who want to avoid, delay or space pregnancy.

This indicator differs from the Restrictions Based on Age indicator by focusing on the range of methods offered to youth. Countries should have in place a policy statement that requires health providers to offer short-acting and long-acting reversible contraceptive services regardless of age. In addition, the policy should leave no ambiguity in the scope of the directive but rather explicitly mention youth’s legal right to access a full range of contraceptive services, including LARCs. Therefore, countries with an explicit policy allowing youth to access a full range of contraceptive services—regardless of age—receive a green categorization for promoting the most supportive policy environment. Countries with policies that state that youth can access a full range of methods, but do not specify that LARCs are included in the method choice, are placed in the yellow category. These countries are on the right track but would have a stronger enabling environment if their policies explicitly mentioned youth’s right to access LARCs.

A country is placed in the red category if it has a policy in place that restricts access to FP services, including specific methods, based on age, marital status, parity, or other characteristics that do not align with WHO medical eligibility criteria. Countries that do not have a policy addressing youth access to a full range of contraceptive methods are placed in the gray category.

It is important to note that the Scorecard does not assess policies’ inclusion of emergency contraception (EC) in the full range of methods for youth when determining categorization of countries for this indicator. This indicator is focused on whether short-term methods and LARCs are included in the method options that are made available to youth. Therefore, countries that do not list EC in the available methods for youth can still receive a green categorization if they have included access to LARCs. However, due to the growing attention on EC as an available method for youth, the summary of this indicator in each country section makes note of whether EC was included in the range of methods for youth.

The WHO recommends educating adolescents about sexuality and contraception to increase contraceptive use and ultimately prevent early pregnancy and poor RH outcomes. Comprehensive sexuality education (CSE) is a specific form of sexuality education that equips young people with age-appropriate, scientifically accurate, and culturally relevant SRH knowledge, attitudes, and skills regarding their SRH rights, services, and healthy behaviors.

A growing body of evidence demonstrates that informing and educating youth about sexuality and SRH have a positive impact on their RH outcomes. Sexuality education offered in schools helps youth make positive, informed decisions about their sexual behavior and can reduce sexually transmitted infections (STIs) and unintended pregnancies, in part due to increased self-efficacy and use of condoms and other contraception. A study in Brazil that implemented a school-based sexual education program in four municipalities measured a 68%increase in participating students’ use of modern contraception during their last sexual intercourse. To be most effective, sexuality education should be offered as part of a package with SRH services, such as direct provision of contraception or links to youth-friendly FP services.

Many approaches exist to implement sexuality education in and out of schools. The Scorecard considers CSE as the gold standard and relies on the “UNFPA Operational Guidance for Comprehensive Sexuality Education,” which focuses on human rights and gender as a framework to effectively implement a CSE curriculum. The UNFPA Operational Guidance outlines nine essential components of CSE that are concise and easy to measure across countries’ policy documents. Further, these guidelines recognize gender and human rights and build on global standards discussed in the United Nations Educational, Scientific, and Cultural Organization’s “International Technical Guidance on Sexuality Education.”

The nine UNFPA essential components for CSE are:

1. A basis in the core universal values of human rights.
2. An integrated focus on gender.
3. Thorough and scientifically accurate information.
4. A safe and healthy learning environment.
5. Linking to sexual and reproductive health services and other initiatives that address gender, equality, empowerment, and access to education, social and economic assets for young people.
6. Participatory teaching methods for personalization of information and strengthened skills in communication, decision-making and critical thinking.
7. Strengthening youth advocacy and civic engagement.
8. Cultural relevance in tackling human rights violations and gender inequality.
9. Reaching across formal and informal sectors and across age groupings.

A country is determined to have the most supportive policy environment and is classified in the green category if its policies not only recognize the importance of sexuality education broadly but also include each of the nine elements of CSE.

A country is considered to have a promising policy environment if it clearly mandates sexuality education in a national policy but either does not outline exactly how sexuality education should be implemented or has guidelines that are not fully aligned with the UNFPA CSE essential components. Under these criteria, a country is classified in the yellow category.

While evidence proves that sexuality education equips youth with the necessary skills, knowledge, and values to make positive SRH decisions, including increased contraceptive use, little evidence exists that abstinence-only education is similarly effective. The 2016 Lancet Commission on Adolescent Health and Wellbeing recommends against abstinence-only education as a preventive health action and found it ineffective in preventing negative SRH outcomes. In fact, some reports suggest that an abstinence-only approach increases the risk for negative SRH outcomes among youth. Therefore, a country that supports abstinence-only education is seen as limiting youth’s access to and use of contraception and, as a result, is grouped in the red category. Any country lacking a sexuality education policy is placed in the gray category.

[vii] Patton et al., "Our Future."

[viii] Santhya and Jejeebhoy, “Sexual and Reproductive Health and Rights of Adolescent Girls.”

The WHO “Guidelines on Preventing Unintended Pregnancy and Poor Reproductive Outcomes Among Adolescents in Developing Countries” recommend that policymakers make contraceptive services adolescent-friendly to increase contraceptive use among this population. This recommendation aligns with numerous findings in the literature. A 2016 systematic assessment to identify evidence-based interventions to prevent unintended and repeat pregnancies among young people in LMICs found that three out of seven interventions that increased contraceptive use involved a component of contraceptive provision. Evidence from a 2020 study showed that providing free short and long-acting reversible contraceptives was associated with an increased likelihood of contraceptive use. Additional evaluations show that when SRH services are tailored to meet the specific needs of youth, they are more likely to use these services and access contraception.

The Scorecard draws upon the service-delivery core elements originally identified in the United States Agency for International Development’s High-Impact Practices in Family Planning (HIPs) brief, “Adolescent-Friendly Contraceptive Services,” as the framework for assessing the policy environment surrounding FP service provision. An updated version of the brief, “Adolescent-Responsive Contraceptive Services: Institutionalizing Adolescent-Responsive Elements to Expand Access and Choice,” was published in March 2021 and reaffirms the same service-delivery elements as showing a direct contribution to increased contraceptive use. The service-delivery elements addressed in this indicator are:

1. Train and support providers to offer nonjudgmental services to adolescents.
2. Enforce confidentiality and audio/visual privacy.
3. Provide no-cost or subsidized services.

Many countries have adolescent-friendly health initiatives that include a wide range of health services, but for a country to be placed in the green category, its policies should specifically reference providing FP services to youth as part of the package of services. A country is placed in the green category for this indicator if its policy documents reference the three adolescent-friendly contraceptive service-delivery elements as defined above. Simply referencing the provision of FP services to youth, but not adopting the three service-delivery elements of adolescent-friendly contraceptive services, indicates a promising but insufficient policy environment, and the country is placed in the yellow category. Countries that reference provider training in youth FP services but do not acknowledge judgment as a barrier or do not specify that the training is to combat provider discrimination receive a yellow categorization. A country is also placed in the yellow category if policies reference making youth services affordable or confidential but do not specify FP services or products.

Countries that do not have a policy that promotes FP service provision to youth are placed in the gray category.

The final indicator addresses demand-side factors, specifically efforts to make youth access to and use of a full range of contraceptive methods more socially acceptable and appropriate within their communities. To support youth’s acceptance of contraception and ensure they are comfortable seeking contraceptive services, it is imperative to spread awareness and build support for a wide range of contraceptive methods in the broader communities in which they live. The 2016 Lancet Commission on Adolescent Health and Wellbeing identified community-support interventions as a critical component of strong sexual and reproductive health (SRH) service packages.

Group engagement activities that mobilize communities through dialogue and action, rather than by only targeting individuals, are considered a promising practice to change social norms around SRH, including contraceptive use Group engagement can be useful to change the discourse around youth sexuality and address misconceptions about contraception within communities. In addition to group engagement, some studies show that gender-synchronized approaches to and male partner engagement in family planning use leads to increased contraceptive use among young married couples and male partners.

The Scorecard draws upon enabling-environment elements originally outlined in United States Agency for International Development’s High-Impact Practices in Family Planning (HIPs) brief, “Adolescent-Friendly Contraceptive Services.” The updated HIPs brief for adolescent-responsive contraceptive services does not specifically reference these two elements but does address their intent by noting that countries should “link multi-sectoral demand side and gender-transformative community engagement efforts to adolescent-responsive contraceptive services, including through strong referral networks.”

This enabling-environment elements assessed in this indicator are:

• Address gender and social norms.
• Link service delivery with activities that build support in communities.

Countries that outline specific interventions to build support within the larger community for youth FP and address gender and social norms are considered to have a strong policy environment and are placed in the green category. Countries that include a reference to building an enabling social environment for youth FP, without providing any specific plan for doing so, are placed in the yellow category. Additionally, countries that discuss one, but not both, of the enabling social environment elements in detail are placed in the yellow category. Countries without any reference to activities to build an enabling social environment for youth FP are placed in the gray category.

No law or policy exists that addresses consent from a third party to access FP services.

Law or policy exists that requires providers to authorize medically advised youth FP services but does not address personal bias or discrimination.

No law or policy exists addressing age in youth access to FP services.

Law or policy exists that restricts access to FP services based on marital status.

Law or policy exists that supports youth access to a full range of FP methods without defining full range of methods to include long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy references targeting youth in provision of FP services but mentions fewer than three of the service-delivery elements for youth-friendly contraceptive services.

Policy outlines detailed strategy addressing two enabling social environment elements for youth-friendly contraceptive services:

• Address gender norms.
• Build community support.

Law or policy exists that supports access to FP services without consent from both third-parties (parents and spouses).

No law or policy exists that addresses provider authorization for youth FP services.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that supports youth access to a full range of FP methods without defining full range of methods to include long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy outlines the following three service-delivery elements for youth-friendly contraceptive services:

• Provider training.
• Confidentiality and privacy.
• Free or reduced cost.

Policy outlines detailed strategy addressing two enabling social environment elements for youth-friendly contraceptive services:

• Address gender norms.
• Build community support.

Law or policy exists that supports access to FP services without consent from one but not both third parties.

No law or policy exists that addresses provider authorization for youth FP services.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that supports youth access to a full range of FP methods, including the provision of long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy outlines the following three service-delivery elements for youth-friendly contraceptive services:

• Provider training.
• Confidentiality and privacy.
• Free or reduced cost.

Policy outlines detailed strategy addressing two enabling social environment elements  for youth-friendly contraceptive services:

• Address gender norms.
• Build community support.

Law or policy exists that supports access to FP services without consent from one but not both third parties.

No law or policy exists that addresses provider authorization for youth FP services.

Law or policy exists that supports youth access to FP services regardless of age

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that supports youth access to a full range of FP methods without defining full range of methods to include long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy references targeting youth in provision of FP services but mentions fewer than three of the service-delivery elements for youth-friendly contraceptive services.

Policy outlines detailed strategy addressing two enabling social environment elements  for youth-friendly contraceptive services:

• Address gender norms.
• Build community support.

No law or policy exists that addresses consent from a third party to access FP services.

No law or policy exists that addresses provider authorization for youth FP services.

Law or policy exists that supports youth access to FP services regardless of age.

No law or policy exists addressing marital status in access to FP services.

Law or policy exists that supports youth access to a full range of FP methods without defining full range of methods to include long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy outlines the following three service-delivery elements for youth-friendly contraceptive services:

• Provider training.
• Confidentiality and privacy.
• Free or reduced cost.

Policy references building an enabling social environment to support youth access to FP but does not include specific intervention activities addressing both enabling social environment elements.

Law or policy exists that supports access to FP services without consent from both third parties (parents and spouses).

No law or policy exists that addresses provider authorization for youth FP services.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that supports youth access to a full range of FP methods without defining full range of methods to include long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy references targeting youth in provision of FP services but mentions fewer than three of the service-delivery elements for youth-friendly contraceptive services.

No policy exists to build an enabling social environment for youth FP services.

No law or policy exists that addresses consent from a third party to access FP services.

No law or policy exists that addresses provider authorization for youth FP services.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that supports youth access to a full range of FP methods without defining full range of methods to include long-acting reversible contraceptives regardless of age, marital status, and/or parity.

No policy exists supporting sexuality education of any kind.

Policy references targeting youth in provision of FP services but mentions fewer than three of the service-delivery elements for youth-friendly contraceptive services.

No policy exists to build an enabling social environment for youth FP services.

No law or policy exists that addresses consent from a third party to access FP services.

Law or policy exists that requires providers to authorize medically-advised youth FP services without personal bias or discrimination.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that restricts youth access to a full range of FP methods based on age, marital status, and/or parity.

Policy supports the provision of sexuality education and mentions all nine UNFPA essential components of comprehensive sexuality education.

Policy outlines the following three service-delivery elements for youth-friendly contraceptive services:

• Provider training.
• Confidentiality and privacy.
• Free or reduced cost.

Policy outlines detailed strategy addressing two enabling social environment elements  for youth-friendly contraceptive services:

• Address gender norms.
• Build community support.

Law or policy exists that supports access to FP services without consent from one but not both third parties.

No law or policy exists that addresses provider authorization for youth FP services.

Law or policy exists that supports youth access to FP services regardless of age.

No law or policy exists addressing marital status in access to FP services.

No law or policy exists addressing youth access to a full range of FP methods. 

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy references targeting youth in provision of FP services but mentions fewer than three of the service-delivery elements for youth-friendly contraceptive services.

Policy references building an enabling social environment to support youth access to FP but does not include specific intervention activities addressing both enabling social environment elements.

Law or policy exists that supports access to FP services without consent from both third parties (parents and spouses).

Law or policy exists that requires providers to authorize medically-advised youth FP services without personal bias or discrimination.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that supports youth access to a full range of FP methods, including the provision of long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of CSE.

Policy outlines the following three service-delivery elements for youth-friendly contraceptive services:

• Provider training.
• Confidentiality and privacy.
• Free or reduced cost.

Policy outlines detailed strategy addressing two enabling social environment elements  for youth-friendly contraceptive services:

• Address gender norms.
• Build community support.

No law or policy exists that addresses consent from a third party to access FP services.

No law or policy exists that addresses provider authorization for youth FP services.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services for unmarried women, but includes language favoring the rights of married couples to FP.

Law or policy exists that supports youth access to a full range of FP methods without defining full range of methods to include long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy references targeting youth in provision of FP services but mentions fewer than three of the service-delivery elements for youth-friendly contraceptive services.

Policy outlines detailed strategy addressing one of the two enabling social environment elements for youth-friendly contraceptive services.

No law or policy exists that addresses consent from a third party to access FP services.

Law or policy exists that requires providers to authorize medically advised youth FP services but does not address personal bias or discrimination.

Law or policy exists that supports youth access to FP services regardless of age.

No law or policy exists addressing marital status in access to FP services.

Law or policy exists that supports youth access to a full range of FP methods, including the provision of long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy outlines the following three service-delivery elements for youth-friendly contraceptive services:

• Provider training.
• Confidentiality and privacy.
• Free or reduced cost.

Policy outlines detailed strategy addressing one of the two enabling social environment elements for youth-friendly contraceptive services.

No law or policy exists that addresses consent from a third party to access FP services.

No law or policy exists that addresses provider authorization for youth FP services.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that supports youth access to a full range of FP methods without defining full range of methods to include long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy outlines the following three service-delivery elements for youth-friendly contraceptive services:

• Provider training
• Confidentiality and privacy
• Free or reduced cost

Policy references building an enabling social environment to support youth access to FP but does not include specific intervention activities addressing both enabling social environment elements.

No law or policy exists that addresses consent from a third party to access FP services.

Law or policy exists that requires providers to authorize medically-advised youth FP services without personal bias or discrimination.

Law or policy exists that supports youth access to FP services regardless of age

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that supports youth access to a full range of FP methods, including the provision of long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy outlines the following three service-delivery elements for youth-friendly contraceptive services:

• Provider training.
• Confidentiality and privacy.
• Free or reduced cost.

Policy outlines detailed strategy addressing two enabling social environment elements  for youth-friendly contraceptive services:

• Address gender norms,
• Build community support.

Law or policy exists that supports access to FP services without consent from one, but not both, third parties (parents and spouses).

Law or policy exists that requires providers to authorize medically advised youth FP services but does not address personal bias or discrimination.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that supports youth access to a full range of FP methods, including the provision of long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy references targeting youth in provision of FP services but mentions fewer than three of the service-delivery elements for youth-friendly contraceptive services.

Policy outlines detailed strategy addressing two enabling social environment elements  for youth-friendly contraceptive services:

• Address gender norms.
• Build community support.

Law or policy exists that supports access to FP services without consent from both third parties (parents and spouses).

Law or policy exists that requires providers to authorize medically advised youth FP services but does not address personal bias or discrimination.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that supports youth access to a full range of FP methods, including the provision of long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy outlines the following three service-delivery elements for youth-friendly contraceptive services:

• Provider training.
• Confidentiality and privacy.
• Free or reduced cost.

Policy outlines detailed strategy addressing two enabling social environment elements  for youth-friendly contraceptive services:

• Address gender norms.
• Build community support.

Law or policy exists that supports access to FP services without consent from one but not both third parties (parents and spouses).

No law or policy exists that addresses provider authorization for FP services.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that supports youth access to a full range of FP methods without defining full range of methods to include long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy outlines the following three service-delivery elements for youth-friendly contraceptive services:

• Provider training.
• Confidentiality and privacy.
• Free or reduced cost.

Policy outlines detailed strategy addressing two enabling social environment elements  for youth-friendly contraceptive services:

• Address gender norms.
• Build community support.

No law or policy exists that addresses consent from a third party to access FP services.

No law or policy exists that addresses provider authorization for youth FP services.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that restricts youth access to a full range of FP methods based on age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy references targeting youth in provision of FP services but mentions fewer than three of the service-delivery elements for youth-friendly contraceptive services.

Policy references building an enabling social environment to support youth access to FP but does not include specific intervention activities addressing both enabling social environment elements.

No law or policy exists that addresses consent from a third party to access FP services.

No law or policy exists that addresses provider authorization for youth FP services.

Law or policy exists that supports youth access to FP services regardless of age.

No law or policy exists addressing marital status in access to FP services.

No law or policy exists addressing youth access to a full range of FP methods.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy references targeting youth in provision of FP services but mentions fewer than three of the service-delivery elements for youth-friendly contraceptive services.

Policy outlines detailed strategy addressing one of the two enabling social environment elements for youth-friendly contraceptive services.

No law or policy exists that addresses consent from a third party to access FP services.

No law or policy exists that addresses provider authorization for youth FP services.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services for unmarried women, but includes language favoring the rights of married couples to FP.

No law or policy exists addressing youth access to a full range of FP methods. 

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy references targeting youth in provision of FP services but mentions fewer than three of the service-delivery elements for youth-friendly contraceptive services.

No policy exists to build an enabling social environment for youth FP services. 

No law or policy exists that addresses consent from a third party to access FP services.

No law or policy exists that addresses provider authorization for youth FP services.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that restricts youth access to a full range of FP methods based on age, marital status, and/or parity.

Policy promotes abstinence-only education or discourages sexuality education.

Policy references targeting youth in provision of FP services but mentions fewer than three of the service-delivery elements for youth-friendly contraceptive services.

Policy references building an enabling social environment to support youth access to FP but does not include specific intervention activities addressing both enabling social environment elements.

Law or policy exists that requires parental or spousal consent for access to FP services.

Law or policy exists that requires providers to authorize medically advised youth FP services but does not address personal bias or discrimination.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that supports youth access to a full range of FP methods without defining full range of methods to include long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy references targeting youth in provision of FP services but mentions fewer than three of the service-delivery elements for youth-friendly contraceptive services.

No policy exists to build community support for youth FP services.

No law or policy exists that addresses consent from a third party to access FP services.

Law or policy exists that requires providers to authorize medically-advised youth FP services without personal bias or discrimination.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that supports youth access to a full range of FP methods, including the provision of long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy outlines the following three service-delivery elements for youth-friendly contraceptive services:

• Provider training.
• Confidentiality and privacy.
• Free or reduced cost.

Policy outlines detailed strategy addressing two enabling social environment elements  for youth-friendly contraceptive services:

• Address gender norms,
• Build community support.

Law or policy exists that supports access to FP services without consent from one but not both third parties.

Law or policy exists that requires providers to authorize medically-advised youth FP services without personal bias or discrimination.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services for unmarried women, but includes language favoring the rights of married couples to FP.

Law or policy exists that supports youth access to a full range of FP methods, including the provision of long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy promotes abstinence-only education or discourages sexuality education.

Policy outlines the following three service-delivery elements for youth-friendly contraceptive services:

• Provider training.
• Confidentiality and privacy.
• Free or reduced cost.

Policy references building an enabling social environment to support youth access to FP but does not include specific intervention activities addressing both enabling social environment elements.

Law or policy exists that supports access to FP services without consent from both third parties (parents and spouses).

Law or policy exists that requires providers to authorize medically-advised youth FP services without personal bias or discrimination.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that supports youth access to a full range of FP methods, including the provision of long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy outlines the following three service-delivery elements for youth-friendly contraceptive services:

• Provider training.
• Confidentiality and privacy.
• Free or reduced cost.

Policy outlines detailed strategy addressing two enabling social environment elements for youth-friendly contraceptive services:

• Address gender norms.
• Build community support.

No law or policy exists that addresses consent from a third party to access FP services.

Law or policy exists that requires providers to authorize medically-advised youth FP services without personal bias or discrimination.

Law or policy exists that supports youth access to FP services regardless of age.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that restricts youth access to a full range of FP methods based on age, marital status, and/or parity.

Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of comprehensive sexuality education.

Policy outlines the following three service-delivery elements for youth-friendly contraceptive services:

• Provider training.
• Confidentiality and privacy.
• Free or reduced cost.

Policy outlines detailed strategy addressing two enabling social environment elements for youth-friendly contraceptive services:

• Address gender norms.
• Build community support.

Law or policy exists that supports access to FP services without consent from both third parties (parents and spouses).

Law or policy exists that requires providers to authorize medically-advised youth FP services but does not address personal bias or discrimination.

Law or policy exists that supports youth access to FP services regardless of age.

No law or policy exists addressing marital status in access to FP services.

Law or policy exists that supports youth access to a full range of FP methods, including the provision of long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy promotes abstinence-only education or discourages sexuality education.

Policy references targeting youth in provision of FP services but mentions fewer than three of the service-delivery elements for youth-friendly contraceptive services.

Policy outlines detailed strategy addressing one of the two enabling social environment elements for youth-friendly contraceptive services.

Law or policy exists that supports access to FP services without consent from both third parties (parents and spouses).

Law or policy exists that requires providers to authorize medically advised youth FP services without personal bias or discrimination.

No law or policy exists addressing age in access to FP services.

Law or policy exists that supports access to FP services regardless of marital status.

Law or policy exists that supports youth access to a full range of FP methods without defining full range of methods to include long-acting reversible contraceptives regardless of age, marital status, and/or parity.

Policy supports the provision of sexuality education and mentions all nine UNFPA essential components of comprehensive sexuality education.

Policy outlines the following three service-delivery elements for youth-friendly contraceptive services:

• Provider training.
• Confidentiality and privacy.
• Free or reduced cost.

Policy outlines detailed strategy addressing two enabling social environment elements for youth-friendly contraceptive services:

• Address gender norms.
• Build community support.

No laws or policies reviewed address consent from a third party when youth are accessing FP services; therefore, Bangladesh is placed in the gray category for this indicator.

The “Bangladesh Essential Health Service Package (ESP), 2016” guidelines for screening for contraceptive use direct providers to follow medical eligibility criteria when clients seek FP services. Additional policies outline plans to train providers to provide non-judgmental services to adolescents, but no policies explicitly require providers to authorize medically advised youth FP services without personal bias or discrimination. Bangladesh is placed in the yellow category for this indicator.

The “National Strategy for Adolescent Health, 2017-2030" affirms adolescents’ right to health regardless of their age as guaranteed by the Constitution of Bangladesh:

Universality and Inalienability

The right to health will be universal and inalienable for all adolescent boys and girls of Bangladesh. They will be entitled to access health related information and services regardless of their gender, age, class, caste, ethnicity, religion, disability, civil status, sexual orientation, geographic divide or HIV status.

Indivisibility

The right of adolescents to their health has equal status over other rights and will not be positioned in a hierarchical order. The right to adolescent health will not be compromised at the expense of other rights.

The “Bangladesh Population Policy 2012” acknowledges the need to bring adolescents under family planning coverage to improve client-centered services but fails to state that adolescents should have access to FP regardless of age:

5. Major Strategies for Implementation of the Population Policy

5.1 Client-Centred Service

Improve service centre practices and door-to-door services to ensure client-centred services, and undertake the following strategies to make them complement each other:

…

d) bring newlyweds, adolescents, and parents of one or two children under the coverage of family planning services on a priority basis.

Though Bangladesh’s policies support adolescents’ right to health and promote client-centered services, they do not include language that explicitly supports youth access to FP services regardless of age. Bangladesh is therefore placed in the gray category for this indicator.

The “National Strategy for Adolescent Health, 2017-2030" refers to a regulation that makes sexual and reproductive health services available only to married women and eligible couples:

Finally it is important to address the issue of unmarried adolescents, who fall outside the existing reproductive health care services system, given the regulation that SRH [sexual and reproductive health] services are available only to married women and eligible couples.

While this regulation could not be identified by name and could not be located, the Strategy then acknowledges the importance of making SRH services, including family planning, accessible to all adolescents regardless of their marital status but does not detail any strategic objectives to reach this goal:

Given...the significant population of adolescents in Bangladesh, where a majority of adolescent girls are given in marriage before the age of 18 years, meeting the sexual and reproductive health needs and rights of this group becomes imperative. These needs can be met by ensuring the provision of quality and age appropriate sexuality education starting with the very young adolescent, the delivery of quality age and gender appropriate SRH information and services and mobilization of the community to accept the importance of meeting the SRH and rights of all adolescents, irrespective of their marital status.

The “Costed Implementation Plan for National Family Planning Program in Bangladesh, 2020-2022" also alludes to a regulation restricting family planning to married couples and specifically targets newly married couples in plans to scale-up FP counseling and services. Furthermore, the plan specifically includes an activity to provide contraception to the “bridegroom/bride,” with no comparable activity targeting unmarried adolescents.

As Bangladesh’s existing policy regulations restrict access to SRH services based on marital status and more recent policies do not go far enough to remove this barrier, Bangladesh is placed in the red category for this indicator.

The “Clinical Contraception Services Delivery Programme Operational Plan, 2011-2016” notes that Bangladesh’s family planning programs use medical eligibility criteria based on World Health Organization (WHO) guidelines:

Medical Eligibility Criteria for Contraceptive use has been developed in perspective of national FP programme of Bangladesh based on WHO guidelines. This criteria has been included in the FP manual. These will help in proper client screening in reducing drop-outs, side-effects/ complications and unnecessary method-switching. At the same time every effort will be made to increase the accessibility of FP users in facilities by making those more attractive and user-friendly by improving provider attitude and management of FP services through proper counseling and screening.

The Operational Plan notes that the FP manual was undergoing an update, but the update could not be accessed at the time of analysis.

As part of its strategy to target adolescents, the “Costed Implementation Plan for National Family Planning Program in Bangladesh, 2020-2022” includes an activity to ensure contraceptive availability, including long acting reversible contraceptives (LARCs), for all adolescents:

7.5 Making all services (both short and LARC) available for the adolescents in the facilities.

Phasing of adolescent friendly contraceptive services

7.5.1 Ensure availability of the logistics at all level (No additional cost required)

The “Bangladesh Essential Health Service Package (ESP), 2016” acknowledges that adolescent health covers “distribution of condoms” and “FP information and provision,” but it does not detail method eligibility for adolescents and youth. The Service Package continues to note that screening for contraceptive use follows medical eligibility criteria but provides no further detail.

The Service Package does not explicitly state that these methods are available regardless of age, parity, and marital status, and the Costed Implementation Plan is the only policy document reviewed that mentions the need to ensure the availability of contraceptives , including LARCs, to adolescents. Bangladesh is therefore placed in the yellow category for this indicator.

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, it is worth noting that Bangladesh’s policies do not specify whether access to EC should be available to adolescents.

The “National Plan of Action for Adolescent Health Strategy, 2017-2030" includes a strategic objective to integrate age-appropriate comprehensive sexuality education (CSE) at all educational levels:

Key Strategy: Promote age appropriate comprehensive sexuality education, which are on par with international standards, through all academic and training instructions.

Major Activities:

• Revise Secondary School and Madrasah Curriculum (Class VI-X) to strengthen the CSE component Include adolescent development and CSE contents in B. Ed. course Conduct Peer Educator training (2 students from each school)

The Plan of Action also mentions CSE in its section focused on adolescent mental health:

Key Strategy: Develop skills among adolescents to deal with stress, manage conflict, and develop healthy relationships.

Major Activities:

• Organize sessions on Comprehensive Sexuality Education (CSE)/Life Skills Education/(LSE) for adolescents through the SHP [sexual health program], AH [adolescent health] clubs…
• Provide training on LSE.

However, the Plan of Action does not provide guidance or details on the specific components of the CSE curriculum or which students will be targeted.

Multiple policies and operational plans address improving knowledge of sexual and reproductive health (SRH) in schools and community settings without providing further details. The “National Children Policy, 2011” acknowledges the need to include information on reproductive health in the school syllabus. The “Costed Implementation Plan for National Family Planning Program in Bangladesh, 2020-2022" includes an activity to incorporate an adolescent health program into the school curriculum. The “Maternal, Neonatal, Child, and Adolescent Health Operational Plan, 2017-2022" includes effective dissemination of SRH knowledge and information through school curricula and community-based dissemination. The Operational Plan also includes an activity to link schools to SRH services, although it provides no detail on whether these linkages are also promoted in the curriculum:

Component 4: Adolescent Health

Activities: …

1. Establishment of referral linkages between school health clinics and other health facilities.

While the “Bangladesh Population Policy, 2012” includes adolescent SRH education activities, including dissemination workshops on family planning for adolescents in schools and colleges and life skills education, these activities specifically target married adolescents.

The “National Education Policy, 2010” outlines aims and objectives of education in Bangladesh and lays out additional aims, objectives, and strategies for different levels (primary, adult, secondary, vocational, etc.) and types of education (such as science, business, and engineering). The policy includes a section on “Women’s Education,” which aims to continue women’s access to education to ensure future development and economic participation and includes a strategy to include reproductive health in the curriculum:

The secondary level curriculum of last two years will include gender studies and issues of reproductive health.

Similarly, a draft version of the “National Youth Policy, 2017” aims to include life skills and education on sexual and reproductive health and rights in the curriculum, but does not outline any further steps or details on recipients or curriculum content:

Include sexual and reproductive health and rights to sexual and reproductive health in the curriculum.

…

9.1.9 Build awareness among youth about reproductive health, rights to reproductive health and about sexual health

…

10.5.3 Equip youth with greater sensibility to violation of human rights anywhere in the society or against any group or community, and motivate them to play an active role in the case of such occurrences.

The “National Communication Strategy for Family Planning and Reproductive Health, 2008,” which is designed to serve as a roadmap for increasing knowledge, improving attitudes, and changing behaviors related to family planning and reproductive health, outlines various approaches to reaching its goal among different target audiences—including adolescents and unmarried youth. Neither approach provides details on a CSE curriculum, but both address the need to increase FP knowledge and awareness about gender equity:

Audience 5: Adolescents

Sub-objectives:

• Increase the number of adolescents that have correct knowledge about their bodies, and can practice proper hygiene;
• Encourage dialogue between parents and children about marriage, fertility, reproductive health, maternal health;

…

Audience 6: Unmarried Youth

Sub-objectives:

…

• Increase awareness among youth (in-school and out-of-school) about the negative effects of gender-based violence;
• Increase knowledge about (gender-specific) sexual health rights;
• Improve the reach of life-skills/family life education programs to include greater numbers of out- of-school youth;
• Increase knowledge about sexual responsibility;
• Increase the number of unmarried youth that delay age at marriage;
• Increase the number of unmarried youth that know the advantages to having no more than two children;
• Increase the number of unmarried youth that have a positive attitude toward family planning

While Bangladesh’s policy environment acknowledges the need for CSE and SRH education in schools, no policy documents provide further details on the content of a curriculum or outline detailed activities that would support UNFPA's essential components of CSE. Bangladesh is therefore placed in the yellow category for this indicator.

In its priority area targeting adolescents and youth, the “Costed Implementation Plan for National Family Planning Program in Bangladesh, 2020-2022” includes activities to train providers to withhold judgment and ensure confidentiality and privacy for youth seeking services:

7.2 Training of providers on adolescent friendly services (AFS10) with privacy and confidentiality—FWVs [family welfare visitors] and SACMOs [sub-assistant community medical officers] focusing on providing non-judgmental services, accurate information on medical eligibility, communication strategy for adolescents.

7.3 Ensuring private and confidential counselling room with doors and window curtains, partitioning the waiting areas so that adolescents’ clients do not have to mix adult clients, not conducting history taking and screening in public

7.4 Developing adolescent friendly communication materials and digital health services.

7.5 Making all services (both short and LARC [long-acting reversible contraceptives]) available for the adolescents in the facilities, phasing of adolescent friendly contraceptive services.

The "National Strategy for Adolescent Health, 2017-2030" acknowledges the need to take into consideration “issues of affordability and accessibility of health services” for vulnerable adolescents and calls for a key focus on making contraceptives and services available to youth for free or at low cost.

The “National Plan of Action for Adolescent Health Strategy, 2017-2030" includes an activity to train providers on adolescent friendly health services and counseling:

Key Strategy: Build capacity for the delivery of age and gender sensitive sexual and reproductive health services which includes HIV/STI prevention, treatment and care.

Major Activities:

• Develop and update comprehensive training module on AFHS [adolescent-friendly health services] and Counselling (including family planning) for Service Providers and Field Workers.
• Organize [Training of Trainers] for Master trainers
• Conduct training of Service Providers and Field Workers in the provision of Adolescent Friendly Health Services and Counselling, particularly on Family planning.
• Review the medical and pre-service training curriculum of health workers (doctors, nurses, midwives, paramedics and field workers) to ensure the inclusion of adolescent health and counselling with special focus on Family planning

The Plan of Action further notes the need to train providers to adopt non-judgmental attitudes when working with adolescents in its section on health systems strengthening:

Key Strategy HWF [Health Work Force] 1: Capacity building of health providers to be sensitive to the needs of all adolescents, including those who are unmarried, through pre service, in service and on the job training;

Major Activities:

• Development of [Management Information System] for HR [human resources] Management and for gap analysis
• Training and mentoring all [healthcare providers]…on [adolescent health] and rights related issues including special health needs by providing pre- and in-service trainings
• Development of Course on Adolescent Health and incorporate it in post-graduation

 Key Strategy HWF 2: Provide health service personnel with training on counselling for adolescents and capacitate them to adopt non-judgmental attitudes when working with adolescents.

Major activities:

• Deployment of human resource to provide adolescent health services based on need
• Train [healthcare providers] on psychosocial counselling, family planning, gender diversity and value clarification issues.

Moreover, the “National Communication Strategy for Family Planning and Reproductive Health, 2008” includes a specific objective to “improve the attitudes of service providers toward adolescents and youth with regard to family planning and reproductive health seeking behavior.”

Furthermore, the “Community-Based Health Care Operational Plan, 2017-2022" outlines an implementation process to develop adolescent counseling corners to provide adolescent-friendly services. Additionally, the “Eighth Five Year Plan, 2020-2025” includes establishing 200 additional adolescent-friendly service centers among the main activities listed for family planning. While the plan aims to ensure the availability of modern contraceptives at a low cost, especially in remote areas, it does not specifically plan for youth’s access to services for free or at reduced costs.

By including provider training for youth-friendly FP services and activities to ensure privacy for youth accessing FP information and services, Bangladesh has fostered a promising policy environment. Bangladesh is placed in the yellow category for this indicator and can further improve its policy environment by ensuring FP services for youth for free or at a reduced cost.

The “Costed Implementation Plan for National Family Planning Program in Bangladesh, 2020-2022” outlines a list of activities to foster a supportive environment for adolescents’ family planning and address gender norms, especially targeting parents, religious leaders, public representatives, local elites, providers, etc.:

Strategy 2- Increasing acceptability of LARC&PM [long-acting reversible contraceptives and permanent methods] through skilled HR [human resources] and engaging males

Activities:

…

2.5 Use satisfied clients/champions for the promotion of LARC&PM in the community

…

2.7 Use religious leader for the promotion of LARC&PM: Extensive workshops to sensitize religious leaders (Note: even though these strategies are in place as stated in FP OPs[operational plans], field observation suggested that they were not effectively implemented)

...

Strategy 8- Targeting adolescents with special focus on males

Activities:

8.1 Counsel adolescent, newly married couple, in-laws, public representatives and local elites to improve gender norms.

…

8.5 Counsel and meetings for parents, providers, religious leaders, and other influential adults (public representatives and local elites etc.) who can foster a supportive environment in health    facilities, schools, places of worship, and in homes

To address underlying barriers to adolescent FP access, including community stigma associated with being sexually active, the “National Plan of Action for Adolescent Health Strategy, 2017-2030" acknowledges the need for social and behavior change communication programs to change community attitudes and behaviors and lays out three strategies:

Strategic Objectives

…

3. To use Social and Behavioral Change Communication [SBCC] interventions to bring about changes in knowledge, attitudes and practices among specific audiences.

Key Strategies

1. Development of messages and materials for communication and advocacy through sound research;
2. Utilize ICT [information and communications technology] (including call centres) and media to reach adolescents, key community members, parents and guardians;
3. Develop the capacity of respective institutions and systems to design, plan, implement and monitor SBCC interventions.

The “National Communication Strategy for Family Planning and Reproductive Health, 2008” lists specific activities to create an enabling social environment for unmarried youth’s access to family planning information and gender equity:

• Engage Imams to discuss reproductive health issues with youth;
• Conduct discussion groups with trained facilitators where youth can learn about, and practice, problem-solving skills with regard to family planning and reproductive health decision-making;
• Educate community gatekeepers (parents, teachers, religious leaders, etc.) about gender equity issues.

The “Maternal, Neonatal, Child, and Adolescent Health Operational Plan, 2017-2022" includes an objective to “create positive change in the behavior and attitude of the gatekeepers of adolescents towards reproductive health.” The plan outlines two relevant strategies to create an enabling social environment:

Advocacy meeting at community level for the gatekeepers of adolescents

...

Carry out multi-sectoral advocacy for creation of supportive environment for adolescents to practice safe behaviors

The Operational Plan does note the specific methods for community mobilization of gatekeepers, but does not go into much detail:

Community mobilization around ASRH [adolescent sexual and reproductive health] issues through court yard meetings, inter-personal communication, and workshops, through partnership with NGOs, to sensitize gatekeepers (parents, religious leaders, community leaders, school teachers, school management committees. etc.)

The “National Women Development Policy, 2011,“ “National Education Policy, 2010,” and “Eighth Five Year Plan, 2020-2025,” aim to establish gender equality, promote girl’s education, and ensure equal gender rights in family planning decision-making.

Since Bangladesh’s policy environment details activities to create an enabling social environment for youth access to family planning information and services and addresses gender norms, Bangladesh is placed in the green category for this indicator.

The right to non-discrimination in the “Loi n° 2003-04 du 03 mars 2003 relative à la santé sexuelle et à la reproduction” states that parental and partner consent is not required for patients to receive reproductive health care:

L’autorisation du partenaire ou des parents avant de recevoir des soins en matière de santé de la reproduction peut ne pas être requise, pourvu que ce procédé ne soit pas contraire à La loi.

Benin is placed in the green category for this indicator because its policies adequately prohibit parental and spousal consent.

The “Plan d’action national budgétisé de planification familiale du Bénin, 2019-2023” acknowledges that provider bias toward young people, particularly those who are unmarried, is a pervasive issue preventing young people from accessing family planning (FP) services:

Quant aux adolescents et jeunes non en union, ils craignent de rencontrer leurs parents et les autres adultes dans les points d’accès à la PF et jugent que leur utilisation de la PF est mal perçue par les prestataires qui préfèrent offrir les méthodes uniquement aux femmes en union.

The “Stratégie nationale multisectorielle de la santé sexuelle et de la reproduction des adolescents et jeunes, 2018-2022” includes an initiative to establish youth-friendly health centers that follow global standards for quality health care services for adolescents and youth. The standards note that adults’ judgement of what is best for adolescents should not supersede their obligation to respect youth rights as outlined in the International Convention on the Rights of the Child, but the standards do not specifically address providers or youth access to family planning.

Benin’s policies, however, do not explicitly state that providers must refrain from applying their personal biases and beliefs when providing FP services to youth. Therefore, Benin falls into the gray category for this indicator.

The “Loi n° 2003-04 du 03 mars 2003 relative à la santé sexuelle et à la reproduction” supports individuals’ access to reproductive health care regardless of age: 

Article 2 : Caractère universel du droit à la santé de la reproduction.

Le droit à la santé de reproduction est un droit universel fondamental garanti à tout être humain, tout au long de sa vie, en toute situation et en tout lieu. Aucun individu ne peut être privé de ce droit dont il bénéficie sans aucune discrimination fondée sur l’âge, le sexe, la fortune, la religion, l’ethnie, la situation matrimoniale.

Article 7 : Droit à la non-discrimination.

Les patients sont en droit de recevoir tous les soins de santé de la reproduction sans discrimination fondée sur le sexe, le statut marital, le statut sanitaire ou tout autre statut, l’appartenance à un groupe ethnique, la religion, l’âge ou l’habilité à payer.

The “Loi n° 2015-08 portant code de l’enfant en république du Bénin” states that individuals under age 18 have the right to access to reproductive health services:

Article 156 : Santé de la reproduction de l’enfant

L’enfant doit avoir accès à la santé de la reproduction sans aucune forme de discrimination, de coercition ou de violence. Il a le droit à l’information la plus complète sur les avantages et les inconvénients de la santé de la reproduction, sur les méthodes de planification familiale et de contraception ainsi que sur l’efficacité des services de santé sexuelle et reproductive.

Benin is placed in the green category for this indicator because the policy environment confirms that youth must be permitted access to family planning services regardless of age.

The “Loi n° 2003-04 du 03 mars 2003 relative à la santé sexuelle et à la reproduction” supports individuals’ access to reproductive health care, which includes family planning, regardless of marital status:

Article 2 : Caractère universel du droit à la santé de la reproduction.

Le droit à la santé de reproduction est un droit universel fondamental garanti à tout être humain, tout au long de sa vie, en toute situation et en tout lieu. Aucun individu ne peut être privé de ce droit dont il bénéficie sans aucune discrimination fondée sur l’âge, le sexe, la fortune, la religion, l’ethnie, la situation matrimoniale.

Article 7 : Droit à la non-discrimination.

Les patients sont en droit de recevoir tous les soins de santé de la reproduction sans discrimination fondée sur le sexe, le statut marital, le statut sanitaire ou tout autre statut, l’appartenance à un groupe ethnique, la religion, l’âge ou l’habilité à payer.

Benin guarantees access to reproductive healthcare regardless of marital status; therefore, it is placed in the green category for this indicator.

While Benin’s policy environment protects the right of individuals to a full range of methods and to the method of their choice, it falls short of addressing youth access to a full range of contraceptive methods.

For example, the “Loi n° 2003-04 du 03 mars 2003 relative à la santé sexuelle et à la reproduction” states that the full range of legal contraceptives must be authorized and available after consultation as part of an individual’s right to choose from a range of effective and safe contraceptive methods. However, it does not specify that this same right must be extended to youth:

La contraception comprend toute méthode approuvée, reconnue effective et sans danger. Elle comprend les méthodes modernes (temporaires, permanentes), traditionnelles et populaires. Toute la gamme des méthodes contraceptives légales doit être autorisée et disponible après consultation. Le droit de déterminer le nombre d’enfants et de fixer l’espacement de leur naissance confère à chaque individu la faculté de choisir parmi toute gamme de méthodes contraceptives effectives et sans danger celle qui lui convient.

The “Stratégie nationale multisectorielle de santé sexuelle et de la reproduction des adolescents et jeunes au Bénin, 2010-2020,” which is specifically concerned with youth reproductive health, defines reproductive health as including the right of individuals to the contraceptive methods of their choice, without explicitly stating that youth should be able to access a full range of contraceptive options:

La santé de la reproduction suppose par conséquent que les individus aient une vie sexuelle satisfaisante et sûre, ainsi que la capacité de se reproduire et la liberté de décider quand et à quelle fréquence le faire. Cette dernière question repose implicitement sur les droits des hommes et des femmes à être informés et à accéder à des méthodes de planification familiale (PF) sûres, efficaces, abordables et acceptables qu’ils auront choisies eux-mêmes, ainsi qu’à d’autres méthodes de leur choix de régulation de la fécondité qui soient conformes à la législation.

The "Plan d’action national budgétisé de planification familiale du Bénin, 2019- 2023" includes an objective to expand the range of family planning services young people can access to include long-acting reversible methods and postpartum family planning services. However, this activity targets young people living in selected remote areas and does not guarantee their access to a full range of contraceptive methods regardless of age, marital status, or parity.

Because Benin does not have a policy extending access to a full range of methods for youth specifically, it is placed in the yellow category for this indicator. To move to the green category, Benin should clarify that youth can access a full range of methods, including long-acting reversible contraceptives.

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, note that Benin’s policy environment does not specifically address youth access to EC.

Benin’s policy environment supports the provision of sexuality education to in-school and out-of-school youth. The “Plan d’action national budgétisé de planification familiale du Bénin, 2019- 2023” includes a strategy to unify multisectoral efforts intended to strengthen comprehensive sexuality education (CSE) by harmonizing the content of CSE programs currently used in both school and non-school environments, and teaching and providing counseling about family planning services in schools:

Stratégies

…

O4. Unifier les efforts multisectoriels (ministères connexes et autres secteurs) notamment éducatifs afin d’identifier le gap et exploiter les synergies, assurer l’efficacité des efforts humains et financiers et renforcer l’éducation complète à la sexualité

…

A02. Harmoniser le contenu des curricula et mise en œuvre de l’approche d’Éducation Complète à la Sexualité pour les adolescents (e)s et les jeunes scolarisés, et non/déscolarisés ou en situation de vulnérabilité en collaboration avec les ministères chargés de l’Éducation, de l’enseignement supérieur, etc. envisageant des visites de centres de santé accrédités, des séances de sensibilisation sur les consultations en PF en milieu scolaire, et l’enseignement potentiel de la PF avant la 3ème.

The “Stratégie nationale multisectorielle de santé sexuelle et de la reproduction des adolescents et jeunes au Bénin, 2010-2020” tasks the Ministry of Secondary Education and Technical and Vocational Training with extending SRH education to technical and vocational secondary schools and promoting SRH awareness activities at colleges. The Ministry of Family and National Solidarity is tasked with reaching vulnerable groups of youth with SRH information.

The “Stratégie nationale multisectorielle” also recognizes the need to tailor information to the specific needs of youth:

Principales options de promotion de la SRAJ [santé reproductive des adolescents et des jeunes]/VIH/sida :
La prise en compte de l’âge, du genre et des conditions socio-culturelles des adolescents et jeunes dans la définition des types et contenus des services d’information, de conseil et de prestations cliniques ou communautaires en SRAJ/VIH/sida.

These policies address two essential components of comprehensive sexuality education (CSE) by personalizing information and reaching across formal and informal sectors and across age groups.

A third component of CSE addressed in Benin’s policy documents is strengthening youth advocacy and civic engagement. The “Stratégie nationale multisectorielle” places strong emphasis on youth advocacy for adolescent reproductive health information and services:

Les Organisations de jeunesse :
… Ces organisations jouent actuellement d’important rôle de mobilisation de jeunes. Elles doivent poursuivre les activités de mobilisation des jeunes et adolescents afin d’être de puissants instruments dans la mise en œuvre de la présente Stratégie Nationale Multisectorielle. Elles doivent contribuer à la promotion de la CCC [communication pour le changement de comportement] en SRAJ, des prestations de services à base communautaire et le plaidoyer en vue de la mobilisation des leaders communautaires et des partenaires techniques et financiers.

The “Stratégie nationale multisectorielle” and the “Programme national de santé de la reproduction, 2011-2015” include a specific objective to strengthen involvement of youth in SRH programming:

Axe : Implication et responsabilisation des jeunes dans la promotion de la SSR [santé sexuelle et reproductive]/VIH/sida

Objectif spécifique : Renforcer l’implication des structures de jeunes organisées à toutes les étapes du processus de prise de décision, de planification, de mise en œuvre et de suivi évaluation.

Although the “Stratégie nationale multisectorielle” acknowledges gender issues facing youth, such as gender-based violence and forced or early marriages, it does not describe integrating gender into a CSE program. 

In addition, the “Plan stratégique intégré de la santé de la reproduction, de la mère, du nouveau-né, de l’enfant, de l’adolescent et jeune (SRMNEAJ), 2017-2021” tasks the Ministry of Secondary Education and Technical and Vocational Training with integrating SRH education into school curricula for adolescents and youth, training teachers on curriculum content, and organizing community sensitization activities. The "Plan stratégique intégré” also tasks the Ministry of Justice with extending SRH education activities for adolescents and youth who are incarcerated.

The “Stratégie nationale multisectorielle de la santé sexuelle et de la reproduction des adolescents et jeunes, 2018-2022” introduces Benin's intention to establish a CSE curriculum  in the education system with a goal to eventually scale-up the curriculum to provide it to out-of-school youth:

Interventions

…

3.6 Instauration d'un programme d’éducation à la sexualité responsable en milieu scolaire et non scolaire

Activités

3.6.1 Accompagner le processus d'intégration de l'éducation à la santé sexuelle dans le système éducatif

3.6.2 Assurer le suivi du processus d'intégration de l'éducation à la santé sexuelle dans le système éducatif

3.6.3 Rendre disponible les curricula d'éducation à la santé sexuelle en milieu extra-scolaire

3.6.4 Préparer la mise à échelle du Programme d'éducation à la santé sexuelle en milieu extra-scolaire

Benin’s policy environment is supportive of sexuality education but does not reference all nine of the United Nations Population Fund (UNFPA) essential components of CSE. Therefore, Benin is placed in the yellow category for this indicator. Going forward, additional sexuality education policies should consider all nine UNFPA essential components of CSE.

The “Stratégie nationale multisectorielle de santé sexuelle et de la reproduction des adolescents et jeunes au Bénin, 2010-2020” and the “Programme national de santé de la reproduction, 2011-2015” include specific objectives to train providers to offer adolescent-friendly contraceptive services. Additionally, provider training described in the “Plan d’action national budgétisé de la planification familiale du Bénin, 2019-2023” includes an objective to improve FP services for adolescents and young people by offering capacity-building activities to providers:

Stratégie

…

O1. Améliorer le plateau technique des formations sanitaires pour l’offre de services de PF de qualité de 2019 à 2023.

…

A4. Renforcement des capacités des prestataires des formations sanitaires publiques et privées pour l’offre de services conviviaux et adaptes de SRAJ [sante de la reproduction des adolescents et des jeunes] : Renforcer les capacités des prestataires de 5% des FS [formations sanitaires] publiques et privées (soit 114 FS offrant la PF) par an ans dans le domaine de l’offre des services de PF adaptes aux adolescentes et jeunes permettra de lever l’obstacle lie à l’attitude de certains prestataires face aux adolescents et jeunes qui se présentent dans les centres de santé pour adopter les méthodes de PF. Elle sera réalisée à travers la formation, l’aménagement des structures de soins, la supervision et le suivi des prestations.

The “Stratégie nationale multisectorielle de santé sexuelle et de la reproduction des adolescents et jeunes au Bénin, 2010-2020” states that a youth-friendly FP service setting should provide confidentiality and affordability:

La formation sanitaire attrayante pour les adolescents et jeunes se définit comme un centre d’accueil ou de conseil, une maison des jeunes, offrant un bon accueil, une ambiance de gaité, d’aise, de confidentialité, une prise en charge adéquate, un traitement et des produits à moindre coût.

The "Plan opérationnel de réduction de la mortalité maternelle et néonatale au Bénin, 2018-2022” identifies improving adolescent’s access to FP through the provision of free contraceptives as a priority :

Des priorités ont été formulées pour la période 2018 – 2022 au nombre desquelles figurent :

…

• La gratuité de la Planification Familiale favorisant l’accès des adolescentes et jeunes à la contraception

…

Activités : Offrir gratuitement toutes les gammes de produits contraceptifs dans les formations sanitaires et cabinets privés de soins.

The "Plan national de développement sanitaire, 2018-2022" also includes free access to FP for young people and women of reproductive age as a priority action to reduce morbidity and mortality among adolescents and young people:

5.5.2. Orientation Stratégique (OS2): Prestation de service et l’amélioration de la qualité des soins

Objectifs Spécifiques : 2.1 Réduire la morbidité, la mortalité de la mère, du nouveau né, de l’enfant, de l’adolescent et du jeune

Axes d’interventions : 2.1.2 Intensification des services de la Planification Familiale

Actions prioritaires:

• Assurer la disponibilité des produits traceurs de la PF jusqu’au dernier niveau des prestations de services ;
• Renforcer l’opérationnalisation du plan d’action budgétisé de PF ;
• Assurer la gratuité de l’accès des jeunes et des femmes en âge de procréer à la PF.

The “Plan d’action national budgétisé de planification familiale du Bénin, 2019-2023” includes activities to provide user-friendly family planning services to young people, such as by making contraceptive services free, creating youth-friendly centers, and training providers:

Activités

…

2.1.1 Mettre en place un mécanisme d'exemption des coûts des contraceptifs pour les adolescents et jeunes 

…

2.1.2 Augmenter  de 50% la couverture nationale  en centres conviviaux intégrés pour les adolescents et jeunes

2.1.3 Faciliter l’utilisation des contraceptifs par les adolescentes et jeunes vulnérables

2.1.4 Elaborer et mettre en œuvre l'initiative «Les formations sanitaires et centres de promotion sociale amis des adolescents et jeunes»

Because Benin’s policy documents address all three service-delivery elements of youth-friendly services, Benin is placed in the green category for youth-friendly FP service provision.

The “Stratégie nationale multisectorielle de santé sexuelle et de la reproduction des adolescents et jeunes au Bénin, 2010-2020” includes an objective to involve local leaders in information and communication activities:

Objectif spécifique N°2 : Renforcer l’implication des Elus locaux, des leaders communautaires et religieux dans les actions d’information sur la SRAJ [santé reproductive des adolescents et des jeunes]/VIH/sida chez les adolescents et jeunes.

2.1 Organiser au niveau de chaque commune du pays un atelier d’élaboration des plans opérationnels de communication en SRAJ/IST[infections sexuellement transmissibles]//VIH/sida au profit des élus locaux et les leaders communautaires et religieux en tenant compte des réalités de chaque commune.

The “Stratégie nationale multisectorielle” also aims to consider gender when designing reproductive health information and services for youth:

3.2. Principales options de promotion de la SRAJ/VIH/sida

…

2. La prise en compte de l’âge, du genre et des conditions socio-culturelles des adolescents et jeunes dans la définition des types et contenus des services d’information, de conseil et de prestations cliniques ou communautaires en SRAJ/VIH/sida.

3.3 Principes directeurs

…La prise en compte des valeurs socioculturelles, de l’éthique et du genre dans la programmation des interventions.

Additionally, the “Politique nationale de la jeunesse, 2001” contains a specific objective and corresponding strategy to consider gender as part of the sexual and reproductive health of adolescents:

Objectif Spécifique 11 : Contribuer au développement de la santé physique, mentale, psychique, sexuelle et de la reproduction des adolescents et des jeunes selon l'approche genre.

Stratégie 11- 3 : Promotion de la santé sexuelle et de reproduction des adolescents et jeunes et d'un environnement physique, légal et social favorisant l'approche genre.

The “Plan stratégique intégré de la santé de la reproduction, de la mère, du nouveau-né, de l’enfant, de l’adolescent et jeune (SRMNEAJ), 2017-2021” tasks the Ministry of Social Affairs and Microfinance with advocacy activities that include promoting dialogue between parents and their child:

Le Ministère en charge des affaires sociales :

…

Il renforcera la promotion du dialogue entre parents et enfants dans le cadre des activités de plaidoyer et de formation que développent les services centraux et décentralisés de ce ministère.

The “Stratégie nationale multisectorielle de la santé sexuelle et de la reproduction des adolescents et jeunes, 2018-2022” emphasizes the need to address gender issues in adolescent and youth reproductive health strategies, referencing the "Loi n 2003-04 du 03 mars 2003 relative à la santé sexuelle et la reproduction," which states the right to reproductive health without discrimination.  The “Plan d’action national budgétisé de planification familiale du Bénin, 2019-2023 ” also outlines an objective to achieve a supportive environment for promoting family planning services by mobilizing support from political leaders, religious figures, and local authorities:

Objectif 4 : Garantir un environnement favorable pour la PF à travers :

Le renforcement des activités de plaidoyer auprès des décideurs (Président de la République du Bénin, Première Dame du Bénin, Institutions nationales, ministère de la santé et ministères connexes) et des leaders administratifs, traditionnels, religieux et des élus.

These policies outline a detailed strategy to build community support for youth family planning services and to address gender norms, including specific interventions. Therefore, Benin is placed in the green category for this indicator.

The “Politiques et normes en matière de santé de la reproduction au Burkina Faso, 2010” states that access to reversible contraceptive methods should not require spousal consent:

Les femmes et les hommes en âge de procréer pourront avoir accès aux méthodes contraceptives réversibles sans recours au consentement de leur conjoint. Toutefois, l’accent doit être mis sur l’importance du dialogue dans le couple pour l’adoption d’une méthode contraceptive.

However, Burkina Faso’s policies do not adequately address parental consent. Therefore, Burkina Faso is placed in the yellow category for this indicator because its policies address one but not both forms of consent.

While the “Plan stratégique santé des adolescents et des jeunes, 2015-2020” describes provider judgment as a barrier to youth access to healthcare, it does not include an explicit statement that providers may not use personal bias or discrimination when offering youth FP services. Therefore, Burkina Faso is placed in the gray category for this indicator.

The “Loi portant santé de la reproduction, 2005” states that all individuals, including adolescents, have equal rights and dignity in reproductive health throughout their life, regardless of age:

Article 8 : Tous les individus y compris les adolescents et les enfants sont égaux en droit et en dignité en matière de santé de la reproduction.

Le droit à la santé de la reproduction est un droit fondamental garanti à tout être humain, tout au long de sa vie, en toute situation et en tout lieu.

Aucun individu ne peut être privé de ce droit dont il bénéficie sans discrimination aucune fondée sur l'âge, le sexe, la fortune, la religion, l'ethnie, la situation matrimoniale ou sur toute autre considération.

Because the law guarantees youth access to FP regardless of age, Burkina Faso is placed in the green category for this indicator.

The “Loi portant santé de la reproduction, 2005” states that all individuals, including adolescents, have equal rights and dignity in reproductive health throughout their life, regardless of marital status:

Article 8 : Tous les individus y compris les adolescents et les enfants sont égaux en droit et en dignité en matière de santé de la reproduction.

Le droit à la santé de la reproduction est un droit fondamental garanti à tout être humain, tout au long de sa vie, en toute situation et en tout lieu.

Aucun individu ne peut être privé de ce droit dont il bénéficie sans discrimination aucune fondée sur l'âge, le sexe, la fortune, la religion, l'ethnie, la situation matrimoniale ou sur toute autre considération.

Because the law guarantees youth access to reproductive health, including FP, regardless of marital status, Burkina Faso is placed in the green category for this indicator.

The “Loi portant santé de la reproduction, 2005” states that adolescents have the right to make decisions about their reproductive health (RH) and to obtain information about all methods of contraception:

Article 11 : Tout individu y compris les adolescents et les enfants, tout couple a droit à information, à l'éducation concernant les avantages, les risques et l'efficacité de toutes les méthodes de régulation des naissances.

The “Protocoles de santé de la reproduction, 2009” state that adolescents should have access to all methods regardless of age or marital status:

Les adolescents et jeunes quel que soit leur âge, leur statut matrimonial doivent avoir accès à toutes les méthodes contraceptives.

Further, the “Protocoles” include long-acting reversible contraceptives (LARCs) in the list of contraceptives that should be available to youth. Similarly, the “Politique nationale de population du Burkina Faso, 2000” contains an objective to promote use of RH services among adolescents, including a specific aim to provide a full range of methods:

Objectif intermédiaire :

1.1 : Promouvoir une grande utilisation des services de santé de la reproduction en particulier par les femmes, les jeunes et les adolescents.

Axes stratégiques :

1.1.2. Mise à la disposition de la population de services de santé de la reproduction de qualité y compris une gamme complète de méthodes contraceptives sûres, fiables et à un coût abordable.

The “Plan national d’accélération de planification familiale du Burkina Faso, 2017-2020” includes an objective to expand the range of FP methods, including LARCs, to benefit young people:

Objectif 2 : Garantir la couverture en offre de services de PF et l’accès aux services de qualité en renforçant la capacité des prestataires publics, privés et communautaires et en ciblant les jeunes ruraux et les zones enclavées avec l’élargissement de la gamme des méthodes y compris la mise à l’échelle des MLDAR [méthodes à longue durée d’action réversibles] et PFPP [planification familiale du post-partum], l’amélioration de la prestation aux jeunes.

Therefore, Burkina Faso is placed in the green category for this indicator.

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, it is worth noting that the “Protocoles” do not include EC in the list of contraceptives that should be available to youth.

Several policies in Burkina Faso acknowledge the importance of sexuality education and describe plans for improving its implementation. The “Politiques et normes en matière de santé de la reproduction au Burkina Faso, 2010” state that young people have the right to sexuality education:

Les jeunes ont droit à l’éducation à la vie sexuelle et à la vie familiale.

The “Politique nationale de population du Burkina Faso, 2000” describes plans for family life and sexuality education in formal and informal education settings and for increasing institutional capacity for population education:

1.5.3. Promotion de l’éducation à la vie familiale et l’éducation sexuelle dans les structures d’enseignement formel et non formel.

2.2.1. Accroissement et/ou consolidation des capacités institutionnelles en matière de formation et d’enseignement en population et développement aux différents niveaux du système éducatif.

The “Troisième programme d’action en matière de population, 2012-2016” explains that Burkina Faso’s population education program, l’éducation en matière de population (EMP), which could not be obtained for this analysis, includes modules on emerging themes such as citizenship, human rights, HIV/AIDS and other sexually transmitted infections, and youth sexual and reproductive health. EMP was introduced in primary and secondary schools in Burkina Faso in the mid-1980s and has since been extended to reach students in informal settings. The “Troisième programme d’action” includes a specific objective to increase the effectiveness of population and citizenship education in formal and informal settings:

Objectif spécifique 3 : Rendre effective l’éducation en matière de population et de citoyenneté (EmPC) dans 100% des structures du système formel et 95% des structures non formelles.

Similarly, the “Plan national de relance de la planification familiale, 2013-2015” includes an activity to revitalize population education in both formal and informal education settings, including training school nurses and staff at youth centers in a youth-focused approach. The “Plan stratégique santé des adolescents et des jeunes, 2015-2020” has a general activity to introduce sexuality education into education and training settings. Furthermore, the “Plan national d’accélération de planification familiale du Burkina Faso, 2017-2020” includes priority actions to incorporate modules on comprehensive sexuality education (CSE) in teaching curricula, build the capacity of students and teachers on CSE, and implement a CSE approach for out-of-school young people.

Burkina Faso’s policy environment is promising because it supports the provision of sexuality education and includes some of the essential components of CSE within its sexuality education program, such as reaching youth across formal and informal sectors, human rights, and citizenship. However, all nine components of CSE are not mentioned as part of the CSE program. Therefore, Burkina Faso is placed in the yellow category for this indicator. Future plans for revitalizing sexuality education in Burkina Faso should consider including all nine of the United Nations Population Fund’s (UNFPA’s) essential components of CSE.

The “Plan stratégique santé des adolescents et des jeunes, 2015-2020” describes provider judgment and lack of confidentiality as barriers to youth access to health care:

L’offre de SSR [santé sexuelle et reproductive] de qualité se trouve limiter par… l’insuffisance de compétences du personnel de santé. En effet, les éléments suivants participent à entraver la qualité des soins et des services pour les adolescents et les jeunes : attitude des prestataires non respectueuse et de jugement, droit à la confidentialité non respecté…

The “Plan stratégique” then includes an adjoining aim to train and supervise providers in the provision of youth sexual and reproductive health services:

Axe 2 :  Renforcement de l’offre de soins et des services de SRAJ [santé reproductive des adolescents et des jeunes] de qualité

Formation continue des prestataires au niveau des formations sanitaires

Renforcement de la supervision des prestataires

Additionally, the “Directives nationales sur la santé scolaire et universitaire au Burkina Faso, 2008” assert that youth centers in schools and universities should provide affordable contraceptives for students and emphasize the importance of confidentiality when providing services to youth:

II. LES DIFFERENTES INTERVENTIONS NECESSAIRES POUR ASSURER LA PRISE EN CHARGE MEDICO-SOCIALE DES PROBLEMES DE SANTE SCOLAIRE ET UNIVERSITAIRE

…

2.2.8. Confidentialité

La confidentialité constitue la pierre angulaire de la fréquentation de tout service de santé par les jeunes. Ainsi la confidentialité ne doit pas être négligée par les prestataires parce qu’ils ont affaire à un public souvent plus jeune.

-La confidentialité doit transparaître dans tous les services de santé. Elle doit en tout temps prévaloir entre le prestataire et les scolaires et universitaires,

-Les informations concernant un scolaire ou universitaire ne peuvent être divulguées à des tiers sauf en cas d’urgence et dans son intérêt,

-Les dossiers des scolaires et universitaires doivent être gardés en lieu sûr. Seuls les prestataires peuvent pouvoir y accéder.

The “Politique et normes en matière de santé de la reproduction, 2010” outlines quality standards for reproductive health. The list of service standards includes patient confidentiality, but is not specific to adolescents and youth:

1.6 Normes de qualité de services

Pour que les programmes de santé soient des programmes de qualité :

- Les services doivent être personnalises,

- Les clients doivent être traites avec dignité,

- Les clients doivent être traités de manière confidentielle,

- Les clients ne doivent pas attendre longtemps avant d’être reçus,

- Les prestataires de service doivent informer les clients sur les méthodes et services disponibles,

- Les prestataires de sante doivent pouvoir reconnaitre leurs limites.

The “Decret n° 2019-0040/PRES/PM/MS/MFSNF/MFPTPS/MATD/MINEFID portant gratuité des soins et des services de planification familiale au Burkina Faso,” agreed upon in December 2018 by the Council of Ministers, granted free family planning health care to everyone in the country:

Article 1: Il est institué la gratuité des soins et des services de planification familiale sur toute l’étendue du territoire national.

Article 2 : La gratuité de la planification familiale est mise en œuvre dans toutes les formations sanitaires publiques par les agents de santé à base communautaire (ASBC) et au sein des formations sanitaires privées conventionnées du Burkina Faso.

The decree notes that family planning will be free in public and select private facilities in contract with the government, but implementation is voluntary. When the decree was initially announced, the Council of Ministers noted that this policy change would especially benefit adolescents and youth:

L’adoption de ce décret permet la mise en œuvre de la mesure de gratuité de la planification familiale dans les structures de santé publique de notre pays et une intensification de l’offre des services de la planification familiale au profit des populations notamment les adolescents, les jeunes et les populations vivant en milieu rural.

Burkina Faso has a strong policy environment for the provision of youth-friendly FP services and is accordingly placed in the green category for this indicator.

Burkina Faso’s policies support an enabling social environment for youth-friendly service provision through addressing gender norms and building support in communities. For example, the “Politiques et normes en matière de santé de la reproduction au Burkina Faso, 2010” acknowledge the multisectoral nature of reproductive health and the required collaboration around gender-related issues, such as:

• la promotion de la scolarisation des jeunes filles et de l’alphabétisation des femmes,
• la promotion de l’autonomisation financière des femmes,
• la promotion d’un environnement physique, politique, juridique, social et économique favorable à la santé, dans un esprit d’équité entre les sexes.

The “Document de la politique nationale genre du Burkina Faso, 2009" includes an objective to eliminate sociocultural barriers related to health access, including taboos surrounding women accessing reproductive health services:

Objectif 2 …. De même, en matière de santé, il importe de travailler à éliminer certains tabous persistants et à promouvoir la liberté de fréquentation des services de santé par les femmes. En outre, l’égalité en matière de sexualité doit être promue à travers les programmes de Santé de la Reproduction et de lutte contre le SIDA.

Several other policy documents from Burkina Faso consider gender-related challenges as they outline support for the promotion of reproductive health services, especially for adolescents and young people.

The "Plan stratégique santé des adolescents et des jeunes, 2015-020" includes a priority activity to promote a favorable social environment for adolescent and youth health, including building capacity among adolescent and youth reproductive health community actors on gender issues:

 Axe 6 : Promotion d’un environnement social et juridique favorable à la santé des adolescents et des jeunes

The “Plan stratégique santé des adolescents et des jeunes, 2015-2020” describes specific activities to promote a social environment conducive to the health of adolescents and to reach community leaders and parents about youth sexual and reproductive health:

Axe 6 : Promotion d’un environnement social et juridique favorable à la santé des adolescents et des jeunes

Renforcement du dialogue parents enfants dans l’éducation sexuelle et les bonnes habitudes d’hygiène et de vie des adolescents et des jeunes

• Formation à la vie familiale des parents et des adolescents et des jeunes
• Communication média sur le rôle des parents
• Utilisation des NTIC [nouvelles technologies de l'information et de la communication] pour rappeler le rôle attendu des parents (SMS)
• Communication média sur l’éducation sexuelle, les bonnes habitudes d’hygiène et de vie

Implication des leaders communautaires et religieux dans l’éducation sexuelle et les bonnes habitudes d’hygiène et de vie des adolescents et jeunes

• Plaidoyer
• Communication média sur l’éducation sexuelle et les bonnes habitudes d’hygiène et de vie

Burkina Faso outlines a detailed strategy to build community support for youth FP services and to address gender norms. Therefore, it is placed in the green category for this indicator.

The “Normes des services de santé de la reproduction, 2012” state that any person of childbearing age can access contraceptives without spousal consent:

Les femmes et les hommes en âge de procréer doivent avoir accès aux méthodes contraceptives réversibles sans recours au consentement de leur conjoint. Toutefois, l’accent doit être mis sur l’importance du dialogue dans le couple pour l’adoption d’une méthode contraceptive.

Although the “Normes des services” address spousal consent, no reviewed policy documents address parental consent. Burundi is placed in the yellow category for this indicator because its policies do not explicitly support youth access to FP services without consent from parents.

The “Normes des services de santé de la reproduction, 2012” acknowledge youth and adolescent rights to dignity and to receiving FP services from trained professionals:

III.2.3.1. Droits en Santé Sexuelle et Reproductive

De façon spécifique, les adolescents et les jeunes jouissent des droits suivants :

…

• Le droit à la dignité : être traité(e) avec courtoisie, considération et prévenance.
• Le droit de bénéficier d’explications suffisantes de l’intervention que vous subissez lorsque vous recevez des soins de santé.
• Le droit d’être pris en charge par des gens formés et qui maîtrisent ce qu’ils

The "Normes des services" establish service quality standards and note that successful programs require well-trained staff that employ sensitivity toward clients and use clinical judgment:

Des programmes réussis exigent un personnel bien formé qui démontre :

• Attention, sensibilité et empathie lorsqu’il informe le client,
• Connaissances, attitudes et compétences pour fournir les services de SR [santé reproductive],
• Connaissance des problèmes réels ou potentiels et capacité de les reconnaître,
• Capacité de prendre des mesures cliniques appropriées en réponse à ces problèmes, y compris quand et où référer les clients qui ont des problèmes graves ; bon jugement clinique,

While Burundi’s policies acknowledge young people’s right to be treated with dignity and that successful facilities show empathy and exercise clinical judgment, they fail to explicitly require health workers to provide medically advised FP services to youth without personal bias or discrimination. Burundi is placed in the gray category for this indicator.

The “Politique nationale de santé, 2016-2025" prioritizes access to sexual and reproductive health (SRH) services for adolescents and young people to improve maternal, newborn, and adolescent health:

Période de l’adolescence (10- 20 ans) : (1) l’information et l’offre des services de santé sexuelle et reproductive des adolescent(e)s et des jeunes axée sur la prévention des grossesses précoces, la prévention des IST[infections sexuellement transmissibles]-VIH/SIDA, la prévention des mariages précoces…

 Période de la jeunesse (20- 24 ans) : (1) l’information et l’offre des services de santé sexuelle et reproductive des jeunes axée sur la prévention des grossesses précoces, la prévention des mariages et maternité précoces, la prévention des IST-VIH/SIDA…

The "Loi n° 1/012 du 30 mai 2018 portant code de l’offre des soins et services de santé au Burundi” supports access to health without discrimination based on age:

Chapitre II : Des principes directeurs de la politique nationale de santé. Nul ne peut être l'objet de discrimination du fait notamment de son origine, de sa race, de son ethnie, de son sexe, de sa couleur, de sa langue, de sa situation sociale, de ses convictions religieuses, philosophiques, ou politiques, du fait d’un handicap physique ou mental, du fait d’être porteur du VIH/Sida ou de toute autre maladie incurable.

The “Module de formation des prestataires de soins en santé sexuelle et reproductive des adolescents et des jeunes, 2020” notes this access to health services includes SRH and FP:

Les adolescents et les jeunes ont les mêmes droits en SSR [santé sexuelle et reproductive] que les adultes, ils sont encouragés à exprimer leurs besoins pour de plus amples informations et un meilleur accès aux services

The “Normes des services de santé de la reproduction, 2012” affirm the rights that adolescents and young people enjoy, including the right of access to SRH services and free choice of contraceptive methods:

III.2.3.1. Droits en Santé Sexuelle et Reproductive

De façon spécifique, les adolescents et les jeunes jouissent des droits suivants :

• Le droit à l’information : être informé(e) des avantages et de la disponibilité de l’ensemble des services essentiels.
• Le droit d’accès : obtenir l’ensemble des services de SSR et à un prix abordable sans discrimination de sexe, de croyances, de race, d’ethnie, de statut marital ou d’origine géographique.

…

• Le droit de libre choix : décider librement de l’utilisation des services de planification familiale et de la méthode à utiliser ou de l’utilisation de l’un des quelconques services disponibles.

As Burundi’s policies support youth access to family planning regardless of age, Burundi is placed in the green category for this indicator.

The "Normes des services de santé de la reproduction, 2012," which include family planning in a service package for youth, support adolescent and youth access to sexual and reproductive health services without discrimination based on marital status:

III.2.3.1. Droits en Santé Sexuelle et Reproductive

De façon spécifique, les adolescents et les jeunes jouissent des droits suivants :

...

Le droit d’accès : obtenir l’ensemble des services de SSR [santé sexuelle et reproductive] et à un prix abordable sans discrimination de sexe, de croyances, de race, d’ethnie, de statut marital ou d’origine géographique.

…

Le droit de libre choix : décider librement de l’utilisation des services de planification familiale et de la méthode à utiliser ou de l’utilisation de l’un des quelconques services disponibles.

Because the law supports youth access to FP services regardless of marital status, Burundi is placed in the green category for this indicator.

The "Politique nationale de la santé de la reproduction, 2007” aims to improve the availability and accessibility of FP services by expanding contraceptive method options, including long-acting reversible contraceptives (LARCs), without specifically mentioning youth access:

Amélioration de la disponibilité et de l’accessibilité des services de PF de qualité :

• Etendre la distribution à base communautaire des contraceptifs non prescriptibles au niveau national ;
• Elargir la gamme des méthodes contraceptives en mettant l’accent sur les méthodes de longue durée d’action.

The “Politique nationale de santé, 2016-2025" describes the need to allow informed free choice of contraceptives to reach contraceptive coverage goals:

Le renforcement de l’accès et l’utilisation des services de planification familiale de qualité tenant compte des besoins et du choix libre éclairé de l’individu afin d’atteindre une couverture contraceptive d’au moins 50 %.

Burundi's “Normes des services de santé de la reproduction, 2012” note that a range of contraceptive methods must be available at all levels of health care:

Toutes les méthodes de contraception suivantes doivent être disponibles selon les normes de paquets d’activités définies par niveaux de soins :

• La méthode de l’allaitement maternel avec aménorrhée (MAMA)
• Les spermicides
• Les préservatifs masculins et féminins
• Les pilules
• Les injectables
• Les implants
• Le Dispositif intra-utérin (DIU)
• La Contraception Chirurgicale Volontaire (CCV)
• La méthode naturelle

While the “Normes des services” further note that men and women of reproductive age have access to all reversible contraceptive methods without spousal consent and that adolescents and youth have the right to freely decide on which methods to use, they do not reference parity or marital status.

Although policy documents value method choice and mix, future policy documents should clearly state that a full range of methods, including LARCs, are available for youth regardless of age, marital status, and parity. Burundi is placed in the yellow category for this indicator.

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, it is worth noting that the reviewed policies do not address youth access to EC.

The “Politique nationale de santé, 2016-2025" aims to introduce sex education and the promotion of gender equality into school curricula, yet only references young people ages 20 to 24:

L’accès pour les jeunes de 20- 24 ans à (1) l’information et l’offre des services de santé sexuelle et reproductive des jeunes axée sur la prévention des grossesses précoces, la prévention des mariages et maternité précoces, la prévention des IST[infections sexuellement transmissibles]-VIH/SIDA, (2) services de prévention et prise en charge des addictions (alcool, tabac, drogues), (3) l’éducation nutritionnelle des jeunes et (4) dans le cadre de l’intersectorialité , introduire des séances d’éducation sexuelle et promotion de l’égalité du genre.

The “Politique nationale" includes the introduction of sexuality education adapted to adolescents and young people’s needs in school curricula:

Période de l’adolescence (10- 20 ans) : … Dans le cadre de l’intersectorialité : - introduction de l’éducation sexuelle adaptée aux adolescent(e)s et aux jeunes dans le cursus scolaire, - promotion de l’égalité du genre dans les écoles,…

 Période de la jeunesse (20- 24 ans) : … Dans le cadre de l’intersectorialité : - introduction de l’éducation sexuelle adaptée aux jeunes dans le cursus scolaire et promotion de l’égalité du genre, - protection des jeunes contre les violences sexuelles et autres formes de violences basées sur le Genre.

The "Plan d’accélération de la planification familiale, 2015-2020" describes activities to ensure sexual and reproductive health information reaches adolescents and young people in and out of school:

Stratégie DE3 : Initiation de stratégies novatrices de communication en direction des adolescents et des jeunes scolarisés et non scolarisés. Au niveau de cette stratégie, il sera question d'utiliser les espaces et les outils de communication auxquels sont beaucoup attachés les adolescents et les jeunes pour les sensibiliser sur la PF.

...

Activité DE3.2 : Appuyer l'intégration de l'éducation sexuelle complète dans les programmes scolaires non encore couverts (8ème, 7ème, 6ème, 5ème) en synergie avec le ministère en charge de l’éducation. Il sera question d'aider à ce qu'il soit pris en compte dans les curricula de formation des classes de la (8ème, 7ème, 6ème, 5ème) l'éducation sexuelle. Il s'agira surtout d'aider à la confession et à la distribution des différents manuels.

Activité DE3.3 : Mettre en œuvre/utiliser les outils de formation sur la SSRAJ [santé sexuelle et reproductive des adolescents et des jeunes] au niveau communautaire avec tous les acteurs (écoles, centres jeunes, associations de jeunes) dans l'ensemble des provinces du pays. Cette activité consistera à reproduire et à mettre à la disposition de tous les acteurs au niveau communautaire et ce dans les 17 provinces du pays, les outils de formation sur la SSRAJ. Ces outils serviront de base de formation dans les différents centres de regroupement des jeunes.

However, as part of a strategic goal to reduce sexually transmitted infections, undesired pregnancies, and high-risk abortions in adolescents and young people, the “Politique nationale de la santé de la reproduction, 2007” aims to promote both abstinence and contraceptive use:

• Promouvoir l’abstinence et /ou l’usage correcte et systématique du Préservatif ;
• Promouvoir la contraception chez les jeunes et les adolescents ;

Burundi’s policy environment is promising as it mandates sexuality education as a necessity for increasing contraceptive use. However, existing activities for implementation do not include each of the United Nations Population Fund’s (UNFPA’s) nine elements of comprehensive sexuality education. Therefore, Burundi is placed in the yellow category for this indicator.

Multiple policy documents outline young people’s rights when seeking sexual and reproductive health (SRH) services. The “Normes des services de santé de la reproduction, 2012” outline adolescents’ and youth rights when seeking SRH services, including the right to privacy, confidentiality, trained providers, and access to services at an affordable price:

III.2.3. Santé des Jeunes

…

III.2.3.1. Droits en Santé Sexuelle et Reproductive De façon spécifique, les adolescents et les jeunes jouissent des droits suivants :

• Le droit d’accès : obtenir l’ensemble des services de SSR [santé sexuelle et reproductive] et à un prix abordable sans discrimination de sexe, de croyances, de race, d’ethnie, de statut marital ou d’origine géographique.
• Le droit à l’intimité : bénéficier d’un environnement intime durant l’assistance ou la prestation des services.
• Le droit à la dignité : être traité(e) avec courtoisie, considération et prévenance.
• Le droit à la confidentialité : être assuré(e) que toute information personnelle restera confidentielle.

The “Loi n° 1/012 du 30 mai 2018 portant code de l’offre des soins et services de santé au Burundi" also guarantees all patients the right to the confidentiality of their information:

Article 16 : Tout patient a le droit de décider de l'usage des informations médicales le concernant et les concernant et les conditions dans lesquelles elles peuvent être transmises à des tiers. Les établissements de santé doivent garantir la confidentialité des informations qu’ils détiennent sur leurs patients même après leur décès. Toutefois le secret médical n'est pas opposable au patient. Le respect du secret médical peut être écarte dans les cas prévus par la loi.

The “Directives de mise en place et de fonctionnement d’un centre de santé ami des jeunes, 2014 ” outline the characteristics of health centers that provide youth-friendly SRH services. The “Directives” emphasize equitable access to services, respect for confidentiality, affordable services, and avoiding stigma and judgment:

IV- 4 Caractéristiques des services offerts dans un CDS [centre de santé] ami des jeunes

Les services de santé sexuelle et reproductive adaptés aux jeunes et adolescents de qualité sont : 

1. Équitables pour tous les jeunes et adolescents sans distinction de sexe, de religion, de niveau d’étude, d’ethnie ou toute autre appartenance sociale;
2. Efficaces et rapides, offert avec ou sans rendez-vous parce qu'ils répondent aux besoins des jeunes et sont appréciés par eux.
3. Dispensés par des prestataires formés et compétents : formé sur des outils harmonisés portant sur la SSRAJ, la psychologie de l’adolescent et la communication adaptée aux jeunes etc ; personnel compréhensif, accueillant, prévenant, qui ne jugent pas et qui traitent chaque adolescent avec autant de soins et de respect. Un personnel avisé y compris le personnel d’appui, motivé et bien soutenu (supervisé par les Equipes Cadres de District sanitaire)
4. Efficients parce qu'ils ne gaspillent pas les ressources ;
5. Accessibles et abordables
6. Confidentiels et garantissant le respect de l’anonymat et évitant la stigmatisation et le jugement.

De nature à fournir des informations sur base des documents pédagogiques intégrés (le plus de services possibles et au même moment) à des heures favorables à la disponibilité des jeunes en l’occurrence les après-midi et les week end.

The "Politique nationale de la santé de la reproduction, 2007" aims to build the capacity of providers to communicate with young people:

Renforcer les capacités des prestataires de santé et autres intervenants en « Comment communiquer efficacement avec les jeunes et les adolescents. »

As part of a strategic goal to reduce sexually transmitted infections, undesired pregnancies, and high-risk abortions in adolescents and young people, the “Politique nationale” plans to integrate adolescent and youth health into the minimum package of services for in-service training and promote user-friendly reproductive health services.

The "Plan d’accélération de la planification familiale, 2015-2020" includes a strategic priority to improve the supply of FP services, including ensuring adolescents and young people access services adapted to their needs. The priority intervention includes multiple activities to train health care workers or integrate FP into service curricula:

Activité O1.1 : Étendre l'offre de services de PF dans l'ensemble des CDS et hôpitaux publics… Rendre disponible les services de PF dans une structures, il s'agira essentiellement de former au moins deux prestataires, d'équiper les structures en matériel de communication pour le changement de comportement, en matériel de prévention des infections, matériel de pose et retrait de DIU [dispositif intra-utérin] et d'implant puis d'approvisionner les FOSA [formations sanitaires] en produits contraceptifs de qualité.

...

Activité O1.3: Intégrer l'offre de PF dans les services de santé de toutes les entreprises qui en disposent… Il s'agira essentiellement de faire des plaidoyers, de former et d'équiper les services de santé de ces entreprises à offrir des services de PF de qualité.

...

Activité O1.7 :Passer à l'échelle l'intégration de la PF dans le paquet d’activité de tous les Agents de Santé Communautaire (ASC) du pays…

The “Plan d’accélération” also includes 10 more activities to build the capacity of service providers to give quality FP services, including modern contraceptives, although the activities are not specific to youth. The activities also involve on-the-job training and the integration of modules into in-service training. Finally, the “Plan d’accélération” lists two specific activities to strengthen access to youth-friendly FP services, including equipping spaces and training providers:

Stratégie O3 : Renforcement de l'accès des adolescents et jeunes aux services adaptés à leurs besoins Cette stratégie a pour objectif de faciliter davantage l'accès des services de PF aux adolescents et aux jeunes. Elle comprend 2 activités.

Activité O3.1 : Aménager et équiper deux CDS par district pour l'intégration effective de l'offre de services conviviaux pour adolescents et aux jeunes Il s'agira d'aménager et d'équiper des espaces à l'intérieur des CDS qui soit adaptés aux adolescents et aux jeunes. Ce qui facilitera l'offre des services de PF à ces derniers. 73 CDS seront aménagés et équipés pour offrir des services adaptés aux adolescents et aux jeunes pour répondre à un besoin de 90 CDS exprimé par le pays.

Activité O3.2 : Former les prestataires de deux CDS par district pour l'offre de services conviviaux pour adolescents et aux jeunes Des sessions de formation seront organisées pour former des prestataires à l'offre des services de PF adapté aux besoins des jeunes. Cette activité permettra de renforcer les capacités de 146 prestataires.

The "Module de formation des prestataires de soins en santé sexuelle et reproductive des adolescents et des jeunes, 2020," which provides the curriculum for training providers on adolescent and youth SRH, notes that providers should be providing evidence-based services without judgment to help adolescents and youth develop autonomy over their sexual health:

CHAPITRE IV : LES DROITS DES ADOLESCENTS ET DE JEUNES EN SANTE SEXUELLE ET REPRODUCTIVE

…

Les adolescents et les jeunes ne comprennent pas toujours entièrement leurs droits sexuels ou il se peut qu’ils ne sachent même pas qu’ils ont des droits. En tant que prestataires, le fait de savoir offrir des informations complètes et factuelles sans jugements, peut aider les adolescents et les jeunes à comprendre leurs options et peut les aider à acquérir suffisamment d’autonomie pour prendre en charge leur santé sexuelle. 

…

CHAPITRE XIII : CLARIFICATION DES VALEURS ET ATTITUDES DESPRESTATAIRES A PROPOS DE LA SEXUALITE DES ADOLESCENTS ET DES JEUNES

…

Déclarez que la prochaine séance fournira aux participants des renseignements qui démontreront l’importance de la prestation de services de SSR aux adolescents et aux jeunes sans jugement de valeur. 

The "Plan stratégique national de la santé de la reproduction, maternelle, néonatale, infantile et des adolescents, 2019-2023" details the priority intervention to improve the availability, accessibility, and use of adolescent health care and services, including reproductive health. The activities outlined discuss the need to improve the youth-friendly services environment but fall short of mentioning privacy and confidentiality.

 The policies reviewed clearly address the need to train and support providers to offer adolescent-friendly contraceptive services. However, while Burundi’s policy environment addresses adapting youth-friendly spaces and free and subsidized SRH services, it fails to link them directly to youth family planning services. Burundi is placed in the yellow category for this indicator.

The “Politique nationale de la santé de la reproduction, 2007” plans to strengthen advocacy within the community for increased support of youth FP:

Renforcement du plaidoyer auprès des pouvoirs publics pour un engagement plus accru en faveur de la PF :

Mener un plaidoyer vigoureux auprès de tous les intervenants existants (décideurs politiques, leaders communautaires et religieux) et potentiels en faveur d’une meilleure prise de conscience de la problématique de la PF et de la promotion de l’accès généralisé aux services de PF par les femmes, les hommes et les jeunes…

The “Plan d’accélération de la planification familiale, 2015-2020” outlines strategies and activities to create an environment favorable to FP:

Stratégie DE1 : Mobilisation sociale pour l'utilisation de la PF

Cette stratégie vise à promouvoir la PF auprès des populations en général et des femmes, des adolescents et des jeunes puis des leaders communautaires.

Activité DE1.1 : Elaborer des supports de sensibilisation de la population basés sur les facteurs explicatifs de la faible utilisation de la PF et adaptés à chaque cible

Activité DE1.2 : Organiser des sensibilisations ciblées de la population à partir des facteurs explicatifs de la faible utilisation de la PF

Activité DE1.3 : Organiser des rencontres d'échanges et de plaidoyer avec les leaders communautaires (religieux, leaders d’opinion) pour leur implication en faveur de la PF

...

Activité DE1.7 : Organiser des activités de mobilisation communautaire (concours, jeux, chansons, sketchs) pour la promotion de la PF. Cette activité va consister à organiser des journées culturelles et récréatives dans chacune des 17 provinces du pays. Il s'agira de créer des regroupements attractifs de masse en vue de faire la promotion de la PF à travers des jeux concours, ciné mobiles, chansons, sketchs...

The "Plan d’accélération" also includes promoting male engagement in FP as a priority and describes activities to use male champions and integrate FP activities into male community groups:

Stratégie DE2 : Promotion de l’engagement des hommes en PF Cette stratégie vise à faire à amener les hommes à s'impliquer d'avantage dans la promotion et à la pratique de la PF.

Activité DE2.1 : Utiliser les hommes champions pour la promotion de la PF auprès de leurs pairs Il s'agira d'identifier dans les différentes communautés et de former des champions ou des personnes qui se sont engagé dans la pratique la PF. Ces champions feront ensuite la promotion de la PF en partageant leurs expériences auprès de leurs pairs dans les lieux de rencontre privilégiés par les hommes.

Activité DE2.2 : Produire et diffuser des outils de communication en faveur de la PF ciblant les hommes. Des messages seront conçus spécifiquement pour hommes en mettant l'accent les aspects qui poussent les hommes à constituer un obstacle à la promotion et à la pratique de la PF.

Activité DE2.3 : Intégrer les activités de PF dans les programmes des groupements communautaires des hommes (pêcheurs, agriculteurs, motards, militaires...) en utilisant des messages adaptés aux différents milieux. Il sera ici question d'organiser des sessions de formation et d'échanges à l'endroit des membres des différents groupements des hommes (pécheurs, d'agriculteurs, motards, militaires...) pour permettre à ces derniers de sensibiliser leurs pairs sur la PF au cours de leurs activités.

Burundi’s “Directives de mise en place et de fonctionnement d’un centre de santé ami des jeunes, 2014” and the “Module de formation des prestataires de soins en santé sexuelle et reproductive des adolescents et des jeunes, 2020” also acknowledge the importance of involving parents, community and religious leaders, and local administration representatives to create a more enabling environment for youth and adolescent sexual and reproductive health.

Burundi’s policies outline specific interventions to build support within the larger community for youth FP and address gender and social norms. Burundi is therefore placed in the green category for this indicator.

Cameroon is placed in the gray category for this indicator because its policies do not support youth access to FP services without consent from parents and spouses.

The "Plan stratégique national de la santé des adolescents et des jeunes au Cameroun, 2015-2019" acknowledges that provider bias toward young people prevents them from accessing services:

Les services, notamment de planning familial, sont inaccessibles aux jeunes. Ils rencontrent beaucoup de barrières : culturelles, économiques, l’attitude discriminatoire des prestataires de services.

The "Normes et standards en SR-PF au Cameroun, 2018" state in the norms on counseling that providers should not force clients to adopt any method:

Si le client se décide, le counseling l’aide à choisir une méthode de contraception appropriée, l’aide à comprendre comment l’utiliser, et le rend capable de l’utiliser correctement pour une protection sûre et efficace. Cette information doit permettre une bonne compréhension de l'efficacité des méthodes contraceptives. Elle doit permettre au client de bien comprendre comment les utiliser correctement, de quelle manière elles agissent, quels en sont les effets secondaires courants, quels sont les risques et les avantages pour la santé, quels sont les signes et symptômes nécessitant de revenir consulter, des informations sur le retour à la fécondité après arrêt des méthodes et des informations sur la prévention des IST [infections sexuellement transmissibles]. Les prestataires ne doivent pas imposer à un client l'adoption d'une quelconque méthode.

Cameroon’s policies, however, do not explicitly state that providers must refrain from applying their personal biases and beliefs when providing FP services to youth. Therefore, Cameroon falls into the gray category for this indicator.

The “Protocoles et algorithmes en SR-PF au Cameroun, 2017" state that adolescents should have access to FP methods of their choosing:

En ce qui concerne la planification familiale, les adolescents peuvent utiliser n’importe quelle méthode de contraception et doivent avoir accès à un choix étendu. L’âge ne constitue pas à lui seul une raison médicale permettant de refuser une méthode a un adolescent.

Cameroon is placed in the green category for this indicator because the policy environment confirms that youth must be permitted access to FP services regardless of age.

The “Protocoles et algorithmes en SR-PF au Cameroun, 2017" support youth’s need for FP services regardless of marital status:

Les adolescentes sexuellement actives mariées ou non ont des besoins en matière de planification familiale. Il faut éviter que le cout des services et des méthodes ne limitent pas les possibilités de choix.

In addition, the “Normes et standards en SR-PF au Cameroun, 2018” state that clients have the right to access reproductive health services regardless of their family situation:

2.1.2. Droit à l’accès aux services

Le droit à l’accès aux services de [santé reproductive] stipule que:

...

Les clients doivent recevoir les services quel que soit leur sexe, leur principe, leur couleur, leur situation familiale, leur orientation sexuelle ou leur résidence.

Although the need for family planning among unmarried adolescents is recognized, the “Normes et standards” do not provide enough language affirming the rights of unmarried youth to access these services. Since Cameroon’s policies lack specific language supporting the right of unmarried people to FP services, it is placed in the gray category for this indicator.

The “Plan stratégique national de la santé des adolescents et des jeunes au Cameroun, 2015-2019” aims to reduce morbidity and mortality linked to reproductive health in adolescents and young people through increased prevalence of modern FP methods:

Augmenter le taux de prévalence contraceptive (méthodes modernes) chez les adolescentes et les jeunes filles d’ici 2019 ;

The “Protocoles et algorithmes en SR-PF au Cameroun, 2017" state that adolescents should have access to FP methods of their choosing:

En ce qui concerne la planification familiale, les adolescents peuvent utiliser n’importe quelle méthode de contraception et doivent avoir accès à un choix étendu. L’âge ne constitue pas à lui seul une raison médicale permettant de refuser une méthode a un adolescent.

...

Les adolescentes sexuellement actives mariées ou non ont des besoins en matière de planification familiale. Il faut éviter que le coût des services et des méthodes ne limitent pas les possibilités de choix.

The "Protocoles et algorithmes" also provide a copy of a rapid consultation checklist from the World Health Organization’s eligibility criteria for contraceptive use (2015), as well as a detailed explanation of each contraceptive method and its definition, eligibility criteria, advantages, disadvantages, and usage. While there is specific reference to youth eligibility and access to a range of methods, the policies do not include long-acting reversible contraceptives.

The “Normes et standards en SR-PF au Cameroun, 2018” state that the full range of contraceptives must be authorized after consultation as part of an individual’s right to choose from a range of methods. However, it does not specify that this same right must be extended to youth:

2.1.3. Droit au choix du service

Le droit du client(e) au choix des services de SR [santé reproductive] stipule que :

• Chaque individu décide librement de pratiquer la planification familiale ou non.
• Chaque individu décide librement de sa méthode contraceptive.
• Les prestataires de services doivent présenter à tout client(e) la gamme complète de méthodes contraceptives pour lui permettre de faire son choix...
• Une cliente qui a choisi une méthode à laquelle elle n'est pas éligible, doit en être informée et les méthodes alternatives devront lui être offertes.

While Cameroon’s policy environment protects the right of individuals to choose from a full range of methods, it falls short of including explicit language allowing youth to access to a full range of contraceptive methods, including long-acting reversible contraceptives. Cameroon is placed in the yellow category for this indicator.

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, it is worth noting that the “Protocoles et algorithmes” include EC in the list of contraceptives available for clients, with no mention of youth eligibility.

Cameroon’s policy environment supports the provision of sexuality education to in-school and out-of-school youth. The “Programme national multisectoriel de lutte contre la mortalité maternelle, néonatale et infanto-juvénile au Cameroun: plan stratégique, 2014-2020” addresses the roles that the Ministries of Education and Health have in equipping young people with knowledge on sexual and reproductive health (SRH).

The “Plan stratégique national de la santé des adolescents et des jeunes au Cameroun, 2015-2019” aims to strengthen social mobilization in favor of youth SRH and includes an objective to improve adolescent and youth knowledge of issues that impact their reproductive health. Activities include spreading information in formal and informal settings:

OS2 : Améliorer le niveau de connaissances des A/J [adolescents/jeunes] sur les questions de SRAJ [santé reproductive des adolescents et des jeunes]

2.1 Élaborer les outils techniques et didactiques en matière de SRA [santé reproductive des adolescents] avec l’implication active des jeunes

2.2 Produire et disséminer les outils d’IEC [Information, Education et Communication] /CCC [Communication pour le Changement de Comportement]

2.3 Former les Leaders des jeunes et les responsables des structures d’encadrement des jeunes en techniques de communication en matière de SRAJ.

2.4 Mener des activités d’information et de sensibilisation des A/J en matière de SRAJ.

2.5 Renforcer l’intégration de la thématique SRAJ (EVF [éducation à la vie de famille]/EVA/EMP/VIH/SIDA) dans les programmes d’éducation des jeunes, en milieu scolaire et extra- scolaire

The “Plan opérationnel de planification familiale, 2015-2020” has a detailed strategy to increase youth knowledge of reproductive health in formal and informal settings. The strategy includes the use of information and communication technology to raise awareness among young people, the implementation of SRH education in schools, and strengthening education through health clubs in schools, including peer educators, with a focus on adolescent girls and young people :

Stratégie D3 : Initiation des stratégies novatrices de communication en direction des adolescents et jeunes scolarisés et non scolarisés

Activité D3.1 : Utilisation des pour sensibiliser les jeunes

Activité D3.2 : Intensification de l’enseignement de la SSR [santé sexuelle et reproductive] en milieu scolaire en synergie avec le ministère en charge de l’Education (MINSEC, MINSUP, MINFOP)

Activité D3.3 : Sensibilisation des adolescentes et jeunes par l’intermédiaire des pairs éducateurs et clubs santé

Activité D3.4 : Sensibilisation des jeunes du secteur informel et du milieu rural sur les questions de SSR à travers les associations des jeunes (socio-éducatives, culturelles et sportives) en synergie avec le MINJEC

The four activities outlined in the “Plan operationnel” show a commitment to reaching across formal and informal sectors, including sharing information through mobile phone lines, websites, health clubs, and youth associations. The third and fourth activities both integrate a focus on gender and support links to SRH services:

Sensibilisation des adolescentes et jeunes par l’intermédiaire des pairs éducateurs et clubs santé Pour le repositionnement de la PF et une implication des adolescentes et jeunes, il sera nécessaire de renforcer l’éducation par les clubs santé au niveau des écoles et les pairs éducateurs de tous les milieux extrascolaires.

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Il y aura aussi l’identification des jeunes capables de porter les messages de la SR [santé reproductive] /PF aux autres jeunes. Il sera organisé deux fois par an une grande activité culturelle et sportive avec des moments de sensibilisation sur la PF et si possible l’offre des services aux adolescentes et jeunes en marge de l’activité.

Cameroon’s policy environment is supportive of sexuality education but does not reference all nine of the United Nations Population Fund’s (UNFPA’s) essential components of comprehensive sexuality education (CSE). Therefore, Cameroon is placed in the yellow category for this indicator. Going forward, additional sexuality education policies should consider all nine UNFPA essential components of CSE.

The three service-delivery elements of youth-friendly contraceptive services are mentioned in Cameroon’s policy environment.

The “Plan stratégique national de la santé des adolescents et des jeunes au Cameroun, 2015-2019" mentions youth’s right to confidentiality and privacy while seeking services:

Respect des droits humains : Le respect des droits humains sous-tend que, pour toute réalisation des programmes de développement, l’être humain soit placé au centre des interventions. Spécifiquement pour les adolescents et jeunes, il s’agit du droit à l’information, à la confidentialité et l’anonymat, la sécurité des soins, au libre choix, à l’intimité, au bien-être, la dignité, etc.

The "Normes et standards en SR-PF au Cameroun, 2018" expand on the right to confidentiality and privacy by including the requirement that providers must guarantee confidentiality while offering FP services:

2.1.5. Droit à la l’intimité et à la confidentialité

Le droit à l'intimité et à la confidentialité stipule que :

• Les locaux doivent garantir l'intimité et la confidentialité des prestataires.
• Les prestataires doivent respecter l'intimité du client(e).
• L'accès au fichier médical doit être strictement réservé aux prestataires de services et aux autres personnes autorisées.
• Le prestataire veille dans la mesure du possible, à ne pas être perturbé durant la consultation.
• Tout le personnel doit respecter le secret professionnel.
• Le personnel médical doit toujours prendre soin d'expliquer la présence d'une tierce personne durant la consultation et solliciter l'avis du client(e) avant d'autoriser la présence de cette tierce personne.

 3.1 Normes pour la planification familiale.

3.1.4. Cibles de la PF : Il s’agit des femmes en âge de procréer, des hommes et des adolescent(e)s et des jeunes.

3.1.5. L’organisation du travail

...

Les prestataires doivent veiller à l'organisation du travail et des locaux afin de garantir la confidentialité dans l'offre de services de PF. L'organisation des locaux et des services doit permettre de garantir cette confidentialité ainsi que le respect de la dignité des clientes depuis la consultation, l'achat des produits, jusqu'à l'administration de la méthode.

The "Plan stratégique”  also includes specific objectives to build the capacity of providers and other health facility personnel to offer youth-friendly RH services, including the provision of modern contraceptives:

3.5.2. Axe stratégique II : Renforcement de l’offre de service de SRAJ [santé reproductive des adolescents et des jeunes de qualité.

OS1 : Introduire les services sanitaires appropriés aux A/J [adolescents/jeunes] dans au moins 25% des formations sanitaires de chaque district de santé.

OS2 : Renforcer les capacités en SRAJ de tous les gestionnaires et les prestataires.

OS3 : Introduire les modules de SRAJ dans les curricula de formation des personnels médicaux et paramédicaux.

Finally, the “Plan stratégique national de la santé de reproduction, maternelle néonatale et infantile, 2014-2020," the "Plan opérationnel de planification familiale, 2015-2020," and "Health Sector Strategy, 2016-2027" all outline strategies to provide services at free or reduced cost. The “Plan strategique“ includes lifting financial barriers for reproductive health, including free annual appointments in schools:

2 : Levee barrières financières

Gratuité des visites médicales annuelles dans les collèges, lycées et universités

The “Health Sector Strategy, 2016-2027” aims to ensure services are adapted to young people’s needs and states that providing free or subsidized services will help improve the use of contraceptives:

Implementation Strategy 1.4.3: Improving FP service delivery and use:

Improving the availability of FP services shall be done through:

(i) scaling up integrated FP service delivery;

(ii) improving the availability of inputs through better management of the supply system and the establishment of an FP support fund;

(iii) capacity building of human resources in FP to make up for the significant shortage of trained personnel;

(iv) development of FP services adopted to the youth and adolescents. It is for this purpose that inventories will be made for a good mapping of the needs of quality inputs and human resources.

As concerns improving the use of contraceptives, it will be achieved through: ...

(ii) removal of financial barriers (subventions or even free healthcare for vulnerable targets) and socio-cultural (religious beliefs, disinformation);

Cameroon has a strong policy environment for the provision of youth-friendly FP services and is placed in the green category for this indicator.

The “Plan stratégique national de la santé des adolescents et des jeunes au Cameroun, 2015-2019” includes a strategic goal to strengthen social mobilization around youth reproductive health:

3.5.1. Axe stratégique I : Renforcement de la mobilisation sociale autour de la SRAJ [santé reproductive des adolescents et des jeunes].

OS1 : Améliorer la communication intégrée pour susciter la prise de conscience sur les problèmes de SRAJ au sein de la communauté (Élus, décideurs, société civile, responsables et Leaders)

OS2 : Renforcer le dialogue parents/enfants sur la SRAJ.

The “Plan stratégique” stresses the urgent need for social mobilization in favor of youth-friendly services within communities:

La communication portant sur la santé de reproduction reste insuffisante et prioritairement faite par les prestataires de soins et les enseignants. Or plusieurs autres personnes comme les parents, les leaders communautaires ont également la responsabilité d’assurer quotidiennement l’éducation de cette cible. Dès lors, il apparaît urgent pour une large mobilisation sociale en faveur de la SAJ [santé des adolescents et des jeunes] d’améliorer la communication intégrée. Celle-ci aura comme principal objectif de susciter une prise de conscience sur les problèmes de SRAJ au sein des communautés. La pertinence d’une telle action repose sur le rôle prépondérant de ces différents acteurs sur l’éducation et le processus de socialisation des A/J [adolescents/jeunes] au niveau familiale voire communautaire.

The “Health Sector Strategy, 2016-2027” aims to improve demand for FP services by strengthening the role that men play in FP promotion:

Implementation Strategy 1.4.2: Improving the demand for FP services

Improving the demand of FP services will be achieved through the development of the following interventions: (i) interpersonal and mass communication in favour of FP to raise awareness on the availability of FP services at the operational level; (ii) strengthening the participation of men as partners in the promotion of FP especially in cultures where women have little decision-making power over their reproductive health.

The “Plan opérationnel de planification familiale, 2015-2020” includes a detailed strategy to strengthen men as partners in promoting reproductive health. While the strategy does not specifically target youth FP, it includes piloting husbands’ schools and promoting family planning among men in agricultural groups:

Stratégie D2 : Renforcement de l’implication des hommes comme partenaires dans la promotion de la SR [santé reproductive] en général et en particulier de la PF

Les hommes sont des décideurs clés mais ils ont souvent peu d'intérêt pour la PF ou qu'ils s'y opposent. Dans certaines localités, l’environnement socioculturel influence les comportements qui favorisent les attitudes pro-natalistes. Cependant, certains pays ont menés, avec succès, les hommes à devenir des champions de la PF. La stratégie de l’Engagement Constructif des Hommes (ECH) sera élaborée et disséminée. Les organisations paysannes la coordination de Cameroon Development Cooperation (CDC), Farmers groups, PALMOR, SODECOTON, etc... seront impliquées dans la sensibilisation des hommes sur la PF. De la même manière l’approche de l’école des maris en expérimentation sera étendue dans plusieurs districts.

The "Programme national multisectoriel de lutte contre la mortalité maternelle, néonatale et infanto-juvénile au Cameroun: plan stratégique, 2014-2020" looks to mainstream gender to strengthen community mobilization and generate demand for the use of health services by women and young people, with an emphasis on the involvement of men, traditional and religious leaders, and young boys. The “Programme national multisectoriel” also aims to take gender into account when implementing its objectives:

Les besoins spécifiques des femmes et filles selon leurs statuts devront être pris en compte dans la mise en œuvre du PLMI [programme national multisectoriel de lutte contre la mortalité maternelle, néonatale et infanto-juvénile]. Un accent devra être mis sur l’implication des hommes, des leaders traditionnels et religieux et des jeunes garçons. Cette implication visera les aspects préventifs de lutte contre la mortalité maternelle et infantile mais également l’accompagnement et la prise en charge psycho sociale et la réinsertion socioéconomique des femmes et filles affectées par les complications liées à la mortalité maternelle.

La prise en compte des spécificités de genre dans le PLMI concerne par ailleurs la définition des activités visant la réduction des discriminations et des violences basées sur le genre y compris les pratiques socioculturelles limitant la demande (et l’accès) des femmes et des filles aux services et soins de SRMNI. Un accent devra être mis sur la jouissance par les femmes et les filles de leurs droits reproductifs, tout en intégrant les besoins des hommes et jeunes en matière de PF afin qu’ils soient des parties prenantes actives à la mise en œuvre du PLMI.

While Cameroon’s policies address the need to build community support for youth FP services and to address gender norms, the policies lack a detailed strategy for building an enabling social environment specifically for youth FP services. Therefore, Cameroon is placed in the yellow category for this indicator.

The “Loi n°06.005 du 20 juin 2006 bangayassi relative à la santé de reproduction” states that individuals are entitled to receive all reproductive health services, including FP, without discrimination and without parental or spousal consent:

Art. 7 : Toute personne a droit à une vie sexuelle satisfaisante, en toute sécurité. Elle a le droit de procréer et doit être libre de le faire au rythme de son choix.

Le droit de procréer implique l’accès à l’information et l’utilisation des méthodes de planification familiale conformément aux normes prescrites ; l’accès à des services de santé devant permettre aux femmes de mener à bien grossesse et accouchement, et donnant aux couples toutes les chances d’avoir des enfants en bonne santé.

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Art. 14 : Les patients sont en droit de recevoir tous les soins de santé en matière de la reproduction sans discrimination aucun, fondée sur le sexe, la religion, l’ethnie, l’âge, le statut sanitaire ou tout autre statut. Sauf dispositions légales contraires, l’autorisation du partenaire ou de ses parents avant le traitement peut ne pas être requise.

The “Politique nationale de la santé de la reproduction, 2015” continues to support access to contraceptive methods without the need for spousal consent:

2.2.1 La Planification Familiale

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Les femmes et les hommes en âge de procréer pourront avoir accès aux méthodes contraceptives réversibles sans recours préalable au consentement de leur conjoint. Toutefois, l’accent doit être mis sur l’importance du dialogue dans le couple pour l’adoption d’une méthode contraceptive ;

The reviewed policies support youth access to family planning without spousal and parental consent. The Central African Republic is placed in the green category for this indicator.

CAR lacks any policy addressing non-medical provider authorization for youth FP services and is therefore placed in the gray category for this indicator.

The “Loi n°06.005 du 20 juin 2006 bangayassi relative à la santé de reproduction” guarantees equitable access to sexual and reproductive health care regardless of age:

Art. 7 : Toute personne a droit à une vie sexuelle satisfaisante, en toute sécurité. Elle a le droit de procréer et doit être libre de le faire au rythme de son choix. Le droit de procréer implique l’accès à l’information et l’utilisation des méthodes de planification familiale conformément aux normes prescrites ; l’accès à des services de santé devant permettre aux femmes de mener à bien grossesse et accouchement, et donnant aux couples toutes les chances d’avoir des enfants en bonne santé.

 Art. 8 : Tous les individus sont égaux en droit et en dignité en matière de la reproduction. Ce droit est universel et fondamental. Il est garanti à tout être humain, tout au long de sa vie, en toute situation et en tout lieu. Aucun individu ne peut être privé de ce droit dont il bénéficie sans aucune discrimination fondée sur l’âge, le sexe, la fortune, la religion, l’ethnie, la situation matrimoniale et sans la moindre coercition ou la violence.

The “Politique nationale de la santé de la reproduction, 2015” also states that all individuals of reproductive age have the right to family planning services. Because the policies reviewed guarantee access to family planning regardless of age, CAR is placed in the green category for this indicator.

The “Loi n°06.005 du 20 juin 2006 bangayassi relative à la santé de reproduction” guarantees youth access to sexual and reproductive health care, including FP, regardless of marital status:

Art. 7 : Toute personne a droit à une vie sexuelle satisfaisante, en toute sécurité. Elle a le droit de procréer et doit être libre de le faire au rythme de son choix. Le droit de procréer implique l’accès à l’information et l’utilisation des méthodes de planification familiale conformément aux normes prescrites ; l’accès à des services de santé devant permettre aux femmes de mener à bien grossesse et accouchement, et donnant aux couples toutes les chances d’avoir des enfants en bonne santé.

 Art. 8 : Tous les individus sont égaux en droit et en dignité en matière de la reproduction. Ce droit est universel et fondamental. Il est garanti à tout être humain, tout au long de sa vie, en toute situation et en tout lieu. Aucun individu ne peut être privé de ce droit dont il bénéficie sans aucune discrimination fondée sur l’âge, le sexe, la fortune, la religion, l’ethnie, la situation matrimoniale et sans la moindre coercition ou la violence.

Because the law guarantees access to family planning regardless of marital status, CAR is placed in the green category for this indicator.

The “Loi n°06.005 du 20 juin 2006 bangayassi relative à la santé de reproduction” states that any individual or couple has the right to choose the method of family planning that works for them:

Art. 9 : Tout individu ou tout couple a le droit de décider librement et avec discernement, de la taille de sa famille dans le respect des lois en vigueur, de l’ordre public et de bonnes mœurs. Pour ce faire, il a le droit de choisir la méthode de planification familiale qui lui convient.

The “Loi n°06.005” also states that contraception includes all methods recognized as effective and safe, including modern and traditional methods. An individual has the right to choose from the full range of methods:

Art. 23 : La contraception comprend toutes méthodes approuvées, reconnues efficaces et sans danger. Ces méthodes peuvent être modernes, traditionnelles ou populaires. Toute la gamme des méthodes contraceptives légales doit être proposée et disponibles.

Art. 24 : Le droit de déterminer le nombre d’enfants et de fixer l’espacement de leur naissance confère à chaque individu la faculté de choisir parmi toute la gamme de méthodes contraceptives efficaces et sans danger, celle qui lui convient.

The “Plan national de développement sanitaire, 2006-2015” aims to provide a minimum package of activities and includes equipping facilities with contraceptive products, although it provides no details on which products:

Services de santé en faveur des femmes améliorés et disposent d’un paquet minimum d’activités selon les normes 

• Evaluer les besoins en équipements en matière de MSR [maternité sans risque], Soins Obstétricaux et Néonataux d’Urgence (SONU), produits contraceptifs ;
• Equiper les structures en matériel : 8 ordinateurs + accessoires ; 100 tables d’accouchement ; 20 motocyclettes ; produits contraceptifs ;

The "Standards des services de santé adaptés aux adolescents et aux jeunes en RCA, n.d." outline the minimum package of services for adolescents and youth along the different tiers of the health system. The “Standards des services” note that all health levels should offer a range of contraceptives (pills, injectables, intrauterine devices, implants, and natural methods) when possible or refer youth to other facilities.

CAR’s policies allow youth to access a range of methods but fall short of clearly stating that long-acting and reversible contraceptives are included in method choice. In the absence of a policy statement that requires health providers to offer short-acting and long-acting reversible contraceptive services to youth, CAR is placed in the yellow category for this indicator.

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, none of CAR’s policy documents reference youth access to EC.

The “Education sexuelle complète des adolescents et des jeunes: manuel de référence de la République centrafricaine à l’usage des formateurs des formateurs, n.d.” provides a general overview of comprehensive sexuality education (CSE) and details the curriculum modules for implementation. The curriculum manual aims to provide young people with essential skills, accurate knowledge of their rights and gender norms, and sexual and reproductive health and rights and is divided into seven main modules: human development; interpersonal relationships; gender; values and attitudes; sexual behaviors; sexual and reproductive health; and rights and needs.

The “Manuel de reference” plainly states that the curriculum content is based in the core values of human rights:

Les directives sur l'éducation sexuelle s'appuient sur une approche basée sur les droits en matière de sexualité, dont les valeurs sont inextricablement liées aux droits humains universels. Il n'est pas possible de séparer les considérations portant sur les valeurs des discussions relatives à la sexualité.

The “Manuel de référence" acknowledges that a well-implemented CSE program should have many qualities, including scientifically accurate information, employment of participatory teaching methods, and activities that take cultural values into account and promote decision making and critical thinking. The curriculum’s general objectives provide further information on the “Manuel’s” focus on scientific information and decision-making:

• Bénéficier d'informations exactes sur les droits sexuels et reproductifs chez l’enfant , l’adolescent et les jeunes ; d'informations pour dissiper les mythes ; de références à des ressources et à des services ;
• Développer des aptitudes à la vie quotidienne notamment dans le domaine de la pensée critique, de la communication, de l’écoute active, de la négociation, du développement autonome, de la prise de décision, de l'estime de soi, de la confiance en soi, de la capacité à s'imposer, de la prise de responsabilités, de la capacité à poser des questions et à demander de l'aide, de l'empathie ;
• Cultiver des attitudes et des valeurs positives grâce à une ouverture d'esprit ; au respect de soi-même et des autres ; à une estime/conscience de soi positive ; à une attitude sans jugement ; à un sens des responsabilités ; a une attitude positive vis-à-vis de leur santé sexuelle et reproductive.

In addition to containing a module dedicated to gender, the “Manuel de référence" acknowledges how the CSE curriculum will aim to eliminate negative norms and taboos related to gender and health:

L’ESC vise avant tout à éliminer les normes et stéréotypes, ainsi que la discrimination et la stigmatisation, tout en embrassant la diversité et le respect de l’évolution des capacités des enfants et des jeunes. Cela exige un effort concerté et soutenu pour contrer le silence et le tabou entourant les questions de sexe, de sexualité, de genre et de santé, au profit d’une approche outillant les jeunes pour aborder leur sexualité de façon positive.

The curriculum also addresses the of education to sexual and reproductive health services and other initiatives, strengthening youth advocacy and civic engagement, and ensures cultural relevance in tackling gender inequality.

The "Politique nationale de la santé de la reproduction, 2015" notes the right of young people to sexual education and family life:

Les jeunes ont droit à l’éducation à la vie sexuelle, à la vie familiale et l'éducation à la parenté responsable.

The “Politique nationale” and other major policy documents, including the “Plan national de développement sanitaire, 2006-2015” and the “Cadre stratégique national de lutte contre le VIH et le sida, 2012-2016,” note the importance of CSE uptake at all education levels.

While CAR’s CSE curriculum adequately addresses seven of the nine United Nations Population Fund’s (UNFPA’s) essential components, it fails to detail how educators will nurture a safe and healthy learning environment and reach both the formal and informal sectors. CAR is therefore placed in the yellow category for this indicator.

The “Loi n°06.005 du 20 juin 2006 bangayassi relative à la santé de reproduction" guarantees an individual’s right to access reproductive health services at an affordable cost and to privacy of information:

Art. 13 : Tout individu ou tout couple a le droit de bénéficier des soins de santé de qualité et de services sûrs, efficaces, accessibles et à un coût abordable.

Art. 15 : Aucune information concernant la santé du patient ou de l’usager ne doit être divulguée sans autorisation expresse de celui-ci. Le patient a le droit de connaître les informations dont le prestataire de soins habilité dispose sur sa personne.

The “Loi n°06.005” also states that government health facilities must be adapted to the needs of specific groups, including young people:

Art. 19 : L’Etat et les collectivités examinent et mettent en place les structures intégrées des soins de santé de la reproduction. Celles-ci doivent être adaptées aux besoins spécifiques de tous, y compris des jeunes. Ces structures doivent poursuivre un but non lucratif, sous réserve des dispositions spécifiques concernant les structures privées de prestation de services.

The “Politique nationale de la santé de la reproduction, 2015” supports continued provider training in sexual and reproductive health, but it is not specific to youth FP or the prevention of judgment or bias:

2.4.8 Formation

Les prestations de SR [santé reproductive] étant soutenues entre autres par des connaissances en pleine évolution, la formation en cours d’emploi et le recyclage des prestataires seront renforcés. Toute formation continue du personnel socio-sanitaire en SR devra répondre à des besoins de formation identifiés. L’enseignement des composantes de SR sera renforcé dans la formation de base et le recyclage du personnel de santé et des agents sociaux.

The "Standards des services de santé adaptés aux adolescents et aux jeunes en RCA, n.d." outline the standards expected of providers working with adolescents and young people, including the right of adolescents to access quality health services without any discrimination related to their age and a guarantee of privacy and confidentiality:

• Le respect des droits humains et en particulier le droit des adolescents et des jeunes à l’accès aux services de santé de qualité sans discrimination aucune liée à leur âge, sexe, religion ou conditions sociales ;
• La prise en compte de la dimension Genre et des valeurs socioculturelles ;
• Le respect des politiques, stratégies et programmes nationaux existants ;
• Le respect des règles d’éthique médicale ;
• La garantie de la confidentialité dans le respect de la vie privée des adolescents et des jeunes ;
• L’assurance que les interventions reposent sur des bases scientifiques prouvées ;
• L’appropriation par la communauté et l’implication de toutes les parties prenantes y compris les adolescents et les jeunes eux-mêmes ;
• L’intégration dans les autres secteurs de développement en privilégiant l’approche multisectorielle.

The "Standards des services" go on to outline the five standards for adolescent and youth health care, including providers having the knowledge and attitudes required to provide services adapted to young people:

Standard II : Tous les prestataires du PPS [point de prestations de services] ont les connaissances, les aptitudes et les attitudes requises, pour offrir des services adaptés aux besoins des adolescents et des jeunes.

Raisons d’être :

• Les adolescents et les jeunes peuvent être tenus à l’écart des services de santé en raison de l’absence d’orientation des prestataires en SAJ [santé des adolescents et des jeunes] ;
• Les adolescents et jeunes déplorent le mauvais accueil et la discrimination dont ils font l’objet lorsqu’ils désirent des services de santé ;
• Les services de santé peuvent être de mauvaise qualité en raison d’un manque de qualification ou de motivation des prestataires y compris le personnel de soutien ;
• Les prestataires sortants des écoles ne reçoivent pas une formation appropriée en SAJ.

The “Standards des Services” continue to outline the minimum package of services for adolescents and young people—which includes family planning—and the actions to be taken at each level of the health system to reach these standards, including training of providers to have the knowledge, skills, and attitudes required to offer services tailored to youth needs.

While the current policy environment outlines standards for providers to enforce confidentiality and audio/visual privacy and train providers to have the appropriate attitudes for youth seeking FP services, it fails to adequately reference the three contraceptive service-delivery elements. To move to a fully supportive policy environment, future policies should link training providers in youth FP services to prevent bias and clarify that affordable costs include no cost or subsidized FP services. CAR is placed in the yellow category for this indicator.

The “Politique nationale de la santé de la reproduction, 2015” acknowledges the role community actors can play in promoting reproductive health:

1.5.3 Rôle des acteurs externs

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Les communautés et les collectivités seront impliquées dans le processus de planification, d’identification des besoins prioritaires, et de toutes les activités de promotion de la santé de la reproduction.

While the most recent reproductive health policy acknowledges gender in its basic principles, including an acknowledgment of the need for a gender approach in implementation, the policy does not identify activities to build support within the community and address gender roles, as the previous version did.

The “Education sexuelle complete des adolescents et des jeunes : manuel de référence de la République centrafricaine à l’usage des formateurs des formateurs, n.d.” supports sensitizing religious leaders on the importance of family planning for adolescents and youth:

Obstacles à la Contraception

Au niveau Religieux

Stratégies : Impliquer les chefs religieux dans les activités de PF

Les convaincre du bienfondé de l’utilisation des méthodes contraceptives cliniques

 The “Standards des services de santé adaptés aux adolescents et aux jeunes en RCA, n.d.” identify community leaders and parents as groups to target to improve youth-friendly health services:

1.1 Objectif général

Améliorer l’accès des adolescents et des jeunes à des services de santé adaptés à leurs besoins ainsi que leur prise en charge en RCA.

…

2.2 Cibles secondaires

• Les groupes cibles secondaires sont constitués de :
• Les parents ;
• Les enseignants ;
• Les prestataires des services de santé ;
• Les jeunes pairs éducateurs et encadreurs de jeunes ;
• Les leaders communautaire

The “Plan stratégique national de sécurisation des produits de santé de la reproduction et de programmation holistique des préservatifs en République centrafricaine, 2013-2017” recommends sensitizing community leaders (including religious leaders, traditional healers, and mothers) on the importance of condom use, but it does not detail any activities.

The “Plan national de développement sanitaire, 2006-2015” outlines a strategic objective to avail quality reproductive health services with male and community support. As part of a minimum package of activities in health facilities, the government of the Central African Republic aims to:

• Sensibiliser les communautés sur les bienfaits des services de SR, en Genre ;

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• Mobiliser et faire participer les communautés aux efforts d’amélioration de la qualité des services de santé en SR.

While the National Health Plan acknowledges that the current environment in CAR does not adequately address gender issues in health strategies, it does not propose interventions to address gender and social norms. Additional documents acknowledge the roles that community leaders can play and the need to address gender norms but do not connect community engagement to youth contraceptive use and do not detail specific intervention activities. . As no policy exists to build an enabling social environment for youth FP services, CAR is placed in the gray category for this indicator.

Chad’s policy environment does not specifically prohibit parental and spousal consent for youth access to FP services. Until it addresses consent from a third party in a future policy, Chad is placed in the gray category for this indicator.

No law or policy was identified that requires providers to provide medically advised FP services to youth without personal bias or discrimination. Chad is placed in the gray category for this indicator.

The “Loi n°006/PR/2002 du 15 avril 2002 portant promotion de la santé de reproduction” guarantees the right to reproductive health regardless of age:

Chapitre 2 - Des principes et droits en matière de santé de la reproduction

Art.3.- Tous les individus sont égaux en droit et dignité en matière de santé de reproduction sans discrimination aucune fondée sur l’âge, le sexe, la fortune, la religion, l’ethnie, la situation matrimoniale ou sur toute autre situation...

Art.6.- Tout individu, tout couple a droit à l’information, à l’éducation et aux moyens nécessaires relatifs aux avantages, aux risques et à l’efficacité de toutes méthodes de régulation des naissances.

Because these policies address access to FP services regardless of age, Chad is placed in the green category for the indicator.

The “Loi n°006/PR/2002 du 15 avril 2002 portant promotion de la santé de reproduction,” which identifies FP as part of sexual and reproductive health services, guarantees the right to reproductive health services regardless of marital status:

Chapitre 2 - Des principes et droits en matière de santé de la reproduction

 Art.3.- Tous les individus sont égaux en droit et dignité en matière de santé de reproduction sans discrimination aucune fondée sur l’âge, le sexe, la fortune, la religion, l’ethnie, la situation matrimoniale ou sur toute autre situation.

Art.6.- Tout individu, tout couple a droit à l’information, à l’éducation et aux moyens nécessaires relatifs aux avantages, aux risques et à l’efficacité de toutes méthodes de régulation des naissances.

Chad is placed in the green category for this indicator as its policies support youth access to FP regardless of marital status.

The “Loi n°006/PR/2002 du 15 avril 2002 portant promotion de la santé de reproduction” guarantees young people’s access to reproductive health services regardless of age, and further details that these services include all FP methods and family planning services:

Chapitre 4 - Des soins et services de santé de reproduction

Art.13.- Par soins et services de santé de la reproduction, on entend notamment :

• L’orientation, l’information, l’éducation, la communication, la recherche, les moyens, les méthodes et, de manière générale, tous les services en matière de planification familiale 

While Chad’s reproductive health law explicitly mentions youth’s right to family planning methods, it is ambiguous in its scope. For Chad to move into the green category, it needs to ensure that long-acting and reversible contraceptives are offered and available among the essential contraceptive options for youth. Chad is placed in the yellow category for this indicator.

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, note that no reviewed policies reference youth access to EC.

The “Plan d’actions quinquennal de mise en œuvre de la politique nationale genre, 2019-2023” includes a strategic objective to reach equal and equitable access to basic social services by men and women, including promoting rights in reproductive health through education:

Dans ce cadre, des actions de plaidoyer, de sensibilisation et de renforcement des capacités sont à développer à l’échelle de l’ensemble des provinces. Par ailleurs il est retenu de promouvoir des initiatives visant à satisfaire les besoins spécifiques de filles et des garçons, des hommes et des femmes dans le secteur de l’éducation, de la formation et de l’alphabétisation, ce ci de manière à créer des conditions favorables de maintien et de succès des filles, au même titre que les garçons dans le système scolaire formel et les femmes au même titre que les hommes dans l’éducation non formelle et l’alphabétisation. Par ailleurs il s’agira de contribuer à l’amélioration de la Santé de la Reproduction et à la réduction de la mortalité maternelle et néonatale de manière à assurer aux hommes et aux femmes des services de santé de la reproduction de qualité de façon à réduire significativement les risques de mortalité liée à la maternité et à permettre à chacune et à chacun d’avoir une vie saine et responsable.

While the “Plan d’action” supports sexuality education among young people and acknowledges the benefits of education to young girls, no policies were identified that addressed sexuality education in detail. Chad is placed in the gray category for this indicator but could move into a more supportive environment by mandating sexuality education in a national policy and including each of the nine UNFPA elements of comprehensive sexuality education.

The “Loi n°006/PR/2002 du 15 avril 2002 portant promotion de la santé de reproduction” guarantees an individual’s right to access affordable reproductive health services:

Art.8.- Tout individu, tout couple a le droit d’accéder à des services de santé de proximité sûrs, efficaces, abordables et acceptables.  

The "Politique nationale de santé, 2016-2030" looks to improve health care delivery to young people through reproductive health services adapted to their needs:

Intervention 2 : Amélioration de la prestation des soins de qualité aux femmes, aux jeunes et aux enfants. Il s’agit de :

• Promouvoir la santé des jeunes et des adolescents en créant des centres de santé reproductive répondant aux besoins des jeunes et des adolescents.

The "Plan national de développement sanitaire, 2018-2023" acknowledges that adolescent health policy is limited in the country. As one of its strategic goals, the “Plan national” aims to promote the health of young people and adolescents through providing health services to youth as part of the package of services at all health levels. To support this goal, the “Plan national” suggests defining policies and strategic plans with interventions, such as youth centers and counseling for youth:

Action 22.1.1 : Définir les politiques, plans stratégiques, les normes relatives à la santé des jeunes, des adolescents, des personnes âgées et des personnes handicapées.

La définition des politiques et des plans stratégiques de santé scolaire, de la santé des adolescents et des personnes âgées favorisera leur développement. Dans la mise en œuvre de ces politiques seront mieux organisés les services de santé existants à disposer des centres de conseils et d’écoute des jeunes et adolescents et des centres de rééducation fonctionnelle. A travers cette action, on renforcera le service national d’hygiène scolaire et universitaire en créant progressivement des services régionaux dans les 23 régions pour mettre en œuvre un paquet de services défini.

Once adolescent health policies, plans, and standards are in place, the next objective is to strengthen the capacities of health personnel to provide services to young people and adolescents:

Action 22.1.3 : Renforcer les capacités du personnel de santé dans la prise en charge des problèmes de santé des adolescents, des jeunes, des personnes âgées et des personnes handicapées.

Une fois les politiques, plans stratégiques et normes relatives à la santé des adolescents, des jeunes, des personnes âgées et des personnes handicapées, élaborés et adoptés, le personnel de santé sera formé à tous les niveaux de la prise en charge et les formations sanitaires équipées conséquemment pour assurer une prise en charge efficace des problèmes de santé de ces catégories de la population. Ce renforcement des capacités devra se traduire entre autres par la prise en compte des interventions relatives à la santé des adolescents, des jeunes, des personnes âgées et des personnes handicapées, dans les plans opérationnels annuels.

The “Plan national” acknowledges that the availability of FP services in the country is high, but facilities have low operational capacity. To remedy this problem, the “Plan national” proposes an intervention to train health personnel in counseling to better present methods of contraception and their side effects and ensure that the FP guidance is included in medical training at all levels:

La disponibilité des services de PF est assez élevée, mais leur capacité opérationnelle est faible. Pour pallier à cette situation, le personnel de santé sera formé en conseil afin de mieux présenter les différentes méthodes de contraception et les effets indésirables. Les directives relatives à la PF MSP - Plan National de Développement Sanitaire : PNDS3 2018-2021 - Tchad seront mises à disposition des formations médicales de tous les niveaux. L’approvisionnement régulier des intrants de la PF sera assuré.

The reviewed policy documents recognize Chad’s nascent status in youth-friendly FP service provision. By guaranteeing the right to affordable FP services and acknowledging the need to train providers to provide services to youth, Chad has a promising but insufficient policy environment. To move to a fully supportive policy environment, policies should link provider training to issues of judgement and ensure confidentiality and audio/visual privacy for youth accessing FP services. Chad is placed in the yellow category for this indicator.

The “Plan d’actions quinquennal de mise en œuvre de la politique nationale genre, 2019-2023” acknowledges the gender inequities that affect women’s control over reproductive health decisions. The policy reinforces the right to health—including reproductive health—as a guiding principle. One of the action plan’s strategic objectives is to reduce gender inequities in access to basic social services and limit traditional practices that hamper young people’s access to sexual and reproductive health care:

Dans ce cadre des actions de plaidoyer, de sensibilisation et de renforcement des capacités sont à développer à l’échelle de l’ensemble des provinces. Par ailleurs il est retenu de promouvoir des initiatives visant à satisfaire les besoins spécifiques de filles et des garçons, des hommes et des femmes dans le secteur de l’éducation, de la formation et de l’alphabétisation, ce ci de manière à créer des conditions favorables de maintien et de succès des filles, au même titre que les garçons dans le système scolaire formel et les femmes au même titre que les hommes dans l’éducation non formelle et l’alphabétisation. Par ailleurs il s’agira de contribuer à l’amélioration de la Santé de la Reproduction et à la réduction de la mortalité maternelle et néonatale de manière à assurer aux hommes et aux femmes des services de santé de la reproduction de qualité de façon à réduire significativement les risques de mortalité liée à la maternité et à permettre à chacune et à chacun d’avoir une vie saine et responsable.

The first action under this objective to reach equal and equitable access to basic social services is to eliminate harmful traditional practices through education of girls and boys:

Act 3.1.1: Rendre sensible au genre le Plan, les Stratégies et programmes d’éducation formelle et non formelle, de formation professionnelle et d'alphabétisation intègrent les questions de genre et favorise la réduction des inégalités entre filles et garçons

The second action under this objective is to contribute to improving reproductive health and reducing maternal morbidity:

Act 3.2.2: Concevoir et mettre en oeuvre des stratégies nationales et notamment provinciales de lutte contre la mortalité maternelle et néonatale en vue de l'accès effective des femmes, des adolescentes et des jeunes à des services de santé sexuelle et reproductive de qualité

While the “Plan d’actions” acknowledges gender and social norms within reproductive health and proposes actions, it does not specifically target interventions around youth family planning. For Chad to create an environment that is fully supportive of youth FP, new policies should specifically outline a strategy to link service delivery with activities that build support for youth FP in communities and link gender strategies to youth FP. Chad is placed in the gray category for this indicator.

The “Plan d’action national budgétisé de planification familiale, 2015-2020” explains that provider and parental judgment toward adolescents, particularly unmarried adolescents, is a barrier to accessing FP services:

Quant aux adolescents et jeunes non en union, ils craignent de rencontrer leurs parents et d’autres adultes dans les points d’accès à la PF et jugent que leur utilisation de la PF est mal perçue par les prestataires qui préfèrent offrir les méthodes uniquement aux femmes en union.

Côte d’Ivoire’s policy environment, however, does not adequately prohibit parental and spousal consent. Côte d’Ivoire should consider addressing these forms of external authorization unequivocally in future legislation but is now placed in the gray category for this indicator.

The “Standards des services de santé adaptés aux adolescents et aux jeunes en Côte d’Ivoire, n.d.,” which include contraception in the minimum package of services, emphasize the importance of providers having adequate skills and attitudes for youth-friendly service provision:

Standard II : Tous les prestataires du PPS [points de prestations de service] ont les connaissances, les aptitudes et les attitudes requises pour offrir des services adaptés aux besoins des A&J [adolescent et jeune].
Raisons - d’être :

• Les A&J déplorent le mauvais accueil, la stigmatisation et la discrimination dont ils font l’objet lorsqu’ils désirent les services de santé de la reproduction ;
• Les prestataires des PPS n’ont pas souvent la formation requise pour offrir des services adaptés aux besoins des A&J au cours de leur formation de base.

Because the “Standards des services” say definitively that providers must have an attitude void of stigma and discrimination, Côte d’Ivoire is placed in the green category for this indicator.

The “Document de politique nationale de la santé de la reproduction et de planification familiale (2ème édition), 2008” guarantees equitable access to sexual and reproductive health (SRH) care regardless of age:

Au regard de ces droits, la politique nationale de la SSR [santé sexuelle et reproductive] exige l’accès équitable à l’information et aux soins sans distinction de sexe, d’âge, de race, d’ethnie, de religion, de région, de classe sociale. Elle insiste également sur le droit pour tout individu de décider librement, de façon éclairée, de sa sexualité et de sa reproduction.

Dans cette optique, la présente déclaration de politique nationale de la santé de la reproduction repose sur des valeurs essentielles suivantes : la solidarité, l’équité, l’éthique et le respect de la spécificité du genre.

The “Politique nationale de population, 2015” includes a specific objective to empower women, which will be achieved through promoting universal access to SRH care for women, girls, and young people:

Objectif général 4
Assurer l’autonomisation de la femme et l’équité de genre

Objectif spécifique 4.1
Réduire les inégalités de genre et les violences basées sur le genre

Pour ce faire, il faut : défendre l’accès universel à la santé sexuelle et reproductive, en particulier pour les femmes, les filles et les jeunes, y compris pendant les périodes de conflits et de situations d’urgence.

Because these policies address access to family planning services regardless of age, Côte d’Ivoire is placed in the green category for this indicator.

The “Plan d’action national budgétisé de planification familiale, 2015-2020” explains that provider and parental judgment toward adolescents, particularly unmarried adolescents, is a barrier to accessing FP services:

Quant aux adolescents et jeunes non en union, ils craignent de rencontrer leurs parents et d’autres adultes dans les points d’accès à la PF et jugent que leur utilisation de la PF est mal perçue par les prestataires qui préfèrent offrir les méthodes uniquement aux femmes en union.

The “Programme d'orientation sur la santé des adolescents destiné aux prestataires de soins de santé, 2006,” a World Health Organization training document officially adopted by the National Program for School and University Health in the Ministry of Health and Public Hygiene for training providers in youth-friendly services, includes guidance on providing contraceptive services to unmarried youth:

Adolescentes non mariées

 ...

Les adolescentes, surtout celles qui ont une relation exclusive, peuvent également souhaiter utiliser d’autres méthodes plus durables [que les préservatifs]. Les prestataires de services de contraception doivent soutenir cette décision.

Because a policy exists that supports youth access to FP for unmarried adolescents, Côte d’Ivoire is placed in the green category for this indicator.

The “Plan stratégique national de la santé des adolescents et des jeunes, 2016-2020” describes the minimum package of services for adolescents, which includes contraception but does not specify which methods should be made available.

The “Programme d'orientation sur la santé des adolescents destiné aux prestataires de soins de santé, 2006” includes eligibility criteria for all contraceptive methods. However, this document represents outdated World Health Organization (WHO) medical eligibility criteria for intrauterine devices (IUDs) and implants. It includes restrictions for IUDs based on age and parity:

Méthode déconseillée aux moins de 20 ans en raison d’un grand risque d’expulsion chez les plus jeunes femmes nullipares

 It also includes restrictions for progestin-only injectables based on age:

Méthode déconseillée aux moins de 18 ans en raison d’un trouble possible du développement osseux

For Côte d’Ivoire to move into the green category, it must adopt the updated WHO medical eligibility criteria (2015), which state that these methods are generally safe for youth and nulliparous women and that the benefits of using the methods outweigh any potential risks. As it is currently written, the “Programme d'orientation” discourages providers from providing these methods to youth who fall within the above-mentioned restrictions, rather than clarifying that they are generally safe for young women regardless of age and parity.

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, note that the Programme d'orientation also includes EC in the list of methods.

The “Programme national de l’education sexuelle compléte de Côte d’Ivoire, 2016-2020” describes the country’s comprehensive sexuality education (CSE) program, which includes all nine of the essential United Nations Population Fund (UNFPA) components of CSE.

For example, the CSE program includes an integrated focus on gender through which youth learn about the role of gender norms in society and the impact of gender norms on sexual and reproductive health (SRH):

1. Genre

Promouvoir l’égalité de genre est un impératif moral. Cette unité aborde efficacement la question du genre, pour les filles comme pour les garçons. Elle décrit le jeu des normes de genre dans la société (dans les relations familiales, à l’école, dans l’expérience de la violence, dans les médias et ailleurs) et explique l’effet des rôles de genre sur la sexualité et la santé sexuelle.

The CSE program also includes components on improving communication skills and decision-making in SRH:

2. Relations interpersonnelles et communication

Cette composante explique les relations et les liens avec les membres de la famille, les amis, les voisins, les connaissances, le ou la petit(e) ami(e), ses enseignants, ses camarades, etc. Le but de cette composante est d’aider les adolescent(e)s à mieux comprendre leurs relations et à les aborder avec plus de confiance.

 3. Valeurs et attitudes

Les jeunes aiment apprendre comment parler de sujets intimes sans gêne et avec confiance. Il s’agit dans cette unité de mettre l’accent sur les attitudes et les valeurs telles que le Respect de soi et d’autrui, l’Estime de soi, la prise de décisions qui permettent aux adolescents et aux jeunes d’être confiant en leurs capacités afin de bénéficier d’une meilleure santé et préparer un avenir radieux.

The CSE program aims to reach youth in and out of school with information that is culturally and age appropriate:

Fournir des conseils aux acteurs concernés sur la manière d’élaborer des matériels et des programmes d’éducation sexuelle conçus pour répondre aux besoins, culturellement pertinents et adaptés à l’âge des bénéficiaires.

…Renforcer les capacités des acteurs de l’éducation formelle et non formelle

Cette stratégie nécessite l’organisation d’ateliers de renforcement des capacités de la communauté éducative et des partenaires sociaux.

The “Plan accéléré de réduction des grossesses à l'ecole, 2013-2015 - campagne zéro grossesse à l'école en Côte d’Ivoire” which lays the groundwork for the “Programme national,” provides a clear link between sexuality education and gender norms by focusing on empowering girls to stay in school and manage their SRH needs. It also has a strong emphasis on linking sexuality education with youth-friendly services.

In addition to these programs, Côte d’Ivoire plans to publish extensive teaching aids and materials on SRH topics such as early pregnancy and parent-child communication on SRH; contraception and youth rights in SRH; gender-based violence and early marriages; and sexually transmitted infections and HIV/AIDS. The materials will be published for four groups: teacher trainees and primary-school, secondary-school, and college students.

Côte d’Ivoire has a strong policy environment for CSE, including reference to all nine of the United Nations Population Fund’s (UNFPA’s) essential components of CSE, and is placed in the green category for this indicator.

The “Politique nationale de population, 2015” includes a strategy to develop and expand youth-friendly sexual and reproductive health (SRH) services, and the “Plan stratégique de la planification familiale, 2012-2016” includes an activity to develop standards for youth SRH services.

The “Plan stratégique national de la santé des adolescents et des jeunes, 2016-2020” discusses training providers in youth-friendly services, including SRH services. The “Plan stratégique de la planification familiale” includes specific activities to establish youth-friendly FP services, including training providers. The “Plan d’action national budgétisé de planification familiale, 2015-2020” acknowledges that adolescents and young people face provider judgment and includes specific activities to develop training manuals, train and supervise providers, and evaluate the performance of centers offering youth-friendly services:

 3.1- Défis en matière de demande des services de PF

Quant aux adolescents et jeunes non en union, ils craignent de rencontrer leurs parents et d’autres adultes dans les points d’accès à la PF et jugent que leur utilisation de la PF est mal perçue par les prestataires qui préfèrent offrir les méthodes uniquement aux femmes en union. Ils ont un faible leadership et sont faiblement impliqués dans les décisions qui concernent leur avenir...

Activité O3.1: Formation des prestataires de 25% des FS [formation sanitaire] pour offrir des services de PF adaptés aux adolescents et jeunes

• Elaboration/Adaptation des manuels de formation en prise en charge des jeunes et adolescents dans les FS offrant la PF;
• Recensement chaque année de 250 FS appropriées pour la prise en charge des adolescents et jeunes;
• Organisation annuelle de 10 sessions de formation de 5 jours de 25 prestataires en prise en charge des jeunes au niveau des chefs-lieux de régions;
• Suivi des activités de formation dans les régions;
• Renforcement de l’équipement des FS pour attirer plus d’adolescents et jeunes;
• Aménagement des services (espace horaire, activités, etc.…) pour prendre en compte les besoins des jeunes;
• Supervision des prestations offertes par les prestataires formés;
• Evaluation de la performance des centres offrant des services aux jeunes.

The “Standards des services de santé adaptés aux adolescents et aux jeunes en Côte d’Ivoire, n.d.” include activities to train providers to have an attitude free of stigma and discrimination when providing youth friendly services:

Standard II : Tous les prestataires du PPS [points de prestations de service] ont les connaissances, les aptitudes et les attitudes requises pour offrir des services adaptés aux besoins des A&J [adolescent et jeune].

Raisons - d’être :

- Les A&J déplorent le mauvais accueil, la stigmatisation et la discrimination dont ils font l’objet lorsqu’ils désirent les services de santé de la reproduction ;

- Les prestataires des PPS n’ont pas souvent la formation requise pour offrir des services adaptés aux besoins des A&J au cours de leur formation de base.

The “Standards des services” also describe the right of youth to privacy and confidentiality when accessing services. The “Plan stratégique de la planification familiale” and the “Plan stratégique de la santé de la reproduction, 2010-2014” include the same activity to advocate for reduced costs for youth SRH services:

Organiser des activités de plaidoyer en direction du gouvernement pour la réduction des coûts des soins de santé sexuelle et reproductive de tous les adolescents et jeunes dans tous les établissements sanitaires.

Côte d’Ivoire’s policy environment is strong in that it addresses all three elements for youth-friendly services. Côte d’Ivoire is placed in the green category for this indicator.

The “Plan stratégique de la santé de la reproduction, 2010-2014” offers a strategy to strengthen the capacity of communities to address youth sexual and reproductive health issues:

Stratégie 3 : Renforcement des capacités des individus, des ménages et des communautés en matière de SR [santé reproductive] des adolescents et des jeunes

Interventions prioritaires

1. Développer et mettre en œuvre un plan de communication sur la santé sexuelle et reproductive des adolescents et jeunes.

2. Renforcer la capacité des relais communautaires sur la santé sexuelle et reproductive des adolescents et jeunes.

The “Stratégie nationale de développement basée sur la réalisation de l'OMD version 4, 2007-2015” describes plans for community awareness campaigns that focus on reducing pregnancies among girls in school and contain information on contraceptive methods:

En outre, des campagnes de sensibilisation média et communautaires sur la santé sexuelle et de la reproduction seront menées pour réduire les taux d’abandons des filles liés aux grossesses et accouchements précoces. Ces campagnes devront mettre en relief les inconvénients de la précocité de la vie sexuelle et des comportements sexuels à risque, les méthodes contraceptives, etc.

The “Plan national de développement, 2016-2020” notes that improved FP use depends on empowering women and ensuring schooling for girls:

Les effets escomptés à terme à travers la réalisation de la « révolution contraceptive », ne seront perceptibles que si des progrès notables sont réalisés dans la scolarisation et en particulier la scolarisation des jeunes filles et l’autonomisation de la femme. Ainsi, il sera question à ce niveau, de garantir un meilleur accès à l’éducation pour toutes les jeunes filles et de favoriser l’autonomisation de la femme à travers des activités génératrices de revenu.

The “Politique nationale de population, 2015” includes a specific objective to promote universal access to sexual and reproductive health for women and girls:

Objectif général 4 Assurer l’autonomisation de la femme et l’équité de genre

Objectif spécifique 4.1 Réduire les inégalités de genre et les violences basées sur le genre

Pour ce faire, il faut : défendre l‟accès universel à la santé sexuelle et reproductive, en particulier pour les femmes, les filles et les jeunes, y compris pendant les périodes de conflits et de situations d’urgence ;

The "Protocole des services de la santé de la reproduction, n.d." also discusses involving parents, communities, and educators in awareness-raising activities on the sexual and reproductive health of adolescents and young people.

Because Côte d’Ivoire’s policies provide specific intervention activities for building community support for youth FP services and address gender norms, the country is placed in the green category for this indicator.

The “Codes larcier de la République démocratique du Congo, tome I droit civil et judiciaire, 2003” give husbands full control over the legal rights of married women:

Art. 444. — Le mari est le chef du ménage. Il doit protection à sa femme ; la femme doit obéissance à son mari.

Art. 448. — La femme doit obtenir l’autorisation de son mari pour tous les actes juridiques dans lesquels elle s’oblige à une prestation qu’elle doit effectuer en personne.

Art. 450. — Sauf les exceptions ci-après et celles prévues par le régime matrimonial, la femme ne peut ester en justice en matière civile, acquérir, aliéner ou s’obliger sans l’autorisation de son mari. Si le mari refuse d’autoriser sa femme, le tribunal de paix peut donner l’autorisation. L’autorisation du mari peut être générale, mais il conserve toujours le droit de la révoquer.

In 2018, the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa, originally adopted by the African Union in 2003 and also known as the Maputo Protocol, was published in the Journal Officiel de la République Démocratique du Congo as "Loi n° 06/015 du 12 juin 2006 autorisant l’adhésion de la République démocratique du Congo au Protocole à la Charte Africaine des droits de l’homme et des peuples, relatif aux droits de la femme en Afrique.” The “Loi n° 06/015”  gives women the right to exercise control over their fertility, including the number of children they have and the spacing of births.

Article 14 : Droit à la santé et au contrôle des fonctions de reproduction. 

1. Les États assurent le respect et la promotion des droits de la femme à la santé, y compris la santé sexuelle et reproductive. Ces droits comprennent :

a) le droit d’exercer un contrôle sur leur fécondité ;

b) le droit de décider de leur maternité, du nombre d’enfants et de l’espacement des naissances;

c) le libre choix des méthodes de contraception ;

d) le droit de se protéger et d’être protégées contre les infections sexuellement transmissibles, y compris le VIH/SIDA ;

e) le droit d’être informées de leur état de santé et de l’état de santé de leur partenaire, en particulier en cas d’infections sexuellement transmissibles, y compris le VIH/SIDA, conformément aux normes et aux pratiques internationalement reconnues ;

f) le droit à l’éducation sur la planification familiale.

DRC’s public health law, the "Loi n°18/035 du 13 décembre 2018 fixant les principes fondamentaux relatifs à l’organisation de la santé publique,” legally protects a woman’s ability to choose to use family planning even if her spouse objects.

Article 82 :

Pour les personnes légalement mariées, le consentement des deux conjoints sur la méthode contraceptive est requis.

En cas de désaccord entre les conjoints sur la méthode contraceptive à utiliser, la volonté du conjoint concerné prime.

Article 84 :

Les conjoints ont le droit de discuter librement et avec discernement du nombre de leurs enfants, de l’espacement de leurs naissances et de disposer des informations nécessaires pour ce fair. En cas de désaccord, la volonté de la femme prime.

While spousal consent is required for contraceptive use, the will of the individual seeking contraception is considered supreme in the case of a disagreement. Similarly, the law encourages spousal discussions on the number of children and spacing of births but, in the case of a disagreement, the woman’s will is supreme.

The “Politique nationale santé de l’adolescent, 2013”  states that the provision of contraceptives to youth is subject to parental consent, which providers must respect. At the same time, somewhat contradictorily, the “Politique nationale” encourages providers to support the self-determination of youth to use reproductive health services. This language does not define the circumstances when parental consent is warranted:

2. La prestation des méthodes contraceptives chez les jeunes doit être subordonnée le cas échéant par le consentement des parents et l’agent de santé est tenu à se plier à cette obligation dans le respect des principes d’administration et d’éthique de ces méthodes. Par contre, il faut recommander l’achat des préservatifs à la pharmacie et les milieux appropriés et les pilules dans un centre de santé.

3. Les prestataires doivent soutenir l’auto-détermination et le libre choix des adolescents à utiliser les services de santé de la reproduction dans le respect de leur dignité et de leur diversité d’opinion ou de culture.

More recently, however, the “Democratic Republic of the Congo Family Planning National Multisectoral Strategic Plan, 2014-2020” includes an activity to:

Create a law favorable to family planning, to protect minors and adolescents, and to promote gender.

Recent legal changes, most notably the 2018 public health law, are very promising and have removed the requirement for spousal consent as a barrier. However, because parental consent for youth’s use of contraception is still permitted under the “Politique nationale”, DRC is placed in the yellow category for this indicator. The country has the potential to move into the green category if future laws are enacted that explicitly prohibit parental consent in all cases.

The  “Normes de la zone de santé relatives aux interventions intégrées de santé de la mère, du nouveau-né et de l’enfant en République démocratique du Congo : Interventions de santé adaptées aux adolescents et jeunes, 2012” detail how providers in health centers should interact with youth when discussing sexual and reproductive health. Providers should ensure confidentiality; use friendly, clear, and respectful communication; avoid judgment; recognize stigma experienced by sexually active youth; and ensure youths’ autonomy in decision-making:

3° Réserver un accueil chaleureux et une communication sympathique à l’adolescent et au jeune.

• Aménager des espaces / environnement sûr et favorable à l’entretien.
• Préserver la confidentialité et l’intimité des adolescents et jeunes.
• Adopter des attitudes attrayantes :
• Se montrer ouvert et accessible ;
• Adopter un ton doux et rassurant ;
• Faire attention à votre attitude (geste, mimique, réaction d’étonnement, de réprobation, de condamnation).
• Traiter les adolescents et jeunes avec courtoisie (saluer avec respect et sympathie, offrir le siège, se présenter).
• User de patience (un certain temps peut être nécessaire pour que les adolescents et jeunes qui ont des besoins particuliers fassent part de leurs problèmes ou prennent une décision).
• Laisser parler l’adolescent ou le jeune sans l’interrompre.
• Eviter de porter de jugement.
• Faire preuve de compréhension quant aux difficultés que les adolescents et jeunes éprouvent à parler de sujets touchant à la sexualité (peur que les parents le découvrent, réprobation des adultes et de la société).

While this policy explicitly states that providers must be nonjudgmental, open, and respectful, it is within the context of youth-friendly services and does not clearly address provider authorization in youth family planning. DRC is placed in the gray category for this indicator.

The “Loi n°18/035 du 13 décembre 2018 fixant les principes fondamentaux relatifs à l’organisation de la santé publique” states that any person of reproductive age can access contraceptives.

Article 81 :

Toute personne en âge de procréer peut bénéficier après avoir été éclairé, d'une méthode de contraception réversible ou irréversible sur consentement libre. En cas de contraception irréversible, le consentement est écrit, après avis de trois médecins, et du psychiatre.

Because the public health law addresses access to contraception regardless of age, DRC is placed in the green category for this indicator.

While the “Loi n°18/035 du 13 décembre 2018 fixant les principes fondamentaux relatifs à l’organisation de la santé publique” recognizes that people of any reproductive age can access contraceptives, it does not explicitly recognize marital status as a criterion for provision or refusal of FP services. Providers and clients may differently interpret this aspect of the law, potentially creating a barrier for youth who want to access contraception. To strengthen the eligibility criteria, the guideline’s eligibility statement should specifically recognize segmented parts of the population, such as married and unmarried youth. Because no policy exists addressing marital status in access to FP services, DRC is placed in the gray category for this indicator.

While the “Politique nationale santé de l’adolescent, 2013” states that contraceptive methods beyond the preferred method of abstinence must be made available to youth, it only references pills and condoms. The related document, “Paquet d’activités PNSA dans la zone de santé,” describes plans for FP activities that include youth-friendly contraceptive methods, rather than explicitly including a full range of methods.

The “Standards des services de santé adaptés aux adolescents et jeunes, 2014” describe the minimum package of youth-friendly services available at each level of the health system, including the community level. The policy emphasizes providing youth with information on reproductive health, rather than providing them with contraception. One exception is the distribution of oral contraception and condoms to youth, which is included in the minimum package of services at the community level.

The “Plan national de développement sanitaire recardré pour la période 2019-2022 : vers la couverture sanitaire universelle" defines the complete list of interventions included in the service package for mothers, children, and adolescents. The list of family planning commodities is exhaustive, ranging from short-term methods to permanent methods, but it identifies the target audience as women of reproductive age who are in union and provides no further language around eligibility.

The “Interventions de santé adaptées aux adolescents et jeunes 2012” encourage condom and contraceptive distribution at the community level and indicate in general terms that youth should be informed about how to prevent unwanted pregnancy in visits to health centers. This policy does not describe providing youth with a full range of contraceptive methods.

Unlike some DRC policies, the “Loi n°18/035 du 13 décembre 2018 fixant les principes fondamentaux relatifs à l’organisation de la santé publique” specifically states that anyone of reproductive age can benefit from both reversible and irreversible contraceptives. Furthermore, the “Loi n° 06/015 du 12 juin 2006 autorisant l’adhésion de la République démocratique du Congo au Protocole à la Charte Africaine des droits de l’homme et des peuples, relatif aux droits de la femme en Afrique" binds DRC to the Maputo Protocol, acknowledges a woman’s right to choose any method of contraception.

However, neither policy explicitly mentions youth’s legal right to access a full range of contraception, including long-acting and reversible contraceptives. As DRC does not have a policy extending access to a full range of methods for youth, it is placed in the gray category for this indicator.

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, no polices reviewed specifically address youth access to EC.

The “Politique nationale santé de l’adolescent, 2013” acknowledges the importance of sexuality education and places emphasis on involving youth, parents, schools, and communities. It does not describe any details or components of what a comprehensive sexuality education (CSE) program should include.

The “Democratic Republic of the Congo Family Planning National Multisectoral Strategic Plan, 2014-2020” identifies poor integration of CSE in primary and secondary schools as a key FP demand-generation problem. To address this concern, the strategic plan includes CSE activities to increase demand for FP services among youth:

Integrate Family Planning in the curriculum of secondary schools, higher education and universities and train teachers in comprehensive sexual education for youth and adolescents.

The “Plan stratégique national de la santé et du bien-être des adolescents et des jeunes, 2016-2020” incorporates a priority focus on activities that support behavior change through CSE in and out of schools:

Les interventions de santé en faveur des adolescents et des jeunes reposent sur la communication pour le changement de comportement soutenue par l’offre des services de prévention. Il s’agit de : l’éducation complète sur la santé reproductive et sexuelle en milieu scolaire et parascolaire. 

The "Plan stratégique" also includes several activities that contribute to CSE, including promoting the core universal value of human rights for adolescents and young people and the provision of safe and healthy learning environments:

Les objectifs spécifiques assignés à ce Plan sont les suivants :

Améliorer le niveau de connaissance et les compétences des adolescents et jeunes sur leurs problèmes spécifiques de santé y compris leurs droits.

D’ici 2020 au moins 50% des adolescents et jeunes adoptent des attitudes et compétences favorables au respect de leurs droits dans les 258 zones. 

D’ici 2020, 890 espaces d'information et communication pour jeunes sont créés dans les 178 zones supplémentaires.

Au moins 50% d’adolescents et jeunes participent aux activités récréatives et socio-éducatives dans les 258 zones d’ici 2020.

The reference to CSE in these strategic plans indicates that the policy environment is promising toward its implementation. However, additional guidelines, in line with the nine United Nations Population Fund (UNFPA) essential components, are necessary to inform the delivery of CSE. The DRC is placed in the yellow category for this indicator.

The policy environment in DRC recognizes the need for youth-friendly FP service provision. The “Democratic Republic of the Congo Family Planning National Multisectoral Strategic Plan, 2014-2020” includes the following activity:

Extend integrated youth-friendly services to all health zones.

Further, the “Plan stratégique national de la santé et du bien-etre des adolescents et des jeunes, 2016-2020” references the provision of youth-friendly services and presents plans for how the country aims to adapt the health system to better meet the needs of adolescent and youth. For example, the "Plan stratégique” explicitly states the importance of having trained staff capable of offering youth services, setting up spaces suitable for young people, and providing contraceptives (defined only as male and female condoms) to this age group.

Ce système devra particulièrement disposer d’un personnel compétent et apte à offrir les soins de santé spécifiques à ce groupe, supprimer le plus possible les barrières à cette cible sans ressources conséquentes, aménager au sein des établissements de soins les espaces d'information et communication pour jeunes, fournir régulièrement les médicaments y compris les contraceptifs et autres intrants (préservatifs féminins et masculins, etc.). 

The “Standards des services de santé adaptés aux adolescents et jeunes, 2014” recognize the rights of adolescents to quality and confidential health services. These services include distribution of oral contraception and condoms. The “Standards des services” include plans for training providers in youth-friendly services, including having the right attitude, and measuring youth satisfaction with these services:

Standard 3 : Tout prestataire de service a les connaissances, les attitudes et les compétences requises lui permettant d’offrir aux adolescents et aux jeunes des services et soins de santé de manière efficace, efficiente et conviviale.

The “Politique nationale santé de l’adolescent, 2013” describes training providers and ensuring confidentiality in the broader context of adolescent health. However, the policy does not mention plans to offer free or subsidized contraceptive provision to young people. The “Plan stratégique” encourages use of a discount for “care of adolescents and young people,” but makes no explicit provision for offering contraceptive products or services at no cost or at subsidized costs.

Therefore, the policy environment is understood to be promising but incomplete, and DRC is placed in the yellow category for FP service provision. When expanding youth-friendly service protocols, policymakers should consider including all three service-delivery elements to improve adolescent and youth uptake of contraception.

DRC’s policy environment recognizes building community support for FP. The “Democratic Republic of the Congo Family Planning National Multisectoral Strategic Plan, 2014-2020” includes an activity to mobilize the community surrounding FP. However, the activity is not specific to youth FP.

The “Paquet d’Activités PNSA dans la zone de santé” that accompanies the “Politique nationale santé de l’adolescent, 2013” broadly outlines activities for building community support for youth health in general, such as advocacy aimed at community leaders and community-outreach activities using multimedia/mass media platforms. However, these activities are not specific to building support for youth access to contraception.

The “Plan stratégique national de la santé et du bien-etre des adolescents et des jeunes, 2016-2020” has as one of its chief priorities the need to promote the health of young people through empowering communities to find solutions to problems affecting adolescent health:

La promotion de la santé des jeunes doit viser notamment la responsabilisation des communautés de base dans la recherche des solutions sur les problèmes affectant la santé des adolescents.

While there is no explicit reference to community support for youth FP services, there is a strategic focus on community mobilization for the promotion of adolescent and youth health, including HIV services, comprehensive sexual and reproductive health education, promotion and availability of condoms, and strengthening the provision of services at the community level:

Axe stratégique 1 : Communication stratégique et mobilisation communautaire pour la promotion de la santé des adolescents et des jeunes

Les interventions de santé en faveur des adolescents et des jeunes reposent… Il s’agit de : (i) services de conseil et dépistage volontaire sur le VIH, (ii) l’éducation complète sur la santé reproductive et sexuelle, (iii) la promotion et la disponibilité des préservatifs, (iv) la promotion de la prophylaxie post exposition (en cas de viols), (v) la prévention des violences, ainsi que (vi) le renforcement du système communautaire en synergies avec les secteurs nationaux clés et de la société civile à fournir des services.

The policy environment aims to build community support for youth sexual and reproductive health education and access to condoms but does not reference building community support for youth access to FP services that include a broader range of contraceptive methods. The “Politique nationale ” mentions gender, primarily related to gender-based violence, in the context of adolescent health broadly. Because DRC does not include specific interventions related to building an enabling social environment, the country is placed in the yellow category for this indicator.

The “National Adolescent and Youth Health Strategy, 2016-2020” refers to a prohibition against third-party consent requirements for youth seeking contraception:

A law permits adolescents and youth to use contraceptives without third party consent.

However, this law is not identified by name and could not be located. The “National Guideline for Family Planning Services in Ethiopia, 2020” notes that adolescents should receive services without needing to obtain parental consent:

…it should be clear that adolescents get service without mandatory parental and guardian authorization/notification. Similarly, “for a woman to get FP services no third-party authorization is required including spousal approval” and providers should affirm that individual decision respected.

Ethiopia’s policies support access to family planning services without parental consent and spousal consent and the country is therefore placed in the green category for this indicator.

Ethiopian policy documents acknowledge the rights of youth to receive family planning services, and the barrier that provider bias can pose. The “National Adolescent and Youth Health Strategy, 2016-2020” states: 

When adolescents and youth attempt to utilize services, they encounter unfriendly environments including breaches in confidentiality, judgmental and disapproving attitudes relating to sexual activity and substance use, and discrimination. This results in failure to provide important services and increase[s] the vulnerability of particular groups.

The policy also outlines multiple priority actions to promote supportive attitudes by providers:

• Build the capacity of health providers to manage and provide AYFHS [adolescent and youth-friendly health services] with a compassionate, respectful and caring manner
• Promote supportive attitudes and behavior by health workers to better engage adolescents and youth in health care services and programs

While these statements are a positive step, the Strategy does not explicitly instruct providers to offer youth-friendly services without judgment or bias. However, the “Standards on Youth Friendly Reproductive Health Services & Minimum Service Delivery Package on YFRH Services: Service Delivery Guideline, n.d.,” which includes FP as part of the youth-friendly service package, mandates that services be provided in adherence with the World Health Organization definitions of adolescent-friendly health services, including:

Adolescent friendly health care providers who…are non-judgmental and considerate[,] easy to relate to and trust worthy.

The “National Guideline for Family Planning Services in Ethiopia, 2020” similarly acknowledges that health professionals must provide unbiased services:

Clients also have the right to access the broadest range of contraceptives to choose and change when they need or encounter any side effects from an earlier method. Health professionals should provide an unbiased counseling service to ensure full, free and informed choice to ensure method mix.

…

In this context, it should be clear that adolescents get service without mandatory parental and guardian authorization/notification. Similarly, “for a woman to get FP services no third-party authorization is required including spousal approval” and providers should affirm that individual decision respected.

Ethiopia is placed in the green category for this indicator because the policy environment includes provisions discouraging provider judgement or discrimination.

Policies reviewed thoroughly address youth’s right to access FP services, regardless of age.

The “National Guideline for Family Planning Services in Ethiopia, 2020” recognizes a rights-based approach that allows clients to choose the method that is most convenient to them, regardless of age, going as far to direct providers that “if a client is [an] adolescent, use the counseling card to inform [them] that [they] can get any method.” The guideline also underscores  the right to access FP services without discrimination based on age or other nonmedical criteria:

Equity and non-discrimination: Individuals have the ability to access comprehensive contraceptive services free from discrimination, coercion and violence. FP services should not vary by non-medically indicated characteristics, such as age, geography, language, ethnicity, disability, HIV status, income, and marital or other status.

Similarly, the “Standards on Youth Friendly Reproductive Health Services & Minimum Service Delivery Package on YFRH Services: Service Delivery Guideline, n.d.” explicitly prohibit age from consideration:

Any person male or female who can conceive or cause conception regardless of age or marital status is eligible for family planning services including family planning counseling and advice.

Based on these inclusions, Ethiopia is placed in the green category for this indicator. Policy documents directly recognize the rights of young people to receive FP services.

The “National Guideline for Family Planning Services in Ethiopia, 2020” includes language acknowledging the right to access FP services regardless of marital status:

Equity and non-discrimination: Individuals have the ability to access comprehensive contraceptive services free from discrimination, coercion and violence. FP services should not vary by non-medically indicated characteristics, such as age, geography, language, ethnicity, disability, HIV status, income, and marital or other status.

The guidelines also recognize the unique context of adolescents and youth seeking family planning and confirm that services need to be accessed regardless of marital status:

Unmarried and married youth may have different sexual, FP, and other SRH needs. FP services can create an opportunity to discuss STIs, HIV, GBV, and other SRH issues. Because of ignorance and psychological and emotional immaturity, adolescents and youths’ compliance with the use of FP methods may not be optimal. In light of these facts, FP services need to be adolescent and youth-friendly and be accessible irrespective of their age and marital status. This implies services to be unbiased, non-discriminatory, affordable, confidential, convenient, and comprehensive.

Ethiopia is placed in the green category for this indicator because relevant policies directly support married and unmarried youth receiving FP services.

Ethiopian policies support youth’s access to a full range of FP methods regardless of age and marital status. The “Standards on Youth Friendly Reproductive Health Services & Minimum Service Delivery Package on YFRH Services: Service Delivery Guideline, n.d.” state as an objective:

[T]o enable youth [to] have access to a range of contraceptive methods and information so that they would be able to decide on when and how they would be able to have children and get protected from unplanned pregnancy.

The Standards further affirm youth access to all contraceptive methods:

Ensure availability and accessibility of all types of modern contraceptives, including LARC [long-acting and reversible contraceptives], for adolescents and youth who are sexually active.

The “National Guideline for Family Planning Services in Ethiopia, 2020” confirms that the provision of contraceptive methods follows the most recent medical eligibility criteria established by the World Health Organization, which allows adolescents and youth to access to a full range of contraceptive methods, including long-acting reversible contraceptives, regardless of age, marital status, or parity.

Ethiopia is placed in the green category for this indicator.

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, it is worth noting that the policy environment in Ethiopia supports youth accessing EC. The “National Adolescent and Youth Health Strategy, 2016-2020” specifically mentions a priority intervention to distribute EC and the Standards also include it in the package of comprehensive sexual and reproductive health services to which youth should have access. 

The “National Adolescent and Youth Health Strategy, 2016-2020” includes a priority intervention related to “comprehensive life skills, family life and sexuality education” and a related target to increase access to comprehensive sexuality education (CSE) to 62.5% of adolescents and youth by 2020. Noting weaknesses in CSE implementation to date, the strategy identifies priority actions that touch on some of the United Nations Population Fund (UNFPA) essential components of CSE, including reaching out-of-school and vulnerable youth. However, several of the UNFPA essential elements of CSE, such as an integrated focus on gender and ensuring scientifically accurate sexual and reproductive health information, are not addressed in these priority actions.

The “School Health Program Framework, 2017” provides further guidance on the provision of sexuality education. The Program Framework includes sexual and reproductive health as one of its 10 packages:

Package 6: Sexual and reproductive health (SRH) services

Access to SRH services is a primary concern of adolescent and youth due to the sensitive nature and risk of sex and sexuality issues. In this package, age appropriate SRH information and education will be provided at each level of school. The provision of SRH services will be comprehensive and rights-based. Comprehensive SRH rights state that services should be voluntary, informed and affordable.

The major focus of the SRH package will occur in the 2nd cycle education and will focus on sexual health education and health behavior promotion, including information on delaying and abstaining sexual activity. …. At the secondary school level, students seeking HIV testing and sexually active students seeking contraceptive services like condoms, oral contraceptives (including emergency contraception), injectables, and implants will be referred to the nearby health facility.

The Program Framework mentions all nine UNFPA essential components either as guiding principles or within activities, but is limited in the breadth of instruction regarding sexuality, sexual behavior, and reproductive health.

Like the National Adolescent and Youth Health Strategy, other policies suggest additional emphasis will be placed on educating Ethiopian youth regarding FP. The “Costed Implementation Plan for Family Planning in Ethiopia, 2015/16-2020” incorporates an activity that seeks to work through the Ministry of Education to strengthen sexuality education:

MC1.4 Advocate with the MOE [Ministry of Education] to assess the capacity of schools to integrate SRH and family planning into the curriculum, including sexual education in the school health programme.

Moreover, the “Education Sector Development Programme V, 2015/16-2019/20” proposes revising the school curriculum by integrating life skills to increase awareness of sexual education:

The revision will address the needs of both males and females and will integrate life skills to increase awareness of issues such as HIV/AIDS, sexual education and DSA [drug and substance abuse], to help all students to lead safe and healthy lives. The curriculum revision will also pay attention to co-curricular activities and structures, to improve linkages and efficiency in the delivery of life skills training through formal and informal channels.

Ethiopia is placed in the yellow category for this indicator. Policies directly support providing some form of sexuality education and indicate that the development of a more robust curriculum is a priority for the country.

The policy environment in Ethiopia strongly supports the provision of youth-friendly FP services. Multiple policies reviewed incorporate youth-friendly FP services.

The “National Reproductive Health Strategy, 2016-2020” discusses the need for services to be tailored to meet the needs of youth. The Strategy outlines strategic interventions to increase access to sexual and reproductive health (SRH) information, education, and services, including provider training:

• Train health workers on adolescent-friendly health care to improve skills on providing quality adolescent and youth-friendly SRH information and services.
• Train the HEWs [health extension workers] on providing appropriate SRH information and services as per the standard.
• Develop and distribute job-aids for health workers including HEWs in all health facilities

To comprehensively address the range of health issues faced by youth in Ethiopia, the Ministry of Health broadened the scope of the most recent adolescent health policy, the “National Adolescent and Youth Health Strategy, 2016-2020.” SRH remains a key feature in this policy, which seeks to increase contraceptive prevalence among youth, reduce unmet need for modern contraception, and reduce unintended adolescent pregnancy.

The “Standards on Youth Friendly Reproductive Health Services & Minimum Service Delivery Package on YFRH Services: Service Delivery Guideline, n.d.” detail specific aspects of youth-friendly service delivery that align with the three elements of service delivery:

SRH services for the youth should be provided at an affordable cost or for those who can not pay for free.

Provision of very essential services like counseling, pregnancy and HIV testing, dispensing of different contraceptive methods should be carried out as much as possible by a single service provider or in an arrangement that ensures the privacy of the youth client.

Health workers are trained to provide services in a non-judgmental and friendly way.

The “National Guideline on Family Planning Services in Ethiopia, 2020” outlines the country’s rights-based approach to service delivery, which refers to an individual’s right to exercise control over their body, sexuality, and reproduction, including “the right to privacy and confidentiality.” The guideline also outlines the minimum standards of quality family planning services, including ongoing training of health care personnel, provision of services without bias or judgment, ensuring privacy and confidentiality in both space and provider-client relationships, and provision of contraceptives at an accessible cost.

All three service delivery elements of adolescent-friendly contraceptive service provision are recognized in the policies reviewed. Thus, Ethiopia is placed in the green category for this indicator.

The importance of building community support for youth FP services features in the priority interventions of Ethiopia’s “National Adolescent and Youth Health Strategy, 2016-2020":

• Leverage existing community health structures to provide adolescent and youth health information and age appropriate CSE [comprehensive sexuality education]- utilize the Health Extension Program involving Health Extension Workers and Health Development Army.
• Undertake community-based initiatives for demand creation through peers, health extension workers, counselors and others.
• Strengthen and engage community-based forums and faith-based organizations, including religious institutions, one-to-five networks, and community support groups, in improving adolescent health.
• Strengthen community involvement in prevention of early and unintended pregnancy.
• Promote education of parents and the community on the health and rights of adolescents and youth.

The Health Strategy recognizes gender inequalities and includes related priority actions:

• Mainstream gender and address its concerns in all adolescent and youth health programs.
• Empower adolescents to challenge gender stereotypes, discrimination and violence within peers/families, educational institutions, workplaces and public spaces.
• Assess and identify key structural forces that affect health and drive disparities, including gender-related structural and institutional biases across sectors.

Community support for youth sexual and reproductive health is featured in other documents, including the “Standards on Youth Friendly Reproductive Health Services & Minimum Service Delivery Package on YFRH Services: Service Delivery Guideline, n.d.” Ethiopia is placed in the green category for this indicator, as the policy documents reviewed thoroughly address building community support for youth FP services and address gender norms.

As no law or policy exists that addresses parental or spousal consent for youth access to FP services, Guinea is placed in the gray category for this indicator. 

The “Plan national de développement sanitaire, 2015-2024” aims to integrate youth sexual and reproductive health services into health facilities with a specific target to reduce experiences of stigmatization or judgment among youth:

80% des ado-jeunes utiliseront les services de santé sexuelle et reproductive sans stigmatisation ni jugement

The “Plan d’action national budgétisé de planification familiale de la Guinée, 2019-2023" also addresses the judgment that youth may experience from providers:

Deuxièmement, l’offre de services de PF est inadaptée aux jeunes. Le personnel soignant des centres ne sait pas comment les recevoir. On peut citer en exemple le manque de confidentialité et même parfois des jugements sévères de la part du personnel des centres.

However, Guinea’s policy environment does not explicitly prohibit providers from exercising personal bias or discrimination. The “Normes et procédures en santé de la reproduction, 2016” uses direct language when discussing the conduct of providers in HIV/AIDS screening, stating that providers must avoid stigmatization and discrimination. For Guinea to be placed in the green category, a definitive statement, similar to that provided for HIV/AIDS services, is needed that says providers may not use personal bias and discrimination against youth in FP services. Guinea is placed in the gray category for this indicator.

The “Loi portant la santé de la reproduction, 2000” states that reproductive health is a right guaranteed to all individuals regardless of age:

Article 2: Caractère universel du droit à la santé de la reproduction

Tous les individus sont égaux en droit et dignité en matière de santé de la reproduction. Le droit à la santé de la reproduction est un droit universel fondamental garanti à tout être humain, tout au long de sa vie, en toute situation et en tout lieu. Aucun individu ne peut être privé de ce droit dont il bénéficie sans discrimination aucune fondée sur l'âge, le sexe, la fortune, la religion, la situation matrimoniale ou sur toute autre considération.

Further, the “Standards de services de santé adaptés aux adolescents et aux jeunes, 2013” state that youth have the right to quality health services regardless of age:

L’élaboration des présents standards de Services de Santé Adaptés aux Adolescents et Jeunes (SSAAJ) a été guidée par les principes suivants:

 …Le respect des droits humains et en particulier le droit des adolescents/jeunes à l’accès aux services de santé de qualité sans aucune discrimination liée à leur âge, sexe, religion ou condition sociale.

The “Standards de services” include contraception in the minimum package of services for adolescents and support youth access to these services regardless of age. Guinea is placed in the green category for this indicator.

The “Loi portant la santé de la reproduction, 2000” states that reproductive health is a right guaranteed to all individuals regardless of marital status:

Article 2: Caractère universel du droit à la santé de la reproduction

Tous les individus sont égaux en droit et dignité en matière de santé de la reproduction. Le droit à la santé de la reproduction est un droit universel fondamental garanti à tout être humain, tout au long de sa vie, en toute situation et en tout lieu. Aucun individu ne peut être privé de ce droit dont il bénéficie sans discrimination aucune fondée sur l'âge, le sexe, la fortune, la religion, la situation matrimoniale ou sur toute autre considération.

This statement is somewhat contradicted by preceding language in the law that refers specifically to married couples when defining reproductive health:

Par Santé de la Reproduction… elle suppose que toute personne se trouvant dans un lien de mariage peut mener une vie sexuelle satisfaisante en toute sécurité, qu'elle est capable de procréer en toute liberté. Cette dernière condition implique d'une part que les conjoints ont le droit d'être informés et d'utiliser la méthode de planification ainsi que d'autres méthodes de planification non contraires à la loi.

Because the law extends access to FP services regardless of marital status, but places particular emphasis on the rights of married couples, it creates room for confusion in its applicability to unmarried youth. Therefore, Guinea is placed in the yellow category for this indicator.

The “Standards de services de santé adaptés aux adolescents et aux jeunes, 2013” outline the minimum package of services for adolescents, which states that all contraceptive methods should be available to youth. However, the “Standards de services” do not define all methods as including long-acting reversible contraceptives (LARCs).

The “Plan d’action national budgétisé de planification familiale de la Guinée, 2019-2023" discusses targeting young people in the supply of FP services by expanding the range of methods, including scale-up of LARCs:

Objectif 2: Garantir la couverture en offre des services de PF EN [espacement des naissances] et accès aux services de qualité en renforçant la capacité des prestataires publics, privés et communautaires et en ciblant les jeunes des zones rurales et enclavées avec l’élargissement de la gamme des méthodes, y compris la mise à l’échelle des MLDA [méthodes à longue durée d’action] et PFPP [planification familiale du post-partum], l’amélioration des services et prestations adaptés aux besoins des jeunes notamment dans les infirmeries scolaires et universitaires sans oublier la prise en charge de la PF intégrée dans les autres services de SR [santé reproductive] (PF postpartum, SAA [soins après avortement], VIH, Vaccination, Fistules, Paludisme, etc…)

While the “Plan d'action” discusses providing LARCs to young people, Guinea’s policy environment does not require health providers to offer LARCs regardless of age. Therefore, Guinea is placed in the yellow category for this indicator.

In Guinea, access to information and education about sexual and reproductive health is a recognized right described in the “Loi portant la santé de la reproduction, 2000”:

Article 4 : Droit à l'information et à l'éducation

Tout individu, tout couple a le droit à l'information et à l'éducation relatif aux risques liés à la procréation et à l'efficacité de toutes les méthodes de régulation des naissances.

Several policies describe plans for introducing sexuality programming in schools. The “Plan d’action national budgétisé de planification familiale de la Guinée, 2019-2023” includes the implementation of a comprehensive sexuality education (CSE) approach to improve young people’s knowledge of sexual and reproductive health :

A1. Mise en place d’une approche d’Education Complète à la Sexualité (ECS) pour les jeunes scolarisés et non/déscolarisés ou en situation de vulnérabilité.

 Activités :

• Produire un argumentaire en faveur de l’éducation complète des adolescents et des jeunes en collaboration avec les leaders religieux pour renforcer les modules complémentaires sur la SRAJ [santé reproductive des adolescents et des jeunes] à intégrer dans l’enseignement des élèves par un consultant pendant 10 jours
• Faire un plaidoyer en direction du Secrétariat d’Etat chargé des Affaires Religieuses, de l’Education Nationale, du MASEF [ministère de l’Action Sociale, de l’Enfance et de la Famille] (MAPF ET L’ENFANCE), de la Société Civile et des Relations avec le Parlement et de la Jeunesse, etc., pour l’intégration des modules des SRAJ dans les curricula de formation
• Élaborer et multiplier les supports éducatifs (affiches, dépliants, boîte à image…) sur l’éducation complète ciblée
• Adapter et traduire les modules pour une formation des adolescent(e)s et des jeunes non scolarisés en arabe et 3 langues nationales
• Identifier et former 20 enseignants expérimentés pour assurer la formation des formateurs
• Animer 5 sessions de formation des enseignants

One of the essential CSE components is to reach youth in formal and informal settings. The “Feuille de route nationale pour accélérer la réduction de la mortalité maternelle, néonatale et infanto-juvénile, 2012-2016” and the “Plan stratégique en santé et développement des adolescents et des jeunes en Guinée, 2015-2019” describe plans to reach youth in and out of school with sexuality education, in addition to broader awareness campaigns to spread information on sexual and reproductive health.

Another essential component of CSE aims to strengthen youth advocacy and civic engagement. The “Plan stratégique” emphasizes youth participation in designing and implementing health programs, but it does not include plans for teaching youth about youth advocacy and civic engagement within a CSE program.

Guinea’s policies do not describe specific components that should be included in a sexuality education program, with the exception of reaching youth in formal and informal settings. Therefore, Guinea is placed in the yellow category for this indicator.

Guinea’s policy environment is promising in its acknowledgement of the importance of health services tailored to youth, but it does not outline all three service-delivery elements of adolescent-friendly contraceptive services.

The “Standards de services de santé adaptés aux adolescents et aux jeunes, 2013” note that adolescents face provider discrimination when they seek sexual and reproductive health services. To remedy this, the Standards de services include a goal to ensure that providers are trained to offer youth-friendly services:

Tous les prestataires ont les connaissances, les compétences, et les attitudes positives (requises) pour offrir des services adaptés aux besoins des adolescents et des jeunes.

The “Plan d’action national budgétisé de planification familiale de la Guinée, 2019-2023” defines a specific target to increase provider capacity for youth-friendly FP services:

A2. Renforcement de l'enseignement de la PF dans les écoles et facultés de formation en santé

• Élaborer/adapter des manuels de formation en prise en charge des jeunes et des adolescents dans les FS [formation sanitaire] offrant la PF
• Identifier et évaluer la performance des OSC actives dans la lutte contre l’infection VIH/sida chez les jeunes et recenser chaque année 20 FS appropriées pour la prise en charge des adolescents et des jeunes
• Renforcer l’équipement des FS pour offrir des services aux adolescents et aux jeunes
• Aménager les services (espace horaire, activités, etc.…) pour prendre en compte les besoins des jeunes
• Superviser les prestations offertes par les prestataires formés

The “Normes et procédures en santé de la reproduction, 2016” describe the procedures that providers should follow when attending to youth at each level of the health system. For example, the document encourages providers to listen attentively to youth. The “Plan stratégique national de la santé maternelle, du nouveau-né, de l’enfant, de l’adolescent et des jeunes, 2016-2020” includes activities to strengthen the capacity of youth-friendly service providers and to combat the stigmatization that youth face when accessing services:

6.5: Santé reproductive et sexuelle des adolescents et jeunes : Amélioration de l’accès des adolescents et jeunes à des services adaptés à leurs besoins du point de vue santé, éducation, emploi et information...

 Interventions :

Renforcement des capacités des prestataires en santé et développement des adolescents et jeunes y compris la lutte contre la stigmatisation des ado/jeunes dans les structures

The “Standards de services” include a guiding principle on respect for the confidentiality and privacy of youth. However, Guinea’s policies do not adequately address the provision of no-cost or subsidized services. The “Standards de services” include an activity to make health products affordable to adolescents, but do not specifically address the cost of FP services. Therefore, Guinea is placed in the yellow category for this indicator.

One of the five overarching standards described in the “Standards de services de santé adaptés aux adolescents et aux jeunes, 2013” includes planned activities for mobilizing communities around youth-friendly services, which include contraceptive services:

Standard 4: La communauté - y compris les adolescents et les jeunes - facilite la mise en place et l’utilisation des services de santé adaptés aux adolescents et aux jeunes.

1. Les organisations à base communautaire les leaders communautaires, les enseignants, les agents communautaires/Assistants sociaux et les associations de jeunes sont mobilisées autour des PPS [points de prestation de services] pour faciliter l’utilisation des services de santé par les adolescents et les jeunes
2. Les organisations à base communautaire, les leaders communautaires et les enseignants, les agents communautaires/Assistants sociaux et les associations de jeunes, sont orientés en vue de faciliter l’utilisation des PPS par les A&J [les adolescents et les jeunes]
3. Les leaders communautaires/parents encouragent les A&J à utiliser les SSAAJ [services de santé adaptés aux adolescents et jeunes].

The “Plan stratégique en santé et développement des adolescents et des jeunes en Guinée, 2015-2019” discusses building support in communities and addressing gender norms. However, this document is not specific to youth sexual and reproductive health services, and it does not describe youth access to contraception; it instead refers to youth health services in general. The “Standards de services” make brief mention of gender mainstreaming, but provide little detail.

Because Guinea’s policies outline a detailed strategy to build community support but do not have a detailed strategy for addressing gender norms in youth access to FP, the country is placed in the yellow category for this indicator.

In its description of the current sexual and reproductive health situation in Haiti, the "Plan stratégique national de santé sexuelle et reproductive, 2019-2023" notes that young people and adolescents under age 18 have limited access to health services without parental permission. The “Plan stratégique” does not specify whether this limited access is due to an unsupportive policy environment or a sociocultural environment. In the absence of clarity within policies around parental consent and with no mention of spousal consent, Haiti is placed in the gray category for this indicator.

The “Manuel de normes en planification familiale et en soins maternels, 2009” establishes the right of everyone, including adolescents and young people, to use the contraceptive method of their choice from a full range of available methods and with no influence from the provider. The “Manuel de normes” also notes that providers should create an environment that allows clients to safely express their needs:

ÉLÉMENT I : CHOIX DE LA MÉTHODE

Le client doit pouvoir obtenir la méthode de son choix. Aussi, l’Institution doit veiller à ce qu’il n’y ait pas de biais au niveau de l’offre des méthodes pour ne pas influencer le choix du client. De plus, l’Institution doit assurer la disponibilité d’une grande gamme de méthodes pour faciliter et satisfaire le choix du client, puisque les besoins de méthode spécifique varient avec l’âge, le statut matrimonial, la parité de la femme et le sexe. 

…

ELEMENT IV : RELATIONS INTER-PERSONNELLES : CLIENT / PRESTATAIRE.

Des relations empreintes de cordialité entre le personnel et le client comptent beaucoup pour induire la satisfaction du client. Que ce soit au niveau de l’accueil pour l’inscription et l’enregistrement, que ce soit lors du Counseling ou de l’examen clinique, le personnel doit faire preuve d’empathie, de respect pour le client. L’environnement de la consultation doit présenter un cachet d’intimité et de confidentialité. Le client doit être mis en confiance pour l’inciter à exprimer sans réserve ses besoins.

Although the “Manuel de norms” notes that health facilities should not allow bias to interfere with method choice, it does not clearly state that providers must authorize medically advised FP services to youth without personal bias or discrimination. Haiti is place in the yellow category for this indicator.

The “Manuel de normes en planification familiale et en soins maternels, 2009" includes women of reproductive age who are sexually active as well as young people with sexual health and reproductive health needs as beneficiaries of family planning services:

Les bénéficiaires des services sont :

1) Les couples qui désirent être informés en matière de planification familiale ou la pratiquer.

2) Les femmes qui ont des besoins en Santé de la Reproduction et sexuelle.

3) Les femmes en âge de procréer sexuellement actives et qui veulent éviter une grossesse non désirée, ou qui cherchent à espacer leurs grossesses et qui sont donc à la recherche d’une méthode d’espacement des naissances.

4) Les hommes en âge de procréer qui veulent assurer eux-mêmes ou partager avec leur partenaire la responsabilité du contrôle des naissances, soit en choisissant une méthode masculine, soit en encourageant leur partenaire à choisir et à utiliser une méthode contraceptive efficace.

5) Les hommes et les femmes qui ne veulent plus avoir d’enfants et qui optent pour une méthode définitive de contraception chirurgicale.

6) Les jeunes qui ont des besoins en santé sexuelle et en Santé de la Reproduction.

7) Les couples qui ont besoin de procréation.

As the “Manuel de normes” supports youth access to family planning, Haiti is placed in the green category for this indicator.

The “Plan stratégique national de santé sexuelle et reproductive, 2019 – 2023” includes a multisectoral strategy to improve the legal framework to support young people in sexual and reproductive health services. However, as no current policy could be identified that supported youth access to FP services regardless of marital status, Haiti is placed in the gray category for this indicator.

The “Manuel de normes en planification familiale et en soins maternels, 2009” includes young people as beneficiaries to family planning services:

Les bénéficiaires des services sont :

…

6) Les jeunes qui ont des besoins en santé sexuelle et en Santé de la Reproduction.

The “Manuel de normes” further states that clients must be able to select methods of their choice, noting that health facilities should ensure a wide range of methods to facilitate client choice:

ÉLÉMENT I : CHOIX DE LA MÉTHODE Le client doit pouvoir obtenir la méthode de son choix. Aussi, l’Institution doit veiller à ce qu’il n’y ait pas de biais au niveau de l’offre des méthodes pour ne pas influencer le choix du client. De plus, l’Institution doit assurer la disponibilité d’une grande gamme de méthodes pour faciliter et satisfaire le choix du client, puisque les besoins de méthode spécifique varient avec l’âge, le statut matrimonial, la parité de la femme et le sexe.

The “Manuel de normes" continues to outline all available methods, including notes on how they work, their efficacy, and advantages and disadvantages, including side effects, eligibility, and limitations. As Haitian policy documents include young people as beneficiaries to family planning and support their access to a range of methods, including long-acting reversible contraceptives, Haiti is placed in the green category for this indicator.

Although the availability of emergency contraception (EC)  is not factored into the categorization of this indicator, note that the “Manuel de normes” also includes EC in the list of methods.

The "Plan stratégique national de santé des jeunes et adolescents, 2014-2017" lists the development of a sexuality education curriculum by the Ministry of Education and Vocational Training as an opportunity to support youth health. The “Plan stratégique” includes an objective to empower young people to be responsible in their sexual behavior and outlines multiple interventions around sexuality education in formal and informal settings:

4.4 Habiliter les jeunes à une sexualité responsable. Interventions

4.4.1 Appui au MENFP [ministère de l’éducation nationale et de la formation professionnelle] pour l’implantation d’un programme d’éducation sexuelle dans les écoles.

4.4.2 Formation/recyclage de trois formateurs de pairs éducateurs par section communale en partenariat avec les ONG [organisations non gouvernementales] œuvrant dans le domaine de la santé des jeunes et des adolescents.

4.4.3 Recensement des organisations de jeunes.

4.4.4 Formations des jeunes par les pairs éducateurs au niveau des associations, groupements de jeunes et autres initiatives de jeunes.

4.4.5 Implantation d’une ligne téléphonique d’informations santé jeunes et adolescent.

4.4.6 Diffusion d’informations santé et santé sexuelle des jeunes sur un réseau social (FACE Book).

4.4.7 Diffusion d’informations dans le cadre de l’organisation de Journées récréatives et de grandes mobilisations de jeunes et d’adolescents.

4.4.8 Célébration de la Journée internationale de la jeunesse.

The "Plan stratégique national de santé sexuelle et reproductive, 2019-2023" aims to strengthen the knowledge of young people ages 10 to 24 on the topic of sexual health. Intervention activities include strengthening the existing sex education program in schools:

Activités :

• Développer une stratégie de communication sur la sexualité et le droit des jeunes.

• Renforcer la formation des ASCP [agent de santé communautaire polyvalent] sur la santé des adolescents et des jeunes.

• Renforcer les capacités des professeurs à transmettre aux jeunes et adolescents dans les écoles, le programme d'éducation sexuelle existant.

While both policies provide approaches to implementing sexuality education in and out of school, no comprehensive sexuality education framework (CSE) could be located, nor do available policies describe the nine essential components of a CSE program as defined by the United Nations Population Fund (UNFPA). Haiti is placed in the yellow category for this indicator.

To support its objective to reduce the number of unwanted pregnancies among youth ages 15 to 24, the "Plan stratégique national de santé sexuelle et reproductive, 2019-2023" aims to implement a youth-friendly pilot project in three public institutions. The three institutions will adapt international standards for quality, comprehensive care for adolescents and young people, and the essential package of services as set by the World Health Organization:

STRATÉGIE 5.2.2 – a) Mettre en œuvre dans au moins trois institutions de santé les normes mondiales de l'OMS [Organisation mondiale de la santé] et de l'ONUSIDA [Programme commun des Nations Unies sur le VIH / sida] pour la qualité des services de santé complets destinés aux adolescents et adaptés au contexte d'Haïti en tenant compte du paquet essentiel de services pour les jeunes de 15 à 24 ans.

Activités :

Adapter les standards internationaux pour des soins de santé complets de qualité destinés aux adolescents et jeunes de 15 à 24 ans.

Mettre en œuvre ces standards dans trois institutions publiques du pays dans le cadre d'un projet pilote.

Évaluer l'amélioration de la qualité des soins complets pour adolescents au terme du projet pilote.

Étendre le projet pilote à d'autres institutions à partir des résultats obtenus dans l'évaluation

The "Plan stratégique national de santé des jeunes et adolescents, 2014-2017" includes objectives and specific interventions to strengthen the health system structure by improving the quality of services for adolescents and young people. The specific interventions promote privacy and confidentiality of services as well as provider training:

2.3 Renforcer progressivement les départements sanitaires pour faciliter un fonctionnement adéquat des services de santé offerts aux jeunes et aux adolescents.

Interventions : ...

2.3.2 Aménagement de salles d’accueil et de consultation amis des jeunes, reflétant un aspect convivial pour les jeunes.

2.3.3 Atelier de sensibilisation des responsables départementaux à l’amélioration du programme de santé des jeunes.

2.3.4 Formation de prestataires formateurs de jeunes…

2.3. 6 Plaidoyer pour l’intégration d’activités SS/SR [santé sexuelle / santé reproductive] des jeunes dans les budgets départementaux.

2.3.7 Elaboration d’un plan opérationnel SJA [santé des jeunes et des adolescents] dans chaque département.

 2.4 Rendre accessible une prise en charge normalisée, intégrée et holistique aux jeunes et aux adolescents.

Interventions

2.4.1 Spécification du Paquet essentiel de services institutionnels aux jeunes et adolescents.…

2.4.6 Approvisionnement des points de services locaux et des organisations de jeunes en intrants SS/SR/PF et autres médicaments pour les jeunes…

2.4.8 Acquisition de matériels, fournitures et équipements audiovisuels pour les espaces de services aux jeunes…

2.4.11 Mise en place de consultations gynécologiques spécifiques accessibles aux jeunes au niveau des [hôpital communautaire de référence].

The “Plan stratégique national de santé des jeunes et adolescents” objective to establish effective communication between young people and providers includes additional activities to train providers to be more holistic in their care:

4.2 Établir des liens efficaces de communication entre jeunes et prestataires des institutions publiques de santé. Interventions

4.2.1 Formation des prestataires en éducation sexuelle, santé sexuelle, prise en charge holistique des jeunes, suivi des interventions visant les jeunes, initiation à l’usage des supports éducatifs.

4.2.2 Réunion de sensibilisation sur les droits sexuels des jeunes et des adolescents.

The “Plan stratégique national de santé des jeunes et adolescents” also notes that interviews with stakeholders revealed that program officials overwhelmingly said health care providers were currently unable to welcome young people without discrimination, and they identified education and training as key to improving the state of youth services.

The “Manuel de normes en planification familiale et en soins maternels, 2009,” which names youth as beneficiaries to family planning services, clearly states that family planning services are free:

1.6. COUT DES SERVICES

Les services de PF sont totalement gratuits.

The “Manuel de normes” emphasizes the importance of provider attitudes and states that providers must provide privacy and confidentiality for all clients:

ELEMENT IV : RELATIONS INTER-PERSONNELLES: CLIENT / PRESTATAIRE. Des relations empreintes de cordialité entre le personnel et le client comptent beaucoup pour induire la satisfaction du client. Que ce soit au niveau de l’accueil pour l’inscription et l’enregistrement, que ce soit lors du Counseling ou de l’examen clinique, le personnel doit faire preuve d’empathie, de respect pour le client. L’environnement de la consultation doit présenter un cachet d’intimité et de confidentialité. Le client doit être mis en confiance pour l’inciter à exprimer sans réserve ses besoins.

Haiti’s policies specifically reference providing FP services as part of a package of services and include the three service-delivery elements: provider training, enforcing confidentiality and privacy, and providing no-cost or subsidized services. Haiti is placed in the green category for this indicator.

The "Plan stratégique national de santé des jeunes et adolescents, 2014-2017" includes an objective to promote favorable behaviors for young people’s health. The objective’s detailed activities include the establishment of partnerships between parents and churches so parents gain a better understanding of how they can share information on sexuality education with their children and a community forum to sensitize parents to their roles in their child’s sexual health. The objective also includes a meeting of community leaders to engage them in promoting an enabling environment for adolescent sexual health:

4.1 Améliorer la communication enfant-parents, en matière de santé en général et de santé sexuelle en particulier, au niveau de toutes les sections communales du pays.

…

4.1.5 Organisation de réunions avec les leaders communautaires pour les engager dans des actions visant la promotion, la protection de la santé et de la santé sexuelle des adolescents et des jeunes.

The “Plan stratégique national de santé des jeunes et adolescents” builds further support for youth FP by including multiple activities with which to engage the community to promote adolescent and youth sexual health:

4.3.1 Organisation de réunions avec les leaders communautaires pour les engager dans des actions visant la promotion et la protection de la santé, de la santé sexuelle des adolescents et des jeunes.

4.3.2 Sensibilisation des communautés lors de festivités patronales, foires et autres activités communautaires de masse et les engager dans des actions visant la promotion et la protection de la santé, de la santé sexuelle des adolescents et des jeunes.

4.3. Diffusion de spots de sensibilisation à la radio pour inciter les communautés et susciter leur intérêt à s’engager dans des actions visant la promotion et la protection de la santé, de la santé sexuelle des adolescents et des jeunes.

The “Plan stratégique national de santé des jeunes et adolescents” falls short of outlining a full gender strategy for youth family planning, but does include an activity on raising awareness for gender equity among providers of public health:

4.2 Établir des liens efficaces de communication entre jeunes et prestataires des institutions publiques de santé.

…

4.2.3   Promotion et sensibilisation pour l’équité de genre et prévention de la violence.

The "Plan stratégique national de santé sexuelle et reproductive, 2019-2023" also links service delivery with activities that build support for FP in communities:

Mobiliser la société civile, les élus locaux, les collectivités territoriales autour d'un plan efficace de promotion de la santé sexuelle et reproductive et des droits des femmes et des filles élabore et mis en œuvre conjointement avec les institutions de santé.

 Activités :

Mobiliser les institutions de santé pour la mise en place de stratégies et plans de communication et de sensibilisation au niveau communautaire en SSR et droits des femmes et des filles, conjointement avec la société civile, les élus locaux, et les collectivités territoriales.

Soutenir l'implication des communautés, groupes de femmes, élus locaux, collectivités territoriales dans l'organisation et la gestion des services communautaires et institutionnels de santé sexuelle et reproductive, dans une optique de renforcement de la qualité des services.

Initier de nouveaux modèles d'intervention en SSR auprès des hommes, tant au niveau communautaire qu'institutionnel.

The “Plan stratégique national de santé sexuelle et reproductive” also outlines a strategy to target parents as key factors in establishing a more favorable sexual and reproductive health environment for young people ages 10 to 24, including training parents on their role in supporting FP information and involving community organizations to promote and protect youth reproductive health needs:

Favoriser la mise en place de programmes de formation et de sensibilisation des parents sur le rôle qu'ils ont à jouer auprès de leurs enfants dans le domaine de l'éducation à la santé, de l'éducation sexuelle et la nécessité de partager avec leurs enfants les informations, expériences et valeurs en matière de sexualité

Encourager l'implication des organisations communautaires et conseils communaux dans des actions visant la promotion, la protection de la santé et de la santé sexuelle des jeunes et des adolescents.

The policies reviewed outline the need to build a supportive social environment for youth FP through engagement of families and communities; however, they fall short of adequately addressing gender norms as they relate to youth access to FP. Haiti is placed in the yellow category for this indicator.

No law or policy in India explicitly addresses consent from a third party to access to FP services. India is therefore placed in the gray category for this indicator.

The “Reference Manual for Doctors: Contraceptive Updates, 2005” provides medical eligibility checklists for each contraceptive method.

The “Rashtriya Kishor Swasthya Karyakram Operational Framework: Translating Strategy into Programmes, 2014” notes that that providers should ideally provide non-judgmental services:

2.10 The quality of counselling services will largely depend on the knowledge, attitude and skills of a counsellor. And in this context, the selection of Counsellors is important. Counsellors should ideally be:

…

• Non-judgmental, with a progressive attitude i.e. in no circumstances, should the counsellor try to impose his or her values

However, India’s policies do not directly require providers to provide medically advised FP services without personal bias and discrimination. Therefore, India is placed in the gray category for this indicator.

The “Reference Manual for Doctors: Contraceptive Updates, 2005” confirms youth access to FP services regardless of age:

In general, adolescents are eligible to use any method of contraception and must have access to a variety of contraceptive choices. Age alone does not constitute a medical reason for denying any method to adolescents, although sterilization is rarely appropriate for this age group. While some concerns have been expressed regarding the use of certain contraceptive methods in adolescents, (e.g., the use of progestogen-only injectables by those below 18 years), these concerns must be balanced against the advantages of avoiding pregnancy and existing guidelines be adhered to. It is clear that many of the same issues regarding appropriate contraceptive use that apply to older clients apply to young people.

Since youth have access to all contraceptive methods regardless of age, India is placed in the green category for this indicator.

Multiple strategy documents discuss contraceptive provision to unmarried adolescents. In “A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health in India, 2013,” the section on adolescent-friendly health services confirms the availability of services to unmarried youth:

Services in adolescent health clinics will be available to all adolescents: married and unmarried, girls and boys, and will be further strengthened. Special focus will be given to establishing linkages with Integrated Counselling and Testing Centres (ICTCs) and making appropriate referrals for HIV testing and RTI/STI [reproductive tract infection/sexually transmitted infection] management; providing comprehensive abortion care; and provision of information, counselling and services for contraception to both married and unmarried adolescents.

The “Implementation Guide on RCH II Adolescent Reproductive Sexual Health Strategy, 2006” includes unmarried men and women as the target group for contraceptives and condom programming in primary health centers and district hospitals. The implementation guide further details the service delivery package for adolescents, which specifics unmarried youth:

SECTION ONE: SERVICE DELIVERY PACKAGE

STANDARD: Health facilities provide specified package of services that adolescents need

Services are to be made available for all adolescents, married and unmarried, girls and boys. Focus is to be given to the vulnerable and marginalized sub-groups. The package of services is to include promotive, preventive, curative and referral services. A plan of service provision as per the level of care may be developed based on the RCH II [Reproductive and Child Health Phase II] service delivery plan presented in the previous section.

With the policy recognition that unmarried youth deserve access to contraception, India is placed in the green category for this indicator.

The “Reference Manual for Doctors: Contraceptive Updates, 2005” states that “adolescents are eligible to use any method of contraception and must have access to a variety of contraceptive choices.” Moreover, according to the “Facilitator’s Guide: Training Manual for Medical Officers, n.d.,” “healthy adolescents are medically eligible to use all currently available methods of contraception.” Multiple reference manuals and guides identify contraceptive methods available in India and who can and cannot use them, acknowledging that some long-acting reversible methods may not be recommended as a first choice for certain age groups.

The "Reference Manual for Doctors" and the "Facilitator’s Guide: Training Manual for Medical Officers" both acknowledge that age is not a medical reason to withhold any contraceptive method, but it should be considered before providing either of two methods to youth of certain ages. The Training Manual includes the following guidance:

Tips for Facilitators

Age does not constitute a medical reason for withholding the provision of any method. However   age is a factor to be taken into account when considering the use of three methods:

…

• Progestin-only injectables (such as Depomedroxy Progesterone Acetate (DMPA), and Norethisterone Enanthate (NET-EN)) are not the first method of choice for those under 18, as there is a theoretical concern that bone development could be hindered.
• Intra-Uterine Contraceptive Devices (IUCD) are not the first method of choice for those under 20, as the risk of expulsion is higher in young, nulliparous women. Infection may lead to infertility as well.

The “Reference Manual for Injectable Contraceptive (DMPA), 2016,” however, states that progestin-only injectables are safe for women of any age, including adolescents.

Further, one of the strategies to reduce adolescent pregnancy in the “Rashtriya Kishor Swasthya Karyakram Strategy Handbook, 2014” includes access to long-acting reversible contraceptives (LARCs):

Referral for clinical contraceptives such intra-uterine contraceptive devices as per the protocol.

While many policy documents include medical eligibility criteria that has been adapted from the World Health Organization medical eligibility criteria, they do not explicitly mention youth’s right to access a full range of contraceptive services, including LARCs, regardless of marital status or parity. India is placed in the yellow category for this indicator.

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, the “Implementation Guide on RCH II Adolescent Reproductive Sexual Health Strategy, 2006” explicitly states that adolescents may have access to emergency contraception without prescription, while the “Guidelines for Administration of Emergency Contraceptive Pills by Health Care Providers, 2008” confirm that EC should be provided to clients within their reproductive years regardless of their age and marital status.

The “Rashtriya Kishor Swasthya Karyakram Strategy Handbook, 2014” identifies the inclusion of family life education and life skills in school curricula as a community-level activity to support adolescent sexual and reproductive health (SRH). The “Strategy Handbook” also acknowledges the importance of peer educators to the strategy’s community approach; peer educators will be trained by teachers to share SRH information and lead discussions in and out of school settings.

The “Operational Guidelines on School Health Programme under Ayushman Bharat, 2018” aims to provide age-appropriate information about health and nutrition in schools, promote healthy behaviors, and create appropriate referrals to health centers and hospitals. However, the Operational Guidelines do not provide further detail on sexuality education beyond noting that SRH is age-appropriate health information for high school-aged students.

The “Adolescence Education Programme Life Skills Development: Facilitator’s Guide, n.d.” aims to support the development of positive behaviors to empower young people to make healthy choices and gain life skills. To reach these goals, the Education Programme outlines five objectives:

1. All schools provide accurate age-appropriate life skills based adolescence education in a sustained manner to young people (10-18 yrs) in schools;
2. Every child is equipped with accurate information, knowledge and life skills to protect themselves from HIV and manage adolescent reproductive sexual health (ARSH) issues and concerns;
3. All out-of-school adolescents are provided basic information and services on adolescent reproductive and sexual health, HIV prevention and prevention of substance abuse
4. Effective integration of adolescence education components in school curriculum as well as the teacher education course takes place; and
5. Linkages to youth friendly services are established and resources for additional information are easily

The Education Programme consists of three components, including “Process of Growing Up,” which covers topics of self-identity, gender roles, addressing myths and misconceptions, and links to youth-friendly services. It also includes peer educators who will be used as support for teachers in informal settings.

As outlined in the “Training and Resource Materials: Adolescence Education Programme [AEP], 2013,” the AEP has an integrated focus on gender and includes components that focus on understanding issues of discrimination and violations. The guiding principles of the Training and Resource Materials emphasize providing accurate and age-appropriate information to adolescents. They also include a peer education component, reaching youth engaged in both informal and organized education activities, thus touching on many of the essential United Nations Population Fund (UNFPA) components for CSE:

Objective 2. To enable adolescents to be aware of implications of child marriage adolescent pregnancy/parenting.

…

Objective 4. To empower adolescents to understand and challenge existing norms and inequalities related to gender and sexuality

…

Objective 5. To enable young people to understand various kinds of discrimination and violations and develop skills to counter/seek redressal

The “Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) Strategy, 2013” seeks to implement life skills education in educational institutions and community settings but does not specifically address education in the context of youth FP.

Since India’s policy environment supports SRH education but does not address all nine essential UNFPA components for CSE, India is placed in the yellow category for this indicator.

The “Implementation Guide on RCH II Adolescent Reproductive Sexual Health Strategy, 2006” lays out standards to guide implementation of adolescent sexual and reproductive health (SRH) interventions, including a standard for service providers to be sensitive to adolescents’ needs:

Due to a variety of reasons, e.g. judgmental attitudes of service providers, many adolescents do not seek health services. Services providers are to be technically competent and motivated to provide services to adolescents as per their need/s. This standard seeks to ensure that the service providers imbibe and demonstrate appropriate attitudes and behaviour to reassure the adolescents in addressing their needs. The standard therefore seeks to address issues relating to service providers attitudes and motivation.

The Implementation Guide also outlines a training to build providers’ capacity to provide services to adolescents without being judgmental, and covers topics related to contraception, pregnancy, and SRH:

The key contents of training are as follows:

• Adolescent growth and development
• Communicating with adolescents
• Adolescent Friendly Reproductive and Health Services
• Sexual and reproductive health concerns of boys and girls
• Nutrition and Anaemia in adolescents
• Pregnancy and unsafe abortions in adolescents
• Contraception for adolescents
• RTIs/STIs [reproductive tract infection/sexually transmitted infections] and HIV/AIDS in adolescents

It also includes a standard to build a conducive environment at health facilities that ensures confidentiality and audio/visual privacy:

• Clinic rooms must have window curtains and a bed-screen surrounding the examination table.
• It is advisable to... give clear instructions to the staff about not allowing any one into the clinic when a client is already there, in order to ensure privacy.
• The confidentiality policy of the clinic may be displayed and clearly expressed to the client in the first session itself.
• Client records to be kept out of reach of unauthorized persons.

The “Rashtriya Kishor Swasthya Karyakra Operational Framework: Translating Strategy into Programmes , 2014” outlines the role and recruitment of health counselors, and notes that counselors should be able to maintain privacy and confidentiality and withhold judgment. Similarly, the operational framework outlines the infrastructure for an adolescent-friendly health clinic (AFHC), and notes the following benchmarks:

Exhibit 2.04: Benchmarks for an AFHC

• Infrastructure clean, bright and colorful
• Can be easily accessed by the adolescents (distance, convenient working hours and cost)
• Adolescents are aware about the clinic and range of service it provides
• Non judgmental and competent health service providers
• Maintains privacy and confidentiality
• Community members are aware of the services provided and understand the need for the same

Both the Rashtriya Kishor Swasthya Karyakra’s operational framework and implementation guidelines include trainings for health care workers, counselors, and peer educators on adolescent-friendly health services but do not provide details on the trainings.

“A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health in India, 2013” states that family planning commodities and services are provided free to every client during community-based doorstep distribution through accredited social health activists. It also acknowledges that adolescents in need of secondary and tertiary care will be entitled to “free treatment through Rastriya Swasthya Bima Yojona or State Health Insurance Scene.”

The “National Population Policy, 2000” supports free supply of contraceptives in its operational strategy to implement a one-stop integrated and coordinated service-delivery package for basic health care and family planning in the community.

Since India’s policy environment includes all three service-delivery elements for youth-friendly contraceptive services, India is placed in the green category for this indicator.

The “Implementation Guide on RCH II Adolescent Reproductive Sexual Health Strategy, 2006” seeks to create an enabling environment in the community for adolescents’ access to sexual and reproductive health (SRH) services by planning activities targeting key stakeholders such as community leaders, parents, teachers, and community-based organizations:

District programme managers are to ensure that steps are taken to help key stakeholders in the community to understand and respond to adolescent needs. Key audiences are to be identified whose support would be needed for creating an enabling environment within the community. Key stakeholders can include policy makers, administrators, community leaders, service providers, parents, teachers, community-based organizations, NGOs and the media.

The community can be engaged in a variety of ways, like seeking their views, providing information, and involving them in prioritizing areas for quality improvement. They can help to publicise and generate demand for high quality services and increase adolescents’ use of them. Linkages may be established with community-based organizations, NGOs [nongovernmental organizations], private practitioners, social marketing and franchising outlets. Media can be effectively engaged in generating awareness about adolescent issues and their importance as well as spreading information about Adolescent Friendly Reproductive and Sexual Health Services. Mass media as well as folk media can be used judiciously

The “Implementation Guide on RCH II Adolescent Reproductive Sexual Health Strategy, 2006” also lays out activities that the district health officer can take to build a supportive environment for youth SRH, including orientation days to raise awareness on adolescent SRH issues and meetings to build support of unmarried adolescents’ service use. The strategy acknowledges that building support requires continuous action:

• Efforts must be made to increase awareness of the community regarding the adolescent needs and how to respond to them.
• Adolescents must be encouraged by the community to access the services.
• Health functionaries organize meetings with other departments and the community at various levels of administration to emphasize the need and role of adolescent-friendly services
• Adolescent health issues to be discussed continuously in routine contacts with the community members.

Moreover, the Implementation Guide aims to give special attention to “gender and equity differentials at every stage of implementation.” It details a list of actions, which includes communication activities at the local level that address gender norms and the prevention of unwanted pregnancy.

The “Rashtriya Kishor Swasthya Karyakram Strategy Handbook, 2014,” under the SRH strategic priority to reduce adolescent pregnancy, includes a strategy and related interventions to address social pressures and cultural norms related to early marriage, conception, and contraception:

Strategies

Address social pressure and concerns related to early marriage, conception and contraception.

.…

Interventions

Communication with individuals, families and communities, including men, to create support and influence cultural norms to reduce early marriage (such as information on the legal status of early marriage) and pregnancy.

Moreover, the  “Rashtriya Kishor Swasthya Karyakram Operational Framework: Translating Strategy into Programmes, 2014” aims to increase awareness among parents, teachers, families, and other stakeholders about adolescent health needs, including SRH, through adolescent health days organized at a village level. While building support for FP services is not directly outlined as part of the content for adolescent health days, one stated purpose is to increase knowledge of and referrals to adolescent-friendly health centers that provide contraceptives.

“A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health in India, 2013” acknowledges the special attention that should be given to community participation and notes that community structures should be mobilized through advocacy and capacity-building to create a conducive environment for utilization of available health services. However, the recommended process focuses on implementing accountability mechanisms and using community events as a platform for service outreach. The strategy mentions focused messaging to community members but without a specific focus on supporting youth FP:

In order to reduce adolescent pregnancy, focused messaging to individuals, families and communities (including men) will be reinforced through the Life Skills Education sessions that are delivered from various adolescent centric platforms including community outreach sessions and Anganwadi centres.

In addition, the Strategic Approach also refers to the Saksham scheme, which aims to empower boys by educating them on gender sensitivity:

Saksham aims to target young boys, in the age group 10–18 years, for their holistic development by giving lessons in gender sensitivity and inculcating in them respect for women.

While India’s policies outline strategies to build community support for youth SRH and address gender norms, they do not specifically address youth FP. India is placed in the yellow category for this indicator.

Despite Kenya’s strong policy environment supporting sexual and reproductive health (SRH) services for adolescents and youth, the legal stance on parental and spousal consent for youth accessing FP services remains noticeably weak.

The “Children Act, No. 8 of 2001, Revised Edition, 2019” which defines a child as anyone under age 18, does not specifically outline when parental consent is required but notes that a child’s right to health care is the responsibility of the parent:

9. Right to Health Care

Every child shall have a right to health and medical care the provision of which shall be the responsibility of the parents and the government.

The “National Guidelines for Provision of Adolescent and Youth Friendly Services in Kenya, 2016” outline a clear strategy to improve adolescents’ access to and use of SRH services. While this document identifies laws and policies requiring parental and partner approval as a structural barrier to youth accessing SRH services, it does not make any definitive statement on the right of adolescents to access services without parental and spousal consent.

Kenya is placed in the gray category for parental or spousal consent since no law or policy exists that addresses consent from a third party for youth to access FP services. The country could move into the green category for the indicator if policymakers pass a new policy with a provision that recognizes youth’s right to access FP services without parental or spousal consent.

Explicit policy language directs providers to offer nondiscriminatory, unbiased care to adolescents based on medical eligibility criteria. The “National Guidelines for Provision of Adolescent and Youth Friendly Services in Kenya, 2016” promote five characteristics of adolescent service provision that follow the World Health Organization’s Quality of Care framework for adolescent service provision: accessible, acceptable, appropriate, equitable, and effective. The National Guidelines specifically address the role of the provider to offer adolescent-friendly health services, including the provision of contraception, in a manner that respects the five quality of care characteristics:

The service providers should be non-judgmental and considerate in their dealings with adolescents and youth and deliver the services in the right way.

Kenya is placed in the green category for this indicator as policies direct providers to deliver nonjudgmental FP services.

The right to health services, including reproductive health services, is recognized at the highest policy level in Kenya. The “Constitution of Kenya, 2010” recognizes the right of all people to access reproductive health care:

Article 43: (1) Every person has the right—(a) to the highest attainable standard of health, which includes the right to health care services, including reproductive health care.

The “Health Act, 2017” includes the right of people of reproductive age to access FP services:

Article 6: (1) Every person has a right to reproductive health care which includes—(a) the right of men and women of reproductive age to be informed about, and to have access to reproductive health services including to safe, effective, affordable and acceptable family planning services.

This strong declaration in favor of all people accessing health care sets the stage for equal access to health care services.

The “National Guidelines for Provision of Adolescent and Youth Friendly Services in Kenya, 2016” recognize adolescents’ right to access services independent of their age, including FP and contraceptive services as a subset of services under the “Minimum Initial Service Package (MISP) for Reproductive Health.” Under the MISP operational guidelines, health providers are directed as follows:

Health staff should be aware that adolescents requesting contraceptives have a right to receive these services, regardless of age or marital status.

This explicit recognition of adolescents’ right to contraception regardless of age is a critical step toward addressing the barriers many youth encounter when trying to access these services. Kenya is placed in the green category for this indicator.

The “National Guidelines for Provision of Adolescent and Youth Friendly Services in Kenya, 2016” recognize adolescents’ right to access services independent of their marital status, including FP and contraceptive services as a subset of services under the “Minimum Initial Service Package (MISP) for Reproductive Health.” Under the MISP operational guidelines, health providers are directed as follows:

Health staff should be aware that adolescents requesting contraceptives have a right to receive these services, regardless of age or marital status.

Kenya is placed in the green category for this indicator as the policy environment includes a clear provision for youth to access FP services regardless of marital status.

Adolescents and youth in Kenya can access a full range of contraception under existing policies. The “National Guidelines for Provision of Adolescent and Youth Friendly Services in Kenya, 2016” include contraception as a component in the essential package of service offerings for adolescents:

Contraception counselling and provision of full range of contraceptive methods, including long-acting reversible methods.

While the “National Family Planning Guidelines for Service Providers, 6th Edition, 2016” support adolescent and youth access to all methods of contraception alongside counseling, it discourages the use of permanent methods:

Adolescents and youth in need of contraceptive services can safely use any method, following the guidelines and MEC [medical eligibility criteria] criteria accordingly.

Permanent methods, such as tubal ligation and vasectomy should be discouraged for adolescents and youth without children 

Any adolescent and youth who requests emergency contraception should receive counseling on all methods of FP

 Adolescents may be less tolerant of side effects. It is important to explain the possible side effects during FP counseling in order to reduce the likelihood of discontinuation and seek alternative methods if the side effects persist.

The National Family Planning Guidelines align with the 2015 World Health Organization medical eligibility criteria guidelines. Therefore, Kenya is placed in the green category for this indicator.

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, note that under these guidelines adolescents and youth are eligible to receive EC.

The cabinet secretaries of the Ministries of Education and Health have jointly signed the “National School Health Policy, 2019.” The Policy does not detail a standalone comprehensive sexuality education (CSE) program but rather integrates several of the United Nations Population Fund’s (UNFPA’s) essential components throughout the document, including the recognition of international and national equal rights to health reproductive health; an integrated focus on gender; access and links to sexual and reproductive health (SRH) information and services; a safe and healthy learning environment; and cultural relevance. However, the Policy does not clearly address the remaining four essential CSE elements: scientifically accurate information, participatory teaching methods, youth advocacy and civic engagement, and connections to the informal sector.

References to sexuality education are vague in the Policy. The most relevant section, “Early/Unprotected sexual activity” alludes to protectionist educational opportunities, such as abstinence, to learn about avoiding sexual situations but does not explicitly mention enabling educational practices, such as linking youth to SRH services or informing youth about contraception:

The design and production of educational materials shall be done in collaboration with Ministry of Education—KIE [Kenya Institute of Education] and Ministry of Public Health and Sanitation (MOPHS).

The adolescent reproductive health materials developed through MOPHS shall be reviewed for relevance in the various school classes’ grades.

Schools shall equip students with adequate skills to avoid situations that would lead to teenage pregnancy, rape and sodomy.

All children, including those with special needs and disability, shall be protected from sexual violence and abuse.

Students shall be taught and instilled with skills to avoid health risks, including rape.

Students shall be taught about the consequences of involving themselves in sexual activities as these may lead to pregnancy, disease, infertility etc.

The “National Adolescent Sexual and Reproductive Health Policy, 2015,” includes more direct CSE guidance for educating youth. In the policy, CSE is defined as:

Age-Appropriate Comprehensive Sexuality Education is an age-appropriate, culturally relevant approach to teaching about sexuality and relationships by providing scientifically accurate, realistic and non-judgmental information. Sexuality education provides opportunities to explore one’s own values and attitudes as well as build decision-making communication and risk reduction skills about many aspects of sexuality.

The guidelines in the “National Adolescent Sexual and Reproductive Health Policy” and the “National Adolescent Sexual Reproductive Health Policy Implementation Framework, 2017-2021” lay out a vision for sexuality education in the country, including elements such as reaching in-school and out-of-school youth, using medically accurate information, and training health care providers to provide SRH information. Further, the “National Guidelines for Provision of Adolescent and Youth Friendly Services in Kenya, 2016” present a framework for youth-friendly service delivery based at schools. Included in this framework are components such as life skills education on decision-making, negotiation, self-assurance, and communication, as well as an emphasis on school discussions on the topic of sexual assault. None of these guidelines, however, cover all nine essential components of CSE.

The policy environment surrounding CSE in Kenya is considered promising but incomplete, and the country has been placed in the yellow category for this indicator.

Kenya has an inclusive and supportive policy environment for the provision of sexual and reproductive health (SRH) services to both youth and adolescents, incorporating the three service-delivery elements of youth-friendly contraceptive services . The “National Guidelines for Provision of Adolescent and Youth Friendly Services in Kenya, 2016” recognize the health and human rights of young people. The guidelines explicitly address the high cost of services as a barrier to youth seeking FP services:

All adolescents and youth should be able to receive health services free of charge or are able to afford any charges that might be in place.

The National Guidelines recognize and address the challenges providers face when balancing personal beliefs with the provision of SRH care to youth:

Health service providers report being torn between personal feelings, cultural and religious values and beliefs and their wish to respect young people’s rights to accessing and obtaining SRH services. Training of service providers should address service provider attitudes and beliefs, and improve provider knowledge of normal adolescent development and special characteristics of adolescent clients and skills—both clinical and counselling.

The “National Family Planning Guidelines for Service Providers, 2016” further reference offering nonjudgmental and private contraceptive services:

Health service providers should receive both pre- and in-service training on but not limited to:

• Essential package for AYFS [adolescent and youth-friendly services]
• Value clarification and attitude transformation
• (VCAT) training on adolescent and youth sexuality and provision of services such as contraception
• Characteristics of adolescent growth and development (including neurobiological, developmental and physical) which impact health
• Privacy and confidentiality

The “National Adolescent Sexual Reproductive Health Policy Implementation Framework, 2017-2021” also outlines several planned activities to expand and improve provider training on adolescent and youth-friendly services.

Since the policy environment addresses the three core elements of youth-friendly service provision, Kenya is placed in the green category for this indicator.

Thematic Area 5 of Kenya’s “National Family Planning Costed Implementation Plan, 2017-2020” outlines several activities to promote FP within the community, one of which targets support for adolescent sexual and reproductive health:

Activity DC 2. Adaptation of a multisectoral/stakeholder approach in provision of accurate and consistent information on FP to communities.

DC 2.1.3. FP coordinators to support adolescents and youth to promote FP among peers.

The “National Adolescent Sexual and Reproductive Health Policy, 2015” states an objective to “promote adolescent sexual and reproductive health and rights” and includes specific actions relevant to building community support and addressing gender norms:

Promote education of parents and the community on Sexual and Reproductive Health and Rights of adolescents

Mainstream gender and address its concerns in all ASRH [adolescent sexual and reproductive health] programs.

Both actions are further detailed in “The “National Adolescent Sexual Reproductive Health Policy Implementation Framework, 2017-2021.”

Additionally, the “National Guidelines for Provision of Adolescent and Youth Friendly Services in Kenya, 2016” recognize the compounding impact of gender norms for youth accessing FP:

Gender inequities and differences that characterize the social, cultural and economic lives of the young people influence their health and development. Thus, adolescents and youth friendly reproductive and sexual health services must promote gender equality

All three policies seek to create an enabling social environment for youth FP, placing Kenya in the green category for this indicator.

The  “Loi n^o2017-043 fixant les règles générales régissant la santé de la reproduction et la planification familiale” addresses an individual’s right to plan their family without consent from their partner:

Article 4.-Toute personne a le droit de fonder une famille, de procréer ainsi que de

Décider librement avec discernement du nombre d’enfants de l’espacement des naissances et ce, indépendamment de l’autorisation de son partenaire.

The “Manuel de référence pour la formation des prestataires de services en santé des adolescents et jeunes, 2018” outlines the roles and qualities that reproductive health providers should adopt when treating adolescents and young people, including ensuring access to services without requiring parental consent:

3.3 Rôles et qualités d’un bon prestataire

…

Tableau 6 : Qualités d’un bon prestataire

Un prestataire de service de santé qui interagit avec les adolescents et les jeunes devrait posséder, pratiquer et maîtriser les caractéristiques d’une communication efficace suivantes

…

6. Assurer la confidentialité : conseiller et traiter les adolescents et les jeunes avec ou sans le consentement des parents et des tuteurs, mais privilégier le consentement volontaire informé ;

These adolescent and health services include contraceptive methods:

4.4 Avantages de la contraception pour les adolescentes

- Report de l’âge de la première grossesse ;

- Prévention des grossesses précoces et non désirées ;

- Prévention des infections sexuellement transmissible y compris le VIH/SIDA ;

- Faible déperdition scolaire.

4.5 Méthodes de contraception pour les adolescents et jeunes

Les prestataires de service de santé doivent avoir :

- avoir d’une manière générale des compétences particulières en matière de contraception et plus particulièrement chez les adolescents.

- maîtriser les méthodes contraceptives adaptées aux adolescents.

Madagascar is placed in the yellow category for this indicator because its policies support youth access to FP services without consent from parents but does not address consent from spouses.

The "Loi n°2017-043 fixant les règles générales régissant la santé de la reproduction et la planification familiale" states that providers are obligated to respect a patient’s confidentiality and individual choice in family planning :

Article 14- Article 14.- L'obligation de confidentialité de respecter les règles de déontologie, d'informer de respecter le choix des individus est imposée aux prestataires de soins de la Santé de la Reproduction et de la Planification Familiale.

The “Normes et procédures en santé de la reproduction, 2017” state that all clients have the right to access services without discrimination and that providers must adhere to the terms of counseling, provide impartial and complete information, and put aside personal prejudices when providing reproductive health services:

Droit à l’accès aux services 

- S’assurer que les services atteindront, sans discrimination, tous les individus qui en ont besoin, même ceux pour qui les services réguliers de santé ne sont pas facilement accessibles notamment pour les adolescents et jeunes.  

Droit à la liberté de choix 

-Fournir des informations impartiales et complètes, pour permettre un choix libre et éclairé par le/la patient(e) : choisir le lieu, le type de prestataire, la modalité d’obtention des soins… 

-Assurer la disponibilité d’une gamme complète en intrants SR [santé reproductive]. 

…

Droit à la dignité

₋Traiter les patients avec courtoisie, considération, attention, et avec le total respect de leur dignité, sans considération de leur niveau d’instruction, statut social, ou tout autre caractéristique qui peut les singulariser ou les faire dénigrer.

₋Mettre de côté ses préjugés personnels, de genre, d’état civil, de statut social ainsi que ses préjugés et attitudes intellectuelles. 

The “Normes” also require service providers to use the medical eligibility criteria when providing contraceptives and notes that providers should respect the terms of counseling to youth:

2. Offre de service PF aux adolescents et aux jeunes

Premier contact : CSB [centre de santé de base] (Sages-femmes, infirmiers et médecins généralistes)

• Bien accueillir les adolescents et les jeunes, avec intimité, confidentialité et convivialité
• Conseiller les adolescents et jeunes qui demandent de l’aide tout en respectant les modalités en counseling
• Informer les jeunes (sexuellement actifs ou non sur le planning familial
• Donner la possibilité d’un choix éclairé sur la Planification Familiale [PF]
• Offrir un service de PF en expliquant l’importance, les avantages et effets indésirables, avec les moyens de les gérer

While the law underscores the providers’ obligation to respect youth choice in reproductive health and family planning and directs them to use medical eligibility criteria, it does not address nonmedical provider authorization. Madagascar is therefore placed in the yellow category for this indicator.

The "Loi n°2017-043 fixant les règles générales régissant la santé de la reproduction et la planification familiale" states that all individuals have the right to reproductive health and family planning regardless of age or marital status:

Article 3.  Tous les individus sont égaux en droit et en dignité en matière de santé de la reproduction. Chaque individu sans discrimination, peut mener une vie sexuelle responsable et sans risque.

Le droit à la Santé de la Reproduction et à la Planification Familiale est un droit fondamental.

Aucun individu ne peut être privé de ce droit dont il bénéficie sans discrimination

Aucune fondée sur l'âge, le sexe, la fortune, la couleur, de la peau, la religion, l'ethnie, la situation matrimoniale ou sur toute autre situation.

Madagascar is placed in the green category for this indicator as the law supports youth access to FP services regardless of age.

The "Loi n°2017-043 fixant les règles générales régissant la santé de la reproduction et la planification familiale" states that all individuals have the right to reproductive health and family planning regardless of age or marital status:

Article 3.  Tous les individus sont égaux en droit et en dignité en matière de santé de la reproduction. Chaque individu sans discrimination, peut mener une vie sexuelle responsable et sans risque.

Le droit à la Santé de la Reproduction et à la Planification Familiale est un droit fondamental.

Aucun individu ne peut être privé de ce droit dont il bénéficie sans discrimination aucune fondée sur l'âge, le sexe, la fortune, la couleur, de la peau, la religion, l'ethnie, la situation matrimoniale ou sur toute autre situation.

The law also states that young people and adolescents can access reproductive healthcare regardless of marital status:

Article 21: Les soins et prestations de services de Santé de la Reproduction comprenant, entre autres, les composantes suivantes : …

3) la santé reproductive des jeunes et adolescents : Conseils et offre de service de Planification Familiale pour les adolescents sexuellement actifs mariés ou non;

Madagascar is placed in the green category for this indicator because the policy environment confirms that youth must be permitted access to FP services regardless of marital status.

The "Loi n° 2017-043 fixant les règles générales régissant la santé de la reproduction et la planification familiale" supports an individual’s right to information on a range of contraceptive methods:

Article 3 : …Chaque individu a droit à l’information, a l’éducation concernant les avantages, les risques et l’efficacité de toutes les méthodes contraceptives. 

The "Plan d’action national budgétisé en planification familiale à Madagascar, 2016-2020" includes a strategic priority on adolescent contraceptive demand creation through information on modern methods:

Priorité 2 : Créer la demande auprès de la population, surtout les jeunes, à travers des informations correctes et appropriées sur les méthodes modernes de PF et des points de services.

The “Plan d’action” also outlines a strategy to increase the range of methods available to young people, including long-acting reversible contraceptives (LARCs):

Des stratégies vont être mises en place pour remédier aux problèmes de manque de formation du personnel, renforcer les compétences des prestataires en PF, améliorer l’offre de la gamme des produits contraceptifs de qualité, notamment des méthodes modernes et de longue durée et enfin favoriser l’accès à la PF de qualité pour tous, surtout parmi les jeunes.

The "Plan de développement du secteur santé, 2020-2024" includes an objective to expand the range of contraceptives available in Madagascar without specifying youth and adolescents as beneficiaries:

Produit  1.1.6: Le contrôle de naissance et la lutte contre la grossesse non désirée est améliorée

Grandes lignes d’interventions

- Vulgarisation et valorisation des NTIC dans l’éducation sur les méthodes contraceptives naturelles

et modernes

- Extension des offres de service PF au niveau communautaire

- Implication effective des hommes dans la PF

- Extension de la gamme de produits contraceptifs

Madagascar's policies outline strategies for increasing youth access to a range of methods, including LARCs. Therefore, Madagascar is placed in the green category for this indicator.

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, note that the “Plan d’action” includes EC in its plans to promote and scale up long-acting and new contraceptive methods, but not in the adolescent-specific section on sexual and reproductive health. Thus, it is unclear whether the policy intends for EC to be accessible to youth.

The "Loi n° 2017-043 fixant les règles générales régissant la santé de la reproduction et la planification familiale" aims to ensure universal access to FP education:

Objectif 3.7 : Assurer l'accès de tous à des services de soins de santé sexuelle et procréative, y compris des fins de la planification familiale, d 'information et d'éducation, et la prise en compte de la santé procréative dans les stratégies et programmes nationaux

The “Plan d’action national budgétisé en planification familiale à Madagascar, 2016-2020” also states the need for reproductive health advocacy and describes an activity to advocate for sexual health education:

CD 2.5 Mettre l’accent sur la sensibilisation des jeunes par rapport à la PF et aux dangers liés à la grossesse précoce. Les jeunes représentent une population vulnérable avec des besoins souvent insatisfaits en raison des barrières culturelles et institutionnelles. Le premier lieu d’éducation des jeunes est l’école. Ainsi, le plaidoyer sera fait à travers la vulgarisation de l’éducation sexuelle dans les écoles publiques et privées vers les professeurs formés.

The “Plan stratégique national en santé de la reproduction des adolescents et des jeunes, 2018-2020” outlines a strategic focus to strengthen access to information that meets adolescents’ and young people’s needs, including interventions in schools:

Axe stratégique 2 : Renforcement de l’accès aux informations répondant aux besoins des adolescents et des jeunes ainsi que des personnes influentes par une communication stratégique

 Interventions Prioritaires

5.4 Intégrer la SRAJ [santé reproductive des adolescents et des jeunes] dans le paquet d’activités des établissements scolaires, des centres sociaux, des Centres d’information et de prise en charge du PVVIH [personne vivant avec le virus de l’immunodéficience humaine]

5.5 Intégrer le programme d’éducation par le pair dans les associations caritatives, confessionnelles et du scoutisme (Kiady, Fanilo, Mpanazava, Tily, Antily...)...

5.7 Poursuivre l’intégration de la SRAJ dans les écoles, centres de formation militaires, garnisons et centres de rééducation pénitentiaires

The "Plan strategique" also lists integration of a comprehensive sexuality education (CSE) program into the public and private school curriculum as a key output:

Produit 7 : Des programmes d’information, d’éducation et d’orientation en matière de SSRAJ ciblant les adolescents et les jeunes sont disponibles et intégrées dans le programme scolaire public et privé.

7 .1 - Mettre à l’échelle le programme d’Education Sexuelle Complète au sein des établissements d’enseignement primaire, secondaire publiques et privés

The “Plan strategique” also lists activities to broaden the reach of a CSE program to out-of-school youth:

6.3 Adapter le programme d’éducation sexuelle complète pour les jeunes non scolarisés 6.4 Adapter les modules sur la SRAJ dans les programmes d’alphabétisation pour la formation de jeunes déscolarisés et non scolarisés, et les centres pour les personnes en situation d’handicap

Finally, the "Plan sectoriel de l'éducation, 2018-2022" outlines the priorities for school health, including the acquisition of responsible health behaviors:

Promouvoir la santé des Jeunes : … En matière de la santé des jeunes, il y a lieu d’augmenter l’accessibilité des jeunes scolarisés aux informations en matière de Santé des Jeunes à travers des actions de sensibilisation au niveau des collèges et lycées afin de leur faire acquérir des comportements responsables en matière de Santé des Jeunes et Adolescents.

The Plan sectoriel" identifies an activity for the next draft of the Malagasy curriculum as the introduction of education on adolescent reproductive health:

Les activités à mettre en œuvre pour élaborer le deuxième draft du u Cadre d’orientation et d’organisation du curriculum malagasy sont :

• la réflexion sur l’introduction des TICE [technologie de l'information et de la communication en éducation], les compétences pour la vie dont l’éducation sexuelle qui englobe la santé reproductive des adolescents (SRA ) et l’éducation des filles, la santé scolaire, l’éducation inclusive, l’éducation à la citoyenneté, l’éducation à la paix, la lutte contre la corruption, l’EDD [éducation au développement durable] avec intégration des thèmes éducation civique, éducation environnementale, éducation maritime.

The “Strategie nationale de lutte contre le mariage des enfants, 2017-2024” discusses several approaches to increase sexual and reproductive health knowledge among adolescents and young people, including in and out of schools:

Axe Stratégique 2.1

Promouvoir la santé et le bien-être pour assurer la réduction de la vulnérabilité des jeunes visant le changement de leur comportement lié à la sexualité

211-Renforcer et intensifier la diffusion des informations et la communication interpersonnelle sur la santé reproductive, la sexualité et les services disponibles auprès des enfants et jeunes

212- Renforcer/Inclure dans le Programme scolaire l'éducation sur la santé sexuelle et de reproduction

213-Conseiller et accompagner les adolescents dans leur choix de comportement sexuel pour s’auto-protéger contre le mariage et la grossesse précoces

214-Renforcer l'éducation sur la santé sexuelle et de reproduction pour les enfants en dehors du système scolaire.

In its strategy to raise awareness of reproductive health and FP among adolescents and youth, the “Plan stratégique intégré en planification familiale et en sécurisation des produits de santé de la reproduction, 2021-2025” specifically addresses scaling up CSE based on the United Nations Educational, Scientific and Cultural Organization (UNESCO) guiding principles:

Objectif spécifique 1.1 : Réduire de 28,9 % à 25% la proportion des adolescentes (15-19 ans) ayant déjà eu un enfant

Tableau 3 : Orientation stratégiques et axes prioritaires

Stratégies : Renforcement des actions de sensibilisations en SR/PF adaptées à chaque tranche d’âge pour les adolescents et les jeunes

Actions prioritaires 

6. Mise à l’échelle de l’éducation complète à la sexualité basée sur les principes directeurs de l’UNESCO 

The sexual and reproductive education strategies discussed in the “Plan stratégique” include strengthening FP communication strategies for in and out-of-school youth:

Strategies :

• Renforcement des stratégies de communication en direction des jeunes scolarisés et non scolarisés.

Résultats attendus

• Les jeunes et les adolescents fréquentant les CSB amis des jeunes, les réseaux de services « Amis des jeunes » sont conscients des avantages de la SR/PF et des dangers liés à la grossesse précoce et en adoptent des comportements sains
• Les élèves des écoles publiques et privées des Chefs-lieux des 113 Districts Sanitaires sont informés et sensibilisés sur l’éducation à la sexualité et adoptent des comportements sains en matière de SR et de PF
• Les jeunes sont sensibilisés sur les avantages de la PF, sur les dangers liés à la grossesse et l’accouchement et adoptent des comportements sains grâce aux TIC (SMS, internet).

Madagascar’s policy environment is supportive of sexuality education but does not outline a detailed CSE policy referencing all nine of the United Nations Population Fund (UNFPA) essential components. Therefore, Madagascar is placed in the yellow category for this indicator.

The "Loi nº 2017-043 fixant les règles générales régissant la santé de la reproduction et la planification familiale" states that providers are obligated to respect a patient’s confidentiality and individual choice in family planning:

Article 14- Article 14.- L'obligation de confidentialité de respecter les règles de déontologie, d'informer de respecter le choix des individus est imposée aux prestataires de soins de la Santé de la Reproduction et de la Planification Familiale.

The "Plan stratégique national en santé de la reproduction des adolescents et des jeunes, 2018-2020" outlines activities to reinforce the competencies of service providers, including training service providers on youth- friendly services:

Axe stratégique 3 : Renforcement de capacités institutionnelles et des compétences techniques et managériales des acteurs impliqués dans la mise en œuvre du PSN [plan stratégique national], y compris les adolescents et les jeunes.

Interventions :

8.1 Instaurer un service convivial de SRAJ [santé reproductive des adolescents et des jeunes] avec renforcement en sensibilisations basées sur la prévention dans la structure de prise en charge des cas de situation d’urgence ;

8.2. Former les prestataires de services (médecin, sage-femme, assistants sociaux ; responsable des centres sociaux, AC [agent communautaire], centre de rééducation et de réinsertion sociale, intervenants sociaux) sur les techniques de communication au profit des groupes spécifiques des adolescents et des jeunes ;

8.3. Développer et mettre en œuvre des stratégies avancées pour les jeunes de rue, les jeunes délinquants, les jeunes de la population clé à haut risque, les jeunes en situation d’handicap, les jeunes en couple et les jeunes parents ;

8.4. Développer et mettre à l’échelle les offres communautaires pour les jeunes en union et jeune parent pour la première fois en utilisant les services de santé disponibles et les événements communautaires ;

The "Plan stratégique " also details the recipients of training activities on adolescent health, including providers, managerial staff, and referral staff:

Axe Stratégique 4 : Offre de services de santé communautaires et cliniques intégrés de SSRAJ de qualité et conviviaux adaptés aux adolescents et jeunes 

Interventions :

12.1 Identifier les besoins de formation et de renforcement de capacités techniques des prestataires et des superviseurs à tous les différents niveaux en matière de SRAJ

12.2 Élaborer le kit de formation de capacités techniques et managériales à l’intention des prestataires et des superviseurs

12.3 Développer le système de référence et de contre référence à partir du niveau communautaire

12.4 Assurer la formation de prestataires de services sur les techniques d’offre de services SSRAJ [santé sexuelle et reproductive des adolescents et des jeunes] aux adolescents et jeunes

12.5. Former le personnel d’appui en accueil et orientation des adolescents et des jeunes clients 12.6 Assurer la formation managériale et les visites d’échanges d’expériences pour les gestionnaires de programmes à divers niveaux (secteurs public et privé) sur les dispositifs d’offre de service de SSRAJ

The "Plan d’action national budgétisé en planification familiale à Madagascar, 2016-2020" describes additional activities to train service providers to better provide services to young people, including training to reduce bias, stigma, and discrimination:

OAS 3.7 Renforcement de l’approche jeune dans la prestation de services PF.

… De nouveaux espaces jeunes, de nouveaux centres amis des jeunes, coins et kiosques des jeunes vont également être créés dans plus de 25% des CSB [centres de santé de base] publics de chaque district sanitaire qui vont être transformés en CSB « Ami des Jeunes ». Ils seront, en outre, mis aux normes en matière d’IEC [information, éducation et communication]/CCC [communication pour le changement de comportement]. Enfin, le personnel de santé va être formé à l’IEC/CCC en PF et à l’approche jeune permettant ainsi une meilleure prise en charge de cette tranche de la population.

OAS 3.7.3 Transformer des CSB2 des 113 DS en CSB Amis des jeunes Paravent pour confidentialité

OAS 3.7.3.1 Identifier des CSB à transformer en CSB Amis des jeunes (salle pour accueil des jeunes, personnel de santé suffisant, ...)

…

OAS 3.7.3.3 Former des formateurs en SRA [santé de la reproduction des adolescents]/approche jeune

The “Normes et procédures en santé de la reproduction, 2017” also outline the family planning services available to adolescents and youth at varying levels of the health system. All levels emphasize ensuring privacy and confidentiality, providing accurate FP information on all methods, and ensuring free method choice in FP services and counseling.

The “Politique nationale de santé des adolescents et des jeunes, 2019” also lays out the required conditions for adolescents and youth-friendly service provision, and emphasizes the affordability of services and nondiscrimination toward adolescents and young people:

2. Accès facile aux services des adolescents et des jeunes.

La politique prévoit l’amélioration de l’accès aux services à travers :

-la disponibilité de l’offre de services de qualité en santé des adolescents et des jeunes, adaptés à leurs besoins : accessibles, acceptables, abordables, équitables, adéquats, efficaces et pérennes ;

-l’augmentation de l’utilisation des services sera renforcée par le biais de la stimulation de la demande ;

la disponibilité et la diffusion des informations sur les offres de service en santé des adolescents et des jeunes ;

-l’application des lois en vigueur concernant les droits en santé sexuelle et reproductive des adolescents et des jeunes ;

-la non-discrimination et la non stigmatisation envers les adolescents et les jeunes.

The "Plan d’action" references a Malagasy policy signed in 2006 that includes a provision of free FP products and services, but the policy could not be located for review. As reviewed policies address training and supporting providers and enforcing confidentiality but do not sufficiently address the cost of services, Madagascar is placed in the yellow category for this indicator.

The "Loi n° 2017-043 fixant les règles générales régissant la santé de la reproduction et la planification familiale" outlines the importance of male involvement in reproductive health (RH):

Article 16 : Les personnes du genre masculin ont le devoir de protéger le droit des femmes à la santé sexuelle et reproductive de ces dernières, notamment leur accès aux services et le respect de leur choix sur la procréation.

The "Plan stratégique national en santé de la reproduction des adolescents et des jeunes, 2018-2020" outlines community dialogues as a priority intervention:

Interventions Prioritaires :

1.3 Programmer des dialogues communautaires pour discuter des droits des jeunes et des comportements responsables en leur faveur

The "Plan stratégique" provides further clarity in detailed strategic communication activities to enable support for youth access to RH services:

Interventions Prioritaires :...

5.9 Renforcer les capacités des acteurs/communauté éducative (parents et animateurs, AC [agent communautaire], éducateurs, jeunes leaders, agents de santé) sur la SRAJ [santé reproductive des adolescents et des jeunes], communication pour le changement social et comportemental des jeunes, et l’orientation vers les services

Axe stratégique 2 : Renforcement de l’accès aux informations répondant aux besoins des adolescents et des jeunes ainsi que des personnes influentes par une communication stratégique...

6.2 Recenser et orienter les activités de communication/ sensibilisation sur SRAJ dans les centres d’écoute, centres de promotion sociale, centres de jeunesse et au niveau des organisations de sports et des loisirs avec un accent sur le genre et le référencement...

6.9 Organiser des séances de communication au profit des personnes influentes, des adolescents et des jeunes en vue de leur appui dans l’orientation des jeunes (parents) vers les services SSRAJ [santé sexuelle et reproductive des adolescents et des jeunes]

The “Plan stratégique” includes other activities to target traditional and religious leaders and others influential in the community to build their capacity to defend adolescent and youth reproductive health:

9.1 Renforcer et mettre à l’échelle un programme d’éducation des parents au niveau communautaire et autour des structures d’encadrement des adolescents et jeunes

9.2 Renforcer les compétences des APART [autorités politiques administratives religieuses et traditionnelles] en vue de mieux défendre les intérêts des groupes d’adolescents et jeunes vulnérables en matière de SSRAJ

9.3 Elaborer et diffuser un catalogue/ répertoire renfermant tous les supports IEC [information-éducation-communication] disponibles pour faciliter l’accès aux utilisateurs

9.4 Organiser des dialogues communautaires et débats médiatiques et événementielles impliquant les autorités et les leaders traditionnels (APART) sur la question SSRAJ notamment sur le mariage des enfants et la grossesse précoce

9.5 Organiser des dialogues communautaires entre parents et adolescents portant sur les obstacles culturels à la promotion de la SSRAJ

9.6 Appuyer les CTD [collectivités locales décentralisées] et les organisations confessionnelles pour l’intégration des activités SSRAJ dans leurs priorités d’actions

The "Plan sectoriel de l’éducation, 2018-2022" includes activities to build support within the community for adolescent RH awareness and acknowledges the challenges that young girls face:

En se référant à la partie « Education Inclusive » du présent Plan Sectoriel de l’Education, la discrimination en termes de genre handicape les jeunes filles et a un impact sérieux sur leur scolarisation. Les parents ont assurément une place importante à assurer auprès des jeunes et notamment des jeunes filles dans leur éducation à la notion de genre et à la santé reproductive. Cependant, parler de ces sujets et notamment de la santé reproductive reste tabou dans certaines familles malgaches, et plus particulièrement dans les zones défavorisées.

The "Plan sectoriel" includes activities to strengthen parents’ knowledge of youth sexual and reproductive health through an awareness campaign in collaboration with local radio stations, as well as educating parents and the community on the importance and necessity of sexual health education.

The “Plan d’action national budgétisé en planification familiale à Madagascar, 2016-2020" also lays out a detailed strategy to strengthen the environment for family planning through community engagement and mobilization. The proposed activities include an information campaign to bridge religious and cultural gaps toward acceptance and use of family planning but fail to specifically address youth access. The “Plan d’action” emphasizes the importance of involving men and husbands in family planning, and proposes an information campaign to specifically address the specific needs of young people:

Des efforts particuliers pour la création de la demande vont être faits pour les hommes et les jeunes. Les hommes partagent autant de responsabilités que les femmes dans la santé de la reproduction. Néanmoins, le manque d’attention leur étant portée suggère que la PF ne les concerne pas. L’implication des hommes et des maris est cruciale pour le succès des campagnes de création de la demande. Les hommes peuvent empêcher les femmes d’utiliser la PF et ainsi d’y avoir recours librement. C’est en réduisant leurs préjugés que l’on assurera leur soutien pour la PF. Pour répondre aux besoins spécifiques des jeunes, des campagnes d’information spécifiques vont être mises en place. Elles insisteront sur les dangers des grossesses précoces et sur les bienfaits de la contraception

Additional policy documents also outline strategies for increasing community support for youth FP, including the “Normes et procédures en santé de la reproduction, 2017,” which works to sensitize community leaders in favor of adolescent RH services, and the “Plan stratégique intégré en planification familiale et en sécurisation des produits de santé de la reproduction, 2021-2025,” which includes a strategy to involve social and religious leaders in community dialogues to gain their support for the new reproductive health law, which supports youth FP.

The “Plan stratégique intégré en planification familiale” also targets male reluctance around contraceptive use in its awareness and advocacy campaigns:

Stratégies

Renforcement des campagnes d’information, de sensibilisation et de plaidoyer sur la SR [santé reproductive]/PF auprès de la population

Actions prioritaires

1. Promotion de la masculinité positive (groupes d'hommes, groupes de papas) en vue de sensibiliser ceux et celles qui sont réticents à l’utilisation des méthodes contraceptives modernes

Madagascar’s policies outline specific interventions to build support within the larger community for youth FP and address gender and social norms. Madagascar is therefore placed in the green category for this indicator.

The “Malawi Costed Implementation Plan for Family Planning, 2016-2020” notes that the country’s family planning approach includes access to services without third-party authorization:

Malawi employs a rights-based approach to family planning that includes voluntarism, informed choice, free and informed consent, respect to privacy and confidentiality without having to seek third party authorization, equality and non-discrimination, equity, quality, client-centered care, and participation and accountability.

The “Preservice Education Family Planning Reference Guide, 2010” confirms adolescents’ right to access contraceptives without third-party authorization:

Adolescents need to know: …

• That [contraceptive] methods are available to them and that they are not required to have parental or spousal consent to receive a contraceptive method.

Malawi is placed in the green category for this indicator as its policies support youth access to family planning services without consent from parents and spouses.

The “Preservice Education Family Planning Reference Guide, 2010” provides information and training activities on family planning for health care providers. The “Family Planning Counseling” section emphasizes clients’ informed choice and their rights to accurate FP information and access to services without discrimination. It further details the characteristics a provider should adopt providing services:

Quality counselling is the main way that health workers support and safeguard the client’s rights to informed and voluntary decision-making. (See Section 6.3.) This means never pressuring a client to choose one family planning method over another, or otherwise limiting a client’s choices for any reason other than medical eligibility. Counselling can support all other clients’ rights as well (ACQUIRE Project 2008).

The key principles for cultivating good client-provider interaction and effective family planning counseling include the following:

…

• Remain nonjudgmental about values, behaviours, and decisions that differ from your own.

The Reference Guide also includes World Health Organization medical eligibility criteria (MEC)—which is grounded in medical authorization and can be used to reduce unjustified barriers to FP services  by evidence—also includes a two-category medical eligibility criteria system for use where resources for clinical judgment are limited. The Reference Guide notes that the MEC are not intended as a national guideline for family planning but rather as a reference. The Reference Guide does, however, continue to reinforce adolescents’ medical eligibility for contraception:

21.9 Adolescent Contraception

Adolescents are medically eligible to use any method of contraception and must have access to a variety of contraceptive choices.

Moreover, the “Malawi National Reproductive Health Service Delivery Guidelines, 2014-2019," require health workers to ensure a “friendly, non-judgmental, and welcome” approach in providing adolescent/youth sexual and reproductive health services, including family planning services.

While Malawi’s policies acknowledge the barriers that provider bias and judgment place on access to family planning and note that providers must use clinical judgment when providing contraceptives, the policy language does not explicitly require providers to service youth despite personal beliefs. Malawi is placed in the yellow category for this indicator.

The “National Health Policy, 2017” notes that health administration in Malawi employs a human rights-based approach:

All the people of Malawi shall have the right to good health, and equitable access to health services without any form of discrimination, whether be it based on ethnicity, gender, age, disability, religion, political belief, geographical location, or economic and/or other social conditions.

The “National Sexual and Reproductive Health and Rights Policy, 2017-2022” reiterates the human-rights based approach when it comes to young people accessing sexual and reproductive health services:

3.6 Young people in Reproductive Health

3.6.2 Policy Statements

3.6.2.1 All young people shall have access to quality youth friendly health services that are safe, guard their right to privacy, ensure confidentiality, and provide respect and informed consent, while also respecting their cultural values and religious beliefs.

The “Preservice Education Family Planning Reference Guide, 2010” confirms that this approach also applies specifically to family planning by stating that youth should have access to any method of contraception regardless of age:

21.9 Adolescent Contraception

Adolescents are medically eligible to use any method of contraception and must have access to a variety of contraceptive choices. Age alone does not constitute a medical reason for denying any method to adolescents.

Malawi’s policies include policy affirmations of youth access to family planning regardless of age. Therefore, Malawi is placed in the green category for this indicator.

The “Preservice Education Family Planning Reference Guide, 2010” clearly states that youth should have access to family planning services regardless of marital status:

Right to access to services: Services must be affordable and available, without social barriers such as discrimination based on gender, age, marital status, fertility, nationality or ethnicity, belief, social class, caste, or sexual orientation.

The "Gender Equality Act, 2013" reinforces that access to FP should be provided regardless of marital status:

...every health officer shall:

(a) respect the sexual and reproductive health rights of every person without discrimination;

…

(c) provide family planning services to any person demanding the services irrespective of marital status or whether that person is accompanied by a spouse;

Because the law supports access to FP services regardless of marital status, Malawi is placed in the green category for this indicator.

The “National Sexual and Reproductive Health and Rights Policy, 2017-2022” acknowledges that public health facilities need to offer a full range of methods to reduce unmet need for young people:

3.1. 1 Family Planning Policy Goal

To reduce unmet need for family planning services through provision of voluntary comprehensive family planning services at all levels to all men, women and young people of reproductive age.

3.1.2 Policy Statements

3.1.2.2 Public health facilities shall offer a full range of family planning services, including emergency contraception.

3.1.2.7 Availability of long acting and permanent methods of contraceptives shall be expanded at all levels of health care service.

3.1.2.10 Emergency contraception shall be made available to all women who have had unprotected sex.

The “Preservice Education Family Planning Reference Guide, 2010” further details the medical eligibility criteria for adolescents, confirming safety and accessibility of all methods for adolescents:

21.8 Medical Eligibility Criteria for Adolescents

All contraceptive methods are safe for adolescents.

21.9 Adolescent Contraception

Adolescents are medically eligible to use any method of contraception and must have access to a variety of contraceptive choices. Age alone does not constitute a medical reason for denying any method to adolescents. While some concerns have been expressed regarding adolescents’ use of certain contraceptive methods (such as DMPA [depot medroxyprogesterone acetate] by youth under 18), these concerns must be balanced against the advantages of avoiding pregnancy. Social and behavioural issues should be important considerations in the choice of contraceptive methods by adolescents.

The Reference Guide provides additional considerations for specific methods, such as the privacy afforded by injectable use and dual protection against sexually transmitted infections by condoms, and clearly states that there is no medical reason to deny intrauterine devices or sterilization to young people. The Reference Guide also provides tables that summarize Malawi’s medical eligibility criteria for contraceptive use, which was summarized from the World Health Organization medical eligibility criteria policy, and acknowledges access to methods regardless of age, parity, and marital status.

As Malawi’s FP guidelines support youth access to a full range of FP methods regardless of age, marital status, and parity, Malawi is placed in the green category for this indictor.

While emergency contraception (EC) eligibility is not factored into this indicator’s rating, there is no clear age limit for young people to access EC even though the Reference Guide indicates no contraindications for EC pills for adolescent women.

Multiple Malawian policies advocate for the provision of sexuality education. The “National Plan of Action for Scaling Up SRH and HIV Prevention Initiatives for Young People, 2008-2012” includes objectives to increase life skills education for in-school youth:

Sub-objective 2.1.1. Scale Up Life Skills Education (LSE) for in-school young people.

Sub-objective 2.1.2 Scaled up LSE for out of school and vulnerable people.

Sub-objective 2.1.3: Scale up LSE for young people in work places.

Sub-objective 2.1.4: Improved and expanded SRH [sexual and reproductive health] peer education activities.

Sub-objective 2.1.5: Increase access to information on gender and legal literacy.

Sub-objective 2.1.6: Young women skilled in GBV [gender-based violence] prevention strategies.

Sub-objective 2.1.7: Increased access to alternative rites of passage program among young undergoing traditional initiation in selected communities.

Sub-objective 2.1.8: Increased exposure to BCC [behavior change communication] and edutainment activities using folk and mass media.

Sub-objective 2.1.9: Increased parent-child communication on SRH and HIV prevention issues in homes and communities.

The “National Youth Policy, 2013” advocates for the provision of comprehensive sexuality education (CSE) to increase youth uptake of family planning services:

3.6.3.2 Provision of comprehensive sexuality education that promotes abstinence, mutual faithfulness and condom use, uptake of family planning services amongst the youth is advocated.

The “Malawi Costed Implementation Plan for Family Planning, 2016-2020” mentions that the Ministry of Education, Science, and Technology has adopted a comprehensive “Life Skills and Sexual and Reproductive Health curriculum” for secondary school students, but a copy of the curriculum could not be reviewed for this analysis.

In the absence of a CSE curriculum that references all nine United Nations Population Fund (UNFPA) essential components, Malawi is placed in the yellow category for this indicator.

The “National Plan of Action for Scaling Up SRH and HIV Prevention Initiatives for Young People, 2008-2012” includes multiple activities to reach their strategic objective of increased utilization of quality youth-friendly sexual and reproductive health (SRH) services:

Sub-objective 3.1.1. YFHS [youth-friendly health services] SRH institutionalized into existing pre- and in-service training programs for health providers.

Sub-objective 3.1.2: Improved attitudes and competence of service delivery teams to provide quality YFHS.

Sub-objective 3.1.3 Improved facility environment and procedures.

Sub-objective 3.1.5: Improved access to quality YFHS by young people.

Sub-objective 3.1.6: increased availability of support services for young people.

Each sub-objective lays out certain key activities that can be taken to reach their desired input; relevant activities include training providers on attitude change and skills-building components for youth SRH and developing and equipping providers with appropriate job aids and tools to assist in delivery of quality services to youth.

The “Guidelines for Family Planning Communication, 2011” specifically note the barriers that youth face while seeking FP services, including negative attitudes of FP providers toward young people. The Guidelines further note that health workers impose barriers through provider bias when they “bring their own cultural and religious orientations to discussions about FP and make decisions on what is best for the client on that basis.” To address these barriers, the Guidelines note that youth have a right to access all health services, including FP services, and that providers should take the following actions:

Health workers

• Provide all clients, regardless of background, with comprehensive FP information and counseling so they can choose a suitable FP method.
• Encourage clients to return if they experience any unusual and persistent side effects with the method chosen.
• Help clients who are dissatisfied with their method to try a different method.
• Support women who have been sexually assaulted to access PEP [post-exposure prophylaxis] in a caring way. Help to refer them to other key legal and support services in a timely manner.

The “National Sexual and Reproductive Health and Rights Policy, 2017-2022” notes young people’s rights to SRH services that ensure privacy and confidentiality:

3.6.2 Young people in Reproductive Health Policy Statements

3.6.2.1 All young people shall have access to quality youth friendly health services that are safe, guard their right to privacy, ensure confidentiality, and provide respect and informed consent, while also respecting their cultural values and religious beliefs

The “Malawi Costed Implementation Plan for Family Planning, 2016-2020” acknowledges the biases that providers have against providing family planning for youth and note that in-service training should include rights-based services.

Strategic outcomes

SDA1. Health care workers are providing high-quality FP information and services and offering the full method mix to clients. In-service training will be reviewed to ensure training materials provide information on long-acting and reversible contraceptives (LARCs). Job aids will be updated, and supportive supervision will be conducted to ensure that health care providers are providing high-quality, rights-based information and services.

 SDA6. Access to family planning by young people is safe, rights-based, and confidential. To increase the availability of YFHS, health workers, children’s corner patrons, and child representatives will be trained on these services. In addition, monitoring tools will be developed to track YFHS, and FP coordinators will be responsible for ensuring each facility in their district has staff providing the services.

The “Preservice Education Family Planning Reference Guide, 2010” notes that family planning providers should use multiple strategies to improve adolescents’ access to FP services. The strategies include training providers to withhold judgment, providing confidentiality and ensuring audio/visual privacy, and offering services free or at low cost:

21.6 Improving Adolescents’ Access to Family Planning Services

Improving adolescents’ access to family planning services involves coordinated efforts by family planning providers, family planning service managers, and local and national health officials.

Strategies include:

• Training providers to offer “youth-friendly” counselling (see Section 21.7)
• Dedicating special areas of family planning clinics for adolescents, to help ensure privacy
• Using outreach and mobile clinics with staff trained to respond to adolescents’ needs
• Offering clinic hours convenient for youth, such as after school and during weekends
• Locating services in convenient, safe areas
• Educating community-based contraceptive distributors and primary health workers (extension workers) about adolescents’ challenges and needs and how they can assist them appropriately
• Offering youth a full range of family planning services, including ECPs [emergency contraception pills] and STI/HIV counselling and testing
• Providing psychosocial support and education about rape and harmful sexual practices and beliefs, such as ritual sexual cleansing
• Strengthening policies related to adolescent reproductive health services
• Obtaining political and community acceptance and support
• Offering services free or at low cost.

Malawi’s “National Youth Friendly Health Services Strategy, 2015-2020" includes a specific objective to enhance the capacity of service providers and implementing partners to deliver youth-friendly health services. To meet this objective, the Strategy identifies key activities that focus on the provision of on-the-job training, including the incorporation of youth-friendly health service standards among key competencies to be attained during pre-service trainings and the development of staff capacity in referral centers.

The policies reviewed clearly address the need to train and support providers to offer youth-friendly contraceptive services, as well as provide confidentiality and audio/visual privacy and free FP services. Malawi is placed in the green category for this indicator.

Malawi’s “National Population Policy, 2012” includes male involvement in reproductive health in its guiding principles and identifies two specific objectives that speak to creating an enabling environment for adolescent-friendly contraceptive services:

Recognizes the need to assist couples and individuals to fully meet their sexual and reproductive health rights and goals, with particular emphasis on male involvement in meeting women and their own reproductive health needs.

…

3.1.4 Policy Area 1: Specific Objective 3

To address cultural, religious, and other barriers of demand, access and use of family planning, including enhancing male involvement in reproductive health, enhancing the role of community members in IEC [information, education, and communication] and distribution of contraceptives, and improving family planning commodity security.

…

3.1.5 Policy Area 1: Specific Objective 5

Enhance the role of national and local traditional, religious, and political leaders in championing population issues among Malawians.

Although not specific to youth access to family planning, the Population Policy recognizes the role that traditional leaders and community members can play in creating an environment supportive of family planning access and use:

Traditional Leaders and community members

The policy recognizes the important role that active participation of traditional leaders such as chiefs and communities at large play in implementation of development programmes at grassroots level. The policy will foster empowerment of traditional leaders to operate as champions of family planning; school enrolment, retention, and progression; reform or eradication of harmful traditional practices such as early marriage, and other population programmes. Community members will also enhance implementation of the policy through their active participation in planning, implementation, monitoring and evaluation. In particular, the policy will enhance the direct role of community members in enhancing IEC campaigns on the small-family norm and delivery of family planning and other reproductive health services within communities.

The “National Gender Policy, 2015” also includes four strategies to address gender within sexual and reproductive health:

Policy Priority Area 2: GENDER IN HEALTH

Objective 1: To improve women and girls’ sexual and reproductive health rights

Strategy 1: Advocate for the modification and elimination of harmful cultural practices affecting reproductive health of women and girls and other vulnerable groups;

Strategy 2: Advocate for increased male involvement in reproductive health services;

Strategy 3: Promote awareness on the benefits of sexual and reproductive health services among women, men, girls and boys;

Strategy 4: Advocate for more user friendly health facilities and services that benefit women and girls, men and boys and vulnerable groups especially those in rural areas.

Within the strategic objective to create an enabling and supportive policy environment to improve SRH for young people, the “National Plan of Action for Scaling Up SRH and HIV Prevention Initiatives for Young People, 2008-2012” lays out multiple sub-objectives:

Faith and community leaders supportive of youth rights and enforcement of laws and policies

• Orient [youth action committees] and [youth technical committees] in advocacy and SRH and HIV/AIDS advocacy plan for young people
• Organize national religious leaders conference to review policies, programs and training curriculum of religious schools in relation to SRH, HIV prevention, some cultural practices and gender practices
• Target different cultural institutions with SRH/HIV interventions (Traditional leaders, traditional healers, Namkungwi’s, Angaliba and marriage counselors)
• Review cultural practices of each cultural group that have an impact on SRH and HIV and identify positive and negative practices (including which harmful practices to illuminate)

The National Plan of Action continues by addressing the need to build community support for youth SRH to reach increased utilization of quality youth-friendly SRH services:

Sub-objective 3.2.1 Increased support for YFHS [youth-friendly health services] among teachers, guardians, and the community leaders

Key Activity: Conduct participatory learning and action at the community level to engage parents, guardians, and community leaders on issues affecting young people in their communities, inform them about available YFHS services and solicit their support.

The “Guidelines for Family Planning Communication, 2011” specifically note the barriers that youth face while seeking FP services, including provider bias when they “bring their own cultural and religious orientations to discussions about FP and make decisions on what is best for the client on that basis” and discouragement from community leaders who do not support FP services for youth.

To address these barriers, the Guidelines outline accurate information that can be used in social and behavior change programming for various target groups, including community and religious leaders. The Guidelines continue to share multiple potential advocacy, social and community mobilization, and behavior change communication interventions that can be used to increase support for FP in the community.

The “Malawi Costed Implementation Plan for Family Planning, 2016-2020” also outlines strategies to engage community and traditional leaders as well as parents to increase support for FP:

DC3. Both partners are involved in FP decisions for their family and are supportive of the use of modern contraceptive by their partners. A key strategy to improve demand for family planning will be to engage chiefs and community leaders to provide accurate information about family planning to men in their communities. Traditional leaders will engage men through “husband school” to educate them on the benefits of family planning and address their questions and concerns. Additionally, the number of men who support the use of modern contraception for themselves or their partners will be increased by conducting community outreach events to engage men in FP dialogue and services.

…

DC5. Youth are supported to access FP information or services by their parents. Parents will be engaged through media, health workers, religious groups, and local outreach groups, such as mothers’ groups and child support committees, to have discussions about sexual and reproductive health rights and issues with their children.

Malawi’s policies outline specific interventions to build support within the larger community for youth FP and address gender norms. Therefore, the country is placed in the green category for this indicator.

The "Loi n° 02-044 relative à la santé de la reproduction, 2002" states that spousal consent is required for permanent contraceptive methods except with a second medical opinion in the case of a life-threatening pregnancy:

Article 14 : Toute personne majeure peut, sur son consentement écrit, bénéficier d'une méthode de contraception irréversible. Toutefois, concernant une personne mariée, l'accord de son conjoint est obligatoire. Sur avis médical confirmé par une contre-expertise, toute femme mariée dont la vie pourrait être menacée par la survivance d'une grossesse peut, sur son seul consentement écrit, bénéficier d'une méthode de contraception irréversible. 

The “Politique et normes des services de santé de la reproduction, 2019” reaffirms the law and clarifies that all contraceptives except permanent ones should be offered to all beneficiaries without parental or spousal consent:

3.4.1 La contraception

c. Bénéficiaires

 Les bénéficiaires des services de contraception sont les hommes, les femmes en âge de procréer et en particulier les femmes jeunes sans enfant, les grandes multipares, les personnes à comportement à risque des IST [infection sexuellement transmissible], VIH et Sida, les malades mentaux, les adolescents(es) et les jeunes, la famille et la communauté. Les méthodes de contraception, à l’exception des méthodes permanentes (ligature des trompes et vasectomie) devront être offertes à tous les bénéficiaires qui en feront le choix, sans exiger l'autorisation ou le consentement parental ou marital.

The requirement of parental consent for permanent methods in the "Politique et normes" contrasts with the previous version of the policy from 2005, which did not identify permanent methods as requiring consent.

The “Loi n° 2011-087 du 30 décembre 2011 portant code des personnes et de la famille” states that wives must obey their husbands and that husbands are the head of the family:

Article 316 : Dans la limite des droits et devoirs respectifs des époux consacrés par le présent Code, la femme doit obéissance à son mari, et le mari, protection à sa femme…

Article 319 : Le mari est le chef de famille. Il perd cette qualité au profit de la femme en cas :

• d'absence prolongée et injustifiée ;
• de disparition ;
• d'interdiction ;
• d'impossibilité de manifester sa volonté.

Le choix de la résidence de la famille appartient au mari. La femme est tenue d’habiter avec lui et il est tenu de la recevoir.

Ce choix doit se faire dans l’intérêt exclusif du ménage.

Les charges du ménage pèsent sur le mari. La femme mariée qui dispose de revenus peut contribuer aux charges du ménage.

Mali is placed in the yellow category for this indicator as youth are unable to access permanent methods of contraception without spousal and parental consent. To improve the policy environment, policymakers should legally protect youth access to all FP services without consent from a parent or spouse.

No law or policy exists that requires providers to authorize medically advised youth FP services without personal bias or discrimination. Mali is placed in the gray category for this indicator.

The “Politique et normes des services de santé de la reproduction, 2019” states that contraceptives should be offered to all adolescents and young people:

3.4.1 La contraception

c. Bénéficiaires

Les bénéficiaires des services de contraception sont les hommes, les femmes en âge de procréer et en particulier les femmes jeunes sans enfant, les grandes multipares, les personnes à comportement à risque des IST [infection sexuellement transmissible], VIH et Sida, les malades mentaux, les adolescents(es) et les jeunes, la famille et la communauté.

Therefore, Mali is placed in the green category for this indicator.

The “Loi n° 02-044 relative à la santé de la reproduction, 2002” states that all individuals and all couples are guaranteed access to reproductive health:

Article 3 : Les hommes et les femmes ont le droit égal de liberté, de responsabilité, d'être informés et d'utiliser la méthode de planification ou de régulation des naissances de leur choix, qui ne sont pas contraires à la loi.

Article 4 : Tout individu, tout couple a le droit d'accéder librement à des services de santé de reproduction et de bénéficier des soins de la meilleure qualité possible.

The “Plan d’action national budgétisé de planification familiale du Mali, 2019-2023” interprets the “Loi n° 02-044” as a guarantee of access to contraceptives by individuals and couples:

Le pays a voté, en juin 2002, la loi sur la santé de la reproduction qui garantit le droit à tous les couples et aux individus de disposer d’informations et de services de qualité en matière de planification familiale.

The “Plan d’action” also supports access to contraception regardless of marital status:

Les contraceptifs sont distribués sans distinction à toutes les femmes (mariées ou non-mariées)

Because Mali’s policies support access to contraceptives for unmarried individuals and couples, Mali is placed in the green category for this indicator.

The “Plan décennal de développement sanitaire et social, 2014-2023” affirms the need to make all methods available to youth, including long-acting reversible contraceptives (LARCs):

RS-1.3 : La planification familiale et mieux repositionné dans les activités de SR [santé reproductive]

… Les interventions prioritaires retenues dans ce domaine sont les suivantes : Développement d’interventions spécifiques pour renforcer la continuité de l’offre de services PF de qualité notamment l’utilisation des méthodes de longue durée, l’augmentation de la demande des services de la PF et la facilitation de l’accès des femmes, des hommes, des jeunes et adolescents aux services de PF.

The “Politique et normes des services de santé de la reproduction, 2019” also support adolescent and youth access to contraceptive methods:

c. Bénéficiaires :

Les bénéficiaires des services de contraception sont les hommes, les femmes en âge de procréer et en particulier les femmes jeunes sans enfant, les grandes multipares, les personnes à comportement à risque des IST [infection sexuellement transmissible], VIH et Sida, les malades mentaux, les adolescents(es) et les jeunes, la famille et la communauté.  

While the policy environment is supportive of youth access to contraceptive methods, it does not explicitly state youth access to a range of methods, including LARCs, regardless of age, marital status, or parity. Therefore, Mali is placed in the yellow category for this indicator.

Although the availability of emergency contraception (EC)  is not factored into the categorization of this indicator, note that the “Politique et normes” includes EC in the general list of contraceptive methods, but not in the adolescent-specific section on sexual and reproductive health. Thus, it is not clear whether the policy intends for EC to be accessible to youth.

The “Loi n° 02-044 relative à la santé de la reproduction, 2002” guarantees information and education on contraception:

Article 12: Sont également autorisées, l’information et l'éducation concernant la contraception dans le respect de l'ordre public sanitaire et de la morale familiale.

The “Guide for Constructive Men’s Engagement in Reproductive Health 2008” describes strategies for educating youth about sexual and reproductive health in informal and formal settings:

Objective:
To increase the number of adolescents and young adults trained and sensitized in sexual and reproductive health who adopt positive behaviors within the community.

Strategies:

… Develop innovative initiatives that promote RH within formal and informal education systems

… Encourage sex education dialogue within the family

The “Plan d’action multisectoriel santé des adolescents et des jeunes, 2017-2021" includes multiple school-based and out-of-school activities to increase young people’s awareness of FP information and services, including activities to build civic engagement (one of the nine essential components of comprehensive sexuality education [CSE]):

Axe stratégique 1 : Amélioration de l’accès à des informations appropriées aux besoins sanitaires des adolescents et des jeunes et mobilisation communautaire dans le processus de développement et de mise en œuvre des programmes et projets de SAJ [santé des adolescents et jeunes ].

Objectif spécifique 1 : Assurer la prise en charge globale des IST [infection sexuellement transmissible]/VIH/Sida chez 80% des adolescents et des jeunes sur toute l’étendue du territoire

…

6. Organiser 100 journées de sensibilisation sur l’offre de services intégrés de PF et VIH chez les jeunes dans les établissements scolaire et universitaire et sur les espaces de jeu.

…

Objectif spécifique 2 : Assurer l’offre des services de Planification Familiale chez 50% des adolescents et des jeunes sur toute l’étendue du territoire,

1. Organiser 70300 séances (causeries éducatives, débats) au niveau scolaire, non scolaire et universitaire sur la PF
2. Organiser / sponsoriser 50 (soit 10 par an) activités événementielles qui regroupent les adolescents et les jeunes (festival, streetball, concert, compétition sportive, caravane ...)
3. Organiser 100 journées d'information et de sensibilisation sur la PF auprès des femmes et des leaders religieux
4. Réaliser et diffuser 200 spots et 200 émissions radio en faveur de la PF

Axe 4 : Implication et responsabilisation des adolescents et jeunes dans la promotion de la SAJ

Objectif spécifique 1 : Impliquer les adolescents et les jeunes dans la conception et la mise en œuvre des programmes et projets en faveur de la SAJ.

1. Re-dynamiser 200 réseaux des organisations d’adolescents et de jeunes du Mali.
2. Harmoniser les modules de formation de sensibilisation et d'éducation pour le changement de comportement en faveur de la SAJ.
3. Organiser 250 sessions de formation à l'endroit des réseaux de jeunes pour le renforcement de leur capacité dans la mise en œuvre des activités en SAJ prévues dans leurs plans d'actions annuels à tous les niveaux.
4. Organiser deux (02) forums nationaux sur la Santé des adolescents et des jeunes avec le réseau des associations
5. Impliquer les organisations de jeunesses au processus d'élaboration et de mise en œuvre des plans d'actions SAJ à tous les niveaux

The “Plan d’action national budgétisé de planification familiale du Mali, 2019-2023” describes a specific activity to improve youth advocacy, one of the nine essential components of CSE, by strengthening partnerships with youth groups working in FP. However, this is not described as a component of a CSE program.

Other policy documents, including the "Politique et normes des services de santé de la reproduction, 2019" and the "Réduction de la mortalité maternelle néonatale et infanto-juvenile: plan stratégique, 2014-2018" support the strengthening of sexual health education for adolescents and young people.

Mali is placed in the yellow category for this indicator because its policy environment supports the provision of sexuality education, but it does not describe the components that should be included in a CSE program.

The "Plan d’action national budgétisé de planification familiale du Mali, 2019-2023” addresses the need for FP programs to account for youth and references a specific policy document, “Plan stratégique de santé et de développement des adolescents et des jeunes, 2017-2021” which aims to contribute to improving the health and development of young people through youth-friendly services. As of February 2022, this policy document could not be located for review.

The Plan d’action builds on the preceding action plan by laying out activities to train providers and the staff who train them to be more youth friendly, as well as create youth-friendly spaces with a focus on confidentiality:

Objectif prioritaire 6 : Améliorer l’adaptation des services PF aux adolescents/ jeunes et les personnes vulnérables

Action prioritaire 11 : Renforcement de l’accès aux services PF y compris PFPP [planification familiale du post-partum] et SAA [soins après avortement] des groupes vulnérables et spécifiques (adolescents et jeunes, personnes vivant avec un handicap, réfugiés, déplacées, personnes vivant avec le VIH, etc.)

Activité : Renforcer l’offre adaptée aux besoins des adolescents et des jeunes

Sous-activités:

1. Former 25 formateurs nationaux et régionaux sur la SAJ [santé des adolescents et des jeunes]...
2. Former 1 435 prestataires des districts sanitaires sur la SAJ (1 personne/74 CSRef [Centre de santé de référence] et 1 personne/1 361 CSCom [Centre de santé communautaire])...
3. Aménager des espaces (salles d'attente, confidentialité, sortie à part) pour adolescents et jeunes dans 1 000 structures de santé pour l'offre des services conviviaux aux adolescents et jeunes...
4. Renforcer les capacités des 1 435 centres pour adolescents et jeunes existants pour l'offre de services conviviaux aux adolescents et jeunes...
5. Intégrer dans les PMA[Paquet minimum d’actions] l'offre de services conviviaux aux adolescents et jeunes de préférence par les prestataires jeunes...
6. Réaliser par les CSCom avec les animateurs des ONG [Organisation non gouvernementale] 2 042 (3 sorties par an pour 680 CSCom pendant 4 ans) sorties ciblées d'offre de services à l'endroit des groupes de jeunes et adolescents (jeunes en situation de rupture familiale, etc.)

The “Plan d’action” also acknowledges that training activities will be done to reduce the stigma and discrimination faced by youth:

Des efforts programmatiques vont aussi être faits pour que des prestations et actes de PF deviennent accessibles financièrement pour tous. Lesdits efforts faciliteront également l’accès à un plus grand nombre de services adaptés aux jeunes dans des structures sanitaires avec un personnel formé à cet effet, réduisant ainsi la stigmatisation et les discriminations auxquelles les jeunes font face dans certains centres.

The “Plan d’action” mentions the president’s declaration to initiate free FP services, including steps that should be taken before the policy is implemented:

O.2.2. Renforcement de l’accès financier aux services de PF, y compris PFPP

Un mécanisme de suivi de la déclaration du Président de la République concernant la gratuité des contraceptifs va être mis en place. Des sessions de plaidoyer seront organisées auprès de la présidence pour assurer la mise en œuvre effective de la mesure (voir l’axe politique, environnement habilitant et financement). Pour permettre cet accès aux services PF, avant que la politique de gratuité ne soit mise en œuvre, le le PANB [Plan d’action nationale budgétisé] prévoit des campagnes annuelles d'intensification de l'offre de PF gratuite à tous les niveaux et les journées gratuites mensuelles de prestation PF dans les structures de santé.

Il convient aussi d’élaborer et de mettre en œuvre des plans d’urgence des districts affectés par la crise avec l’offre gratuite de services dans les camps de déplacés ou de réfugiés et pour les communautés d’accueils.

The “Guide for Constructive Men’s Engagement in Reproductive Health 2008” discusses confidentiality:

Objective:
To increase the number of adolescents and young adults trained and sensitized in sexual and reproductive health who adopt positive behaviors within the community.

Strategies:

…Reinforce a climate of trust and confidentiality with teenagers and youth when they access RH [reproductive health] services

The “Réduction de la mortalité maternelle néonatale et infanto-juvenile : plan stratégique, 2014-2018” also includes an action item to improve the welcoming environment for youth when seeking RH services:

Stratégie 3.3 : Promotion de l’approche qualité d’intervention des structures Les interventions prioritaires :

• Améliorer l’accueil dans les structures pour un accès facile des femmes, des hommes, des jeunes et adolescents aux services de SR [santé reproductive] ;

The “Plan stratégique de sécurisation des produits de la santé de la reproduction (SPSR), 2017-2021 au Mali” states in its objectives to make reproductive health products available and affordable to all users:

Ce plan stratégique qui entre en étroite ligne avec les orientations stratégiques du PRODESS III, marque la volonté du Ministère de la Santé et de l’Hygiène Publique de :

1. Rendre les produits SR de qualité constamment disponibles, abordables, et accessibles aux utilisateurs ;

The “Plan d’action multisectoriel santé des adolescents et des jeunes, 2017-2021” includes two specific objectives to increase family planning service use by adolescents and young people and to reduce incidence of undesired and teenage pregnancies. To reach those goals, the “Plan d’action multisectoriel” outlines specific activities that will help increase family planning demand, including one to train providers:

Objectif spécifique 2 : Assurer l’offre des services de Planification Familiale chez 50% des adolescents et des jeunes sur toute l’étendue du territoire 

            Activités :

1. Former 400 prestataires des formations sanitaires et des centres jeunes pour offrir les services de PF adaptés aux adolescents et aux jeunes.
2. Assurer l’approvisionnement régulier de 1500 structures sanitaires par niveaux de la pyramide sanitaire en intrants de la PF en quantité et en qualité
3. Former/Recycler 100 gérants de dépôt et directeurs techniques des centres en gestion logistique des produits contraceptifs

Mali is placed in the green category for this indicator because its policies adequately address all three adolescent-friendly service-delivery elements.

The “Programme de développement socio-sanitaire, 2014-2018” includes a plan to engage parents through developing a training curriculum on communicating with adolescents about sexual and reproductive health:

Afin de promouvoir la planification familiale au Mali, le MPFFE [Ministère de la Promotion de la Femme, la Famille et l’Enfant] se propose de sensibiliser les membres des communautés sur la santé de la reproduction et la planification familiale ainsi que de diffuser la politique de la législation relative à la SR [santé de la reproduction]…Un plan intégré de communication pour le repositionnement de la PF sera élaboré et un curriculum de formation des parents sur la communication avec les enfants et les ados sur la SR développé.

The “Plan d’action national budgétisé de planification familiale du Mali, 2019-2023” recognizes the importance of an enabling environment in access to family planning. The first strategic priority of the “Plan d’action” is to create demand, especially for young people and adolescents, by developing partnerships with the community:

Priorité 1 : Créer la demande auprès des populations, notamment chez les jeunes, les adolescents, les femmes et les hommes, y compris en contexte humanitaire, en développant un partenariat stratégique avec les élus locaux, les leaders communautaires et religieux.

Actions within the strategic priority to create demand include strengthening the commitment of community members—including elected officials and religious and community leaders—to support family planning and spreading awareness and building support within the broader community through dialogue and action:

CD1.1. Renforcement de l’engagement des élus locaux, leaders religieux, communautaires en faveur de la PF

 L’engagement des leaders communautaires, religieux et élus locaux sera obtenu à travers le renforcement de leur niveau de connaissance et de leur implication en matière de PF (multiplication des sessions de formation et d’orientation des leaders femmes, jeunes et hommes et renforcement des contacts avec les communes en faveur de la SR/PF des jeunes). Les stratégies suivantes seront utilisées, telles que l’adaptation et la multiplication des outils et supports de communication sur la PF, la formation en PF, l’utilisation de l'approche Jigisigi Fête de Mariage, basée sur l’utilisation d’un livret donnant au couple des informations sur leur santé en général et sur leur santé reproductive en particulier.

CD1.2. Amélioration de la communication sur la PF à l'endroit des communautés

 La mobilisation communautaire pour la promotion de la PF se réalisera à travers l'implication des groupements féminins et de jeunes/adolescents, des associations professionnelles, des municipalités, et des médias modernes et traditionnels dans les activités. Pour ce faire, les stratégies suivantes seront utilisées, notamment, le développement de partenariats avec les municipalités, l’organisation de campagnes nationales PF et d’autres activités de masse, l’utilisation d’approches comme Térikunda Jèkulu (TJ).

The “Plan d’action” also details a male engagement strategy focused on building male FP champions through peer learning and education groups:

CD1.3. Renforcement de la participation des hommes dans la promotion de la SR/PF (ECH)

 L’engagement des hommes est envisagé sous trois angles :

1. L’homme en tant que client des services de la SR pour lui-même
2. L’homme en tant que partenaire de soutien au sein du couple en matière de reproduction
3. L’homme en tant que facteur de changement au sein de la communauté

Cette stratégie d’engagement constructif des hommes sera matérialisée dans le PANB [Plan d’action nationale budgétisé] 2019-2023 à travers les expériences dites de « l’école des maris », « clubs des maris », « clubs des futurs maris », et « l’approche Handarey »

Finally, the Plan d’action aims to strengthen the decision-making power of women, adolescent girls, and young women in the choice and use of family planning, as well as mobilize adolescents and young people through appropriate communication.

The “Plan d’action multisectoriel santé des adolescents et des jeunes, 2017-2021” includes multiple activities to better increase community awareness of youth family planning, including awareness days with religious leaders:

Axe stratégique 1 : Amélioration de l’accès à des informations appropriées aux besoins sanitaires des adolescents et des jeunes et mobilisation communautaire dans le processus de développement et de mise en œuvre des programmes et projets de SAJ [santé des adolescents et des jeunes].  

…

Objectif spécifique 3 : Augmenter l’utilisation des services de Planification Familiale pour les adolescents et les jeunes d’ici 2021

Activités :

1. Organiser 70300 séances (causeries éducatives, débats) au niveau scolaire, non scolaire et universitaire sur la PF
2. Organiser / sponsoriser 50 (soit 10 par an) activités événementielles qui regroupent les adolescents et les jeunes (festival, streetball, concert, compétition sportive, caravane ...)
3. Organiser 100 journées d'information et de sensibilisation sur la PF auprès des femmes et des leaders religieux 4. Réaliser et diffuser 200 spots et 200 émissions radio en faveur de la PF

Mali’s policy environment adequately addresses gender norms and describes activities for engaging the community to support youth access to FP. Therefore, Mali is placed in the green category for this indicator.

The “Plan d’action national budgétisé en faveur de l’espacement des naissances de la Mauritanie, 2019-2023” acknowledges the difficulty young people face in discussing FP with their parents. However, no law or policy exists that prohibits parental or spousal consent for youth access to FP services. Mauritania is placed in the gray category for this indicator.

The “Plan d’action national budgétisé en faveur de l’espacement des naissances de la Mauritanie, 2019-2023” acknowledges the issue of provider stigma toward youth seeking FP services:

Deuxièmement, l’offre de services de PF est inadaptée aux adolescents et les jeunes. Le personnel soignant des centres ne sait pas comment les recevoir. On peut citer en exemple le manque de confidentialité et même parfois des jugements sévères de la part du personnel des centres. De plus, quand l’offre de service de PF ne fait pas défaut c’est l’accès, que ce soit au niveau géographique ou financier, surtout pour les adolescents et les jeunes en situation de vulnérabilité.

However, no law or policy exists explicitly stating that providers must avoid discrimination or bias toward youth. Mauritania is placed in the gray category for this indicator.

The “Projet de loi relative à la santé de la reproduction, 2017” states that all individuals, including adolescents, are equal in dignity and rights related to reproductive health; it also prohibits discrimination based on age:

Article 7

Tous les individus, y compris les adolescents et les enfants, tous les couples sont égaux en droit et en dignité en matière de santé de la reproduction.

Le droit à la santé de la reproduction est un droit universel fondamental garanti à tout être humain, tout au long de sa vie.

Aucun individu ne peut être privé de ce droit dont il bénéficie sans discrimination aucune fondée sur l’âge, le sexe, la fortune, la couleur, la religion, l’ethnie, la situation matrimoniale ou sur toute autre situation.

Mauritania is placed in the green category for this indicator.

The “Projet de loi relative à la santé de la reproduction, 2017” states that all individuals, including adolescents, are equal in dignity and rights related to reproductive health (RH) and prohibits discrimination based on marital status:

Article 7

Tous les individus, y compris les adolescents et les enfants, tous les couples sont égaux en droit et en dignité en matière de santé de la reproduction.

Le droit à la santé de la reproduction est un droit universel fondamental garanti à tout être humain, tout au long de sa vie.

Aucun individu ne peut être privé de ce droit dont il bénéficie sans discrimination aucune fondée sur l’âge, le sexe, la fortune, la couleur, la religion, l’ethnie, la situation matrimoniale ou sur toute autre situation.

As the law protects youth access to RH regardless of marital status and includes FP as a component of RH services, Mauritania is placed in the green category for this indicator.

The “Projet de loi relative à la santé de la reproduction, 2017” includes “family planning/birth spacing” among reproductive health care services. The “Projet de loi” states that all people, including adolescents, must receive information and education on all methods of birth spacing:

Article 9

Tout couple, toute personne y compris les adolescents et les enfants, a droit à l’information, à l’éducation concernant les avantages, les risques et l’efficacité de toutes les méthodes d’espacement des naissances.

While the law guarantees information and education on all methods of birth spacing, it does not guarantee youth access to a range of contraceptive methods, including long-acting reversible contraceptives (LARCs).

Further, the “Guide de planification familiale—espacement des naissances, édition révisée en avril 2008,” which includes protocols for providing each contraceptive method, states that oral contraceptives are the best method for adolescents and that intrauterine devices (IUDs) should be avoided:

4. AUTRES FEMMES A RISQUE

…Adolescente : la contraception orale constitue la meilleure méthode ; conseiller également l'utilisation du préservatifs si partenaires multiples et éviter surtout le DIU [dispositif intra-utérin].

Future updates to the document should align with the World Health Organization medical eligibility criteria for contraceptive use. A more recent document, “Guide de la pratique sage-femme en Mauritanie, 1ère édition, 2014,” states that IUDs and implants are acceptable for young women, and that IUDs are acceptable for nulliparous women:

Plusieurs études ont démontré que les méthodes contraceptives de longue durée sont plus efficaces que celles de courte durée.

Le DIU et l’implant sont donc des méthodes contraceptives intéressantes, même pour les jeunes femmes. Contrairement à une certaine idée reçue, le DIU n’est pas uniquement indiqué chez les femmes ayant eu un enfant.

The “Plan d’action national budgétisé en faveur de l’espacement des naissances de la Mauritanie, 2019-2023” looks to improve access to a varied and comprehensive range of contraceptive methods, with an emphasis on young people:

3.3.1. Objectifs stratégiques

Objectif 2 : Garantir la couverture en offre de services de PF] /EN [espacement des naissances] et l’accès aux services de qualité en renforçant la capacité des prestataires publics, privés et communautaires et en ciblant les jeunes ruraux et les zones enclavées avec l’élargissement de la gamme des méthodes y compris la mise à l’échelle des MLDA [méthodes à longue durée d’action] et PFPP [planification familiale du post-partum], l’amélioration des services et prestations adaptés aux besoins des jeunes.

Despite the two recent documents that take a more favorable approach to method choice for youth, the policy environment does not consistently guarantee access to a full range of methods for youth. Mauritania is placed in the red category for this indicator.

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, note that EC is included in the 2008 “Guide de planification familiale”, but it is not included in the recommended methods for youth. The 2014 “Guide de la pratique” does not include EC because it focuses on LARC methods.

Mauritania’s policies support the provision of sexuality education for youth. The "Plan d’action national budgétisé en faveur de l’espacement des naissances de la Mauritanie, 2019-2023" prioritizes the implementation of a comprehensive sexuality education (CSE) approach for adolescents and young people in formal and informal education settings:

CD2.1. Mise en place d’une approche d’Education Complète à la Sexualité (ECS) pour les adolescents et les jeunes non/déscolarisés (en situation de vulnérabilité).

 L’éducation complète à la sexualité permet aux adolescents et aux jeunes de prendre des décisions concernant leur sexualité en connaissance de cause. Elle est dispensée sur plusieurs années et fournit aux jeunes des informations adaptées à leur âge et correspondant au développement de leurs capacités : des informations scientifiques et académiques concernant le développement humain, l’anatomie et la grossesse, mais également des renseignements sur la contraception et les infections sexuellement transmissibles (IST), notamment le VIH. Au-delà de leur caractère purement informatif, ces programmes favorisent également la confiance ainsi qu’une meilleure communication. Ils doivent en outre traiter des questions sociales qui entourent la sexualité et la procréation, notamment les normes sociales, la vie de famille et les relations humaines. En prenant en compte les résultats du diagnostic, il s’agit de mieux intégrer les questions de SSR [santé sexuelle et reproductive] et autres spécificités des adolescent(e)s et des jeunes à travers les enseignements formel et non formel. L’intensification de l’enseignement de la SSR/PF dans les écoles de base doit être faite à travers la mise à jour des modules de formation des enseignants et la révision des curricula destinés aux élèves. Les enseignants expérimentés seront formés pour être des formateurs. Ces groupes de formateurs animeront des sessions de formation des enseignants au cours plusieurs sessions par an. Les enseignants formés travailleront avec les élèves sur des questions de la SSR/PF en utilisant les modules révisés. Des dépliants comportant les messages essentiels seront élaborés pour les élèves.

However, the “Plan d’action” only partially addresses the nine essential components of CSE as defined by the United Nations Population Fund (UNFPA). Mauritania is placed in the yellow category for this indicator.

Mauritania’s policy environment acknowledges the importance of youth-friendly sexual and reproductive health (SRH) services. The “Programme national de santé de la reproduction : projet de plan d’action, 2007” includes specific activities to pilot and study the feasibility of youth-friendly SRH services. The “Programme national de santé de la reproduction : plan stratégique SR, 2008-2012” aims to increase the supply of youth-friendly SRH services. It addresses training providers on specific communication techniques with youth and offering youth certain FP methods (condoms, pills, and emergency contraception):

RESULTAT ATTENDU 2: L´offre et l´utilisation des services de SSRAJ [santé sexuelle et reproductive des adolescents et des jeunes] est augmenté

ACTIONS 2

• Former les prestataires en techniques spécifiques de communication avec les A et J [adolescents et jeunes]...
• Faciliter l’accès des AJ à la contraception (méthodes adaptées (préservatif, pilule, contraception d’urgence…)

The “Plan d’action national budgétisé en faveur de l’espacement des naissances de la Mauritanie, 2019-2023” includes a specific activity to train providers to offer youth-friendly services:

OA1.4. Renforcement des capacités des prestataires des FS [formation sanitaire] dans l'accès à la contraception et les services adaptés de SRAJ [santé reproductive des adolescents et des jeunes] aux adolescents et aux jeunes mariés. Renforcer les capacités des prestataires des PPS [point de prestations de services] dans le domaine de l’offre des services de PF adaptés aux adolescents et aux jeunes permettra d’accroître l’utilisation des services de PF/contraception des adolescents et des jeunes dans les PPS car ceux-ci seront mieux adaptés à leurs besoins spécifiques. Elle sera réalisée à travers la formation, l’aménagement des structures de soins, la supervision et le suivi des prestations

The “Plan d'action” also outlines an activity to provide free contraceptives on “family planning days” and includes a priority action to continuously advocate for free FP, particularly for adolescents and young people:

P3.5. Plaidoyer auprès des décideurs pour la gratuité des services de PF en particulier chez les adolescents et les jeunes de 2019 à 2023. Au cours des activités de journées spéciales de PF, les méthodes modernes de PF sont offertes gratuitement et les clientes sont souvent nombreuses, dépassant les objectifs fixés par les services de santé et autres prestataires. Cet état de fait soutient que les coûts des produits constituent une barrière importante à l’utilisation des services et produits contraceptifs dans les FS. Ces coûts peuvent varier d’une structure à une autre. Le plaidoyer sera fait pour viser la gratuité définitive des produits contraceptifs comme c’est le cas lors des journées spéciales PF. Il sera constitué une équipe de plaidoyer, un plan de plaidoyer doit être élaboré ainsi qu’un suivi régulier de la mise en œuvre du plan. Ce plaidoyer sera renforcé pour la gratuité de la PF pour les adolescentes et les jeunes qui sont davantage concernées par les barrières financières

However, because the policies do not connect provider training to issues of judgment and do not address audio/visual confidentiality and privacy, Mauritania is placed in the yellow category for this indicator.

The “Programme national de santé de la reproduction : projet de plan d’action, 2007” includes among its sexual and reproductive health (SRH) goals for youth a briefly described activity to reach out to leaders and to mobilize the community:

2.4 Développer des actions de plaidoyer auprès des autorités et des leaders et de mobilisation sociale au niveau de la communauté

The “Programme national de santé de la reproduction : plan stratégique, SR 2008-2012” aims to promote adolescent SRH among political, religious, and traditional leaders:

Plaidoyer auprès des leaders politiques, religieux, traditionnels pour la promotion de la SR [santé de la reproduction] des A et J [adolescents et jeunes]

The adolescent SRH goals within the “Programme national de santé de la reproduction : plan stratégique” include an action to address age at first marriage and harmful traditional practices. However, detail is not provided beyond that action.

The “Plan national de développement sanitaire, 2017-2020” aims for all health facilities to provide a minimum package of youth and adolescent reproductive health services through involvement with community actors:

3.2.3. Santé de l’adolescent et du jeune

… Accès équitable des adolescentes et des jeunes aux services cliniques et d’information de qualité :

Un paquet minimum d’activités SRAJ [santé reproductive des adolescents et des jeunes] sera assuré par tous les CS [centres de santé] en collaboration avec les acteurs communautaires, en particulier les associations de jeunes et les ONG [organisation non gouvernementale] engagés dans la santé des adolescents et des jeunes.

Des centres de prise en charge des violences à l’égard des jeunes femmes et des adolescents seront mis en place progressivement au niveau des structures de référence en commençant par les hôpitaux.

L’implication des acteurs communautaires – à travers des accords de partenariats formalisés – permettra d’assurer du programme ciblé de SRAJ adaptés aux spécificités et aux besoins des jeunes et des adolescents en zones rurales et périurbaines.

The “Plan d’action national budgétisé en faveur de l’espacement des naissances de la Mauritanie, 2019-2023” aims to provide an enabling environment for family planning through interaction with political and community leaders:

Objectif 4 : Garantir un environnement favorable pour la PF à travers :

• Le renforcement des activités de plaidoyer auprès des décideurs (Président de la République de Mauritanie, Premier Ministre, Institutions nationales, ministère de la santé et ministères connexes) et des leaders administratifs, traditionnels, religieux et des élus.

Within its priority actions, the “Plan d'action” also targets men and community leaders as family planning advocates. The constructive engagement approach looks to build FP champions through training:

CD3.1. Mise en œuvre de la stratégie de l’engagement constructif des hommes (ECH) dans le curriculum de la PF/EN [espacement des naissances].

… L’engagement des hommes est envisagé selon trois axes :

• Homme en tant que client des services de la SR [santé reproductive] pour lui-même
• Homme en tant que partenaire de soutien au sein du couple en matière de reproduction
• Homme en tant facteur changement au sein de la communauté.

Cette stratégie d’engagement constructif des hommes va soutenir et amplifier celle en cours dite de « l’école des maris ». …Cette stratégie responsabilise mieux la communauté dans la résolution des problèmes liés à la SR. L’approche « maris modèles » quant à elle fait référence aux époux qui accompagnent leurs épouses aux services de santé, les soutiennent pour l’auto prise en charge pendant la période périnatale, sensibilisent d’autres époux et recherchent des solutions pour l’accès aux soins…

CD3.2. Formation et implication des leaders religieux et coutumiers sur les outils de plaidoyer et les droits à la santé en faveur de la SR/PF.

… Etant donné que les leaders religieux, les chefs de villages et notables constituent des décideurs et leaders d’opinion influents capables d’appuyer les efforts de promotion de la PF, il y a lieu de former de nouveaux champions parmi eux pour conduire en leur direction un plaidoyer soutenu en vue d’accroître leur engagement en faveur de la PF et les mettre à contribution dans la mobilisation des communautés

While Mauritania’s policy documents include plans to engage community members in supporting family planning and address gender norms, there is no detailed strategy for building an enabling social environment for youth FP specifically. Mauritania is placed in the yellow category for this indicator.

The “National Reproductive Health Commodity Security Strategy, 2015” confirms access to permanent contraceptives without spousal consent:

Contraceptives such as condoms, injectables, oral pills and other RH [reproductive health] commodities are included in Essential Drug List (EDL). There is no barrier as such in terms of age and parity for clients to access contraceptives. No prescription is required to purchase contraceptives (condoms, pills, and injectables) in the market i.e. pharmacies… Spousal consent is not required to obtain a permanent method of family planning.

The “National Adolescent Health and Development Strategy 2075, 2018” also discusses the role of parental consent when it comes to adolescent privacy and confidentiality when accessing integrated services:

Integrated services will be delivered to adolescents focusing on the following points based on primary health care:

…

Privacy: Ensure privacy and confidentiality of adolescents with none or minimal parental consent.

While the “National Family Planning Costed Implementation Plan, 2015-2020” aims to ensure that women and girls exercise informed choice when using FP, it does not specifically address consent from a third party.

While Nepal’s policies protect access to permanent contraceptives without spousal consent and acknowledge adolescents’ right to services with minimal or no parental consent, they do not clearly protect youth access to all methods without consent from a third party. Nepal is placed in the gray category for this indicator.

The “National Adolescent Health and Development Strategy 2075, 2018” discusses strategies and potential actions the government should take to reach improved sexual and reproductive health knowledge, perception, and behavior. To make contraceptives available to adolescents and youth, the Strategy proposes nonjudgmental services:

Ensure non-judgmental and non-discriminatory services in private sector, health facilities and pharmacies

While the Strategy supports the need for providers to avoid judgment and discrimination, it does not require providers to authorize medically advised FP services. Nepal is therefore placed in the gray category for this indicator.

The “National Family Planning Costed Implementation Plan, 2015-2020” states that access to FP services is a human right and should be provided without discrimination and coercion. The “Safe Motherhood and Reproductive Health Rights Act, 2018” reiterates the right of every person, including adolescents, to reproductive health.

3. Right to reproductive health:

(1)  Each woman and adolescent shall have the right to obtain education, information, counseling and service relating to sexual and reproductive health.

...

(4)   Each person shall have the right to contraceptive information and usage.

The “National Reproductive Health Commodity Security Strategy, 2015” states that there are no age restrictions to the contraceptives included in the essential drug list:

Contraceptives such as condoms, injectables, oral pills and other RH [reproductive health] commodities are included in Essential Drug List (EDL). There is no barrier as such in terms of age and parity for clients to access contraceptives.

The “National List of Essential Medicines, 2021” covers a wide range of contraceptives, including oral pills, injectables, intrauterine devices, barrier methods, and implants. Nepal is placed in the green category for this indicator.

The “National Family Planning Costed Implementation Plan, 2015-2020" states that access to FP services is a human right and should be provided without discrimination and coercion.

Without a provision that explicitly protects youth access to FP services regardless of marital status, Nepal is placed in the gray category for this indicator.

The “National Adolescent Health and Development Strategy 2075, 2018” includes multiple activities to fulfill adolescents’ contraceptive needs, some of which reference access to long-acting reversible contraceptives (LARCs):

Strategy: Fulfill unmet needs and requirements of adolescents and ensure quality contraceptive services.

• Provide counseling on selection of appropriate contraceptive methods
• Provide quality contraceptive services including emergency contraception in both public and private health facilities through trained service providers
• Provide counseling services on clinical contraceptive devices such as intrauterine contraceptive devices (IUCDs) according to the protocol
• Raise awareness and provide counseling on dual protection usage of condoms and increase accessibility
• Include and visibly list family planning/ contraceptive services especially for newly married adolescents when organizing mobile health camps for adolescents.

The “National Reproductive Health Commodity Security Strategy, 2015” states that there are no age restrictions to contraceptives included in the essential drug list:

Contraceptives such as condoms, injectables, oral pills and other RH commodities are included in Essential Drug List (EDL). There is no barrier as such in terms of age and parity for clients to access contraceptives.

The “National List of Essential Medicines Nepal, 2021” covers a wide range of contraceptives, including oral pills, injectables, intrauterine devices, barrier methods, and implants, but does not note any eligibility criteria for the methods.

However, while Nepal’s policies are promising in that they acknowledge no age or parity restrictions to contraceptive access, they do not explicitly mention youth’s legal right to access a full range of contraceptive services, including LARCs. Nepal is therefore placed in the gray category for this indicator.

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, it is worth noting that Nepal’s policies do not explicitly specify whether access to ECs should be available to adolescents.

The “Nepal Safe Motherhood and Newborn Health Roadmap, 2030” recognizes the importance of a comprehensive sexual and reproductive health (SRH) education at schools:

Given the high enrolment rates in primary schools in Nepal and gender parity in enrolment, another key opportunity to provide accurate and relevant information is Sexual and Reproductive Health (SRH) education at schools. SRH education and life skills education should be comprehensive, including covering risks of adolescent pregnancy, and MoHP [Ministry of Health and Population] should continue to advocate that it is made compulsory for both boys and girls.

The “Nepal Health Sector Strategy Implementation Plan, 2016-2021” includes key interventions to incorporate comprehensive sexuality education (CSE) in school curricula:

7. Comprehensive sexuality education incorporated in school curriculum
8. Develop and implement curriculum for school-based health education (include mental health, ayurveda, nutrition, sexual and reproductive health, gender-based violence)

.…

15. Update school curricula on Comprehensive Sexuality Education (CSE) in line with ITGSE [International Technical Guidance on Sexuality Education] (in coordination with MoE [Ministry of Education]) and also develop text book accordingly with capacity building of the teachers 

The key interventions listed in the “National Family Planning Costed Implementation Plan, 2015-2020" provide further details on CSE:

Support integration and implementation of Comprehensive Sexuality Education (CSE) in schools secondary and higher level. Support will be provided to fully implement CSE curriculum in grades 6-10 and interactive sessions with students in grades 11-12 will be conducted. It will include advocacy with the Ministry of Education, training of educators/teachers and updating teaching materials and other communication tools.

The Costed Implementation Plan also includes interventions that reach across formal and informal sectors to improve youth access to contraceptive information and services:

Design, implement and evaluate special programme to increase access and utilization of FP among adolescents and young people. To support access to contraceptives information and services among adolescents and young people, a peer education programme will be developed and implemented both in- and out-of school.

.…

3. Reach adolescents with FP messages through innovative approaches (m-health & e-health)

3.1 Utilize SMS technology to promote FP use amongst adolescents/youth

3.2 Introduce FP messages through mobile health apps

3.3 Implement hotline telephone program for adolescents

3.4 Pilot & implement e-health FP program for adolescents in urban areas

.…

7.1 Develop age-specific peer education program (both in-school and out-of-school youth)

…

7.3 Integrate FP into school health programme (no additional costs)

The “National Adolescent Health and Development Strategy 2075, 2018” outlines a strategic objective and possible actions to improve SRH knowledge and promote CSE:

1. To improve knowledge, perception and behaviors of sexual and reproductive health and promote comprehensive sexuality education through extensive collaboration with education sector;

.…

Review and revise curriculums of lower secondary and secondary level and focus on behavioral and emotional changes that occur during adolescence and other matters related to adolescent health and development as well as matters identified by adolescents themselves in order to encourage dialogue and debate on adolescent sexual and reproductive health and healthy lifestyle

Although the Strategy does not provide specific details on a CSE curriculum, it briefly touches on the need to provide safe sex information in schools:

2.1 To improve knowledge, perception and behavior related to sexual and reproductive health

Promote responsible sexual behavior.

Provide counseling on masturbation, sexual abstinence before marriage and safe sex, if needed, through health facilities, adolescent-friendly information corner in schools or peer groups.

The Strategy also notes the importance of including topics on sexual abuse and gender-based violence in the school curriculum:

Help improve school curriculum (about teen safety, domestic violence, and child protection) for developing skills and knowledge about sexual abuse and gender violence/abuse and possible safety measures.

Nepal’s policy environment is promising as it focuses on SRH education and awareness-raising activities for youth, but it does not address all nine UNFPA essential components. Nepal is therefore placed in the yellow category for this indicator.

The “Nepal Health Sector Strategy Implementation Plan, 2016-2021” outlines the program components of the Family Health Division within the Ministry of Health and Population, and notes that the key function of the Adolescent Sexual and Reproductive Health department is to create an adolescent-friendly environment:

Create a conducive environment in public health facilities for adolescents to access adolescent reproductive health services.

The Implementation Plan also includes an activity to train service providers on adolescent sexual and reproductive health to improve availability of human resources, with a focus on rural retention and enrollment:

Train services provider on ASRH [adolescent sexual and reproductive health] basic (5 day) package from Adolescent Friendly Service Sites/Centres

Create a conducive environment in public health facilities for adolescents to access adolescent reproductive health services

The “National Adolescent Health and Development Strategy 2075, 2018” notes that the Ministry of Health and Population introduced the five-day Adolescent Sexual and Reproductive Health Training Package in 2015. Health facilities have started to implement and monitor adolescent-friendly services although details of the adolescent-friendly certification requirements could not be accessed for review. The strategy includes training providers under its objective to create a safe and supportive environment:

Provide orientation and training on National Adolescent Sexual and Reproductive Health and adolescent-friendly services to service providers of all health facilities.

The Strategy notes that adolescent-friendly services should provide nonjudgmental services to improve sexual and reproductive health knowledge, perception, and behavior:

Ensure non-judgmental and non-discriminatory services in private sector, health facilities and pharmacies.

The Strategy also discusses the role of parental consent when it comes to adolescent privacy and confidentiality when accessing integrated services, but is not specific to family planning:

Integrated services will be delivered to adolescents focusing on the following points based on primary health care:

.…

Privacy: Ensure privacy and confidentiality of adolescents with none or minimal parental consent.

The “Safe Motherhood and Reproductive Health Rights Act, 2018” requires that individuals accessing reproductive health services and information also receive confidentiality. In addition, the Act states that each person has the right to affordable reproductive health services.

Furthermore, the “National Family Planning Costed Implementation Plan, 2015-2020” and “National Reproductive Health Commodity Security Strategy, 2015” confirm that FP services have been integrated into the reproductive health package as a basic health service and are now provided free of charge to the entire population at government facilities. In addition to free contraceptives, the government provides a nominal wage compensation for permanent methods.

While Nepal’s policy environment discusses the implementation of adolescent-friendly services, it provides no details on what these services entail and whether spaces and providers will ensure non-judgmental services with confidentiality and privacy. As Nepal’s policies confirm free contraceptives, it is placed in the yellow category for this indicator.

The “National Family Planning Costed Implementation Plan, 2015-2020" includes an intervention to address sociocultural barriers for youth access to FP services, including involving key stakeholders at the district and community levels:

Strategic Action Area: Enabling Environment

A policy environment that enables the above four Action Areas to be implemented effectively is key for a successful FP programme. Strategic interventions in this area include increasing advocacy at all levels for FP; addressing legal and socio-cultural barriers to young people accessing FP; strengthening the integration of services; and developing/updating national polices and strategies to facilitate task shifting. Estimated resources required to implement the key interventions are presented in Annex C.

 Key Interventions:

• Increase Advocacy for Family Planning. Identify national champions for FP from multiple fields and support them to advocate for FP by providing advocacy materials/tools and conducting follow up meetings. Develop and distribute advocacy packages using global evidences and tools, including modeling exercises, (in English and Nepali) for key stakeholders. Support high level advocacy events at central level and districts engaging parliamentarians, governmental officials and donors as well as civil society organizations and media. Support advocacy events at community level including celebration of FP day at community level.

Under the strategic action to increase demand for contraceptives, the Costed Implementation Plan also includes an activity to reduce misconceptions around FP methods in communities:

Reduce fear of side effects, myths and misconceptions about FP through various communication channels. Support development of [information, education, and communication] materials that emphasize value of daughters and clarify information about modern contraceptives to be used by [female community health volunteers], health workers and community leaders. Organize forums and interactive sessions on clients’ satisfaction in communities.

The “National Adolescent Health and Development Strategy 2075, 2018” includes a strategic objective to create a supportive social environment to promote reproductive health:

Strategy: Raise awareness about safe reproductive and sexual behaviors in community and family

Possible actions:

• Organize discussion/debate on reproduction related problems faced by adolescents

…

• Organize health camps and provide orientation/counseling services related to adolescent sexual health in schools

The Strategy also discusses how adolescent health programs should identify and address “the special gender needs of adolescents” in a fair and non-discriminatory manner to ensure gender equity. It identifies multiple actions that can be taken to address gender norms in the community:

• Increase public awareness about different types of violence including gender violence by developing IEC materials

…

• Increase public awareness about laws and punishments related to gender violence, forced marriage, child marriage, and domestic violence.
• Organize adolescent-targeted gender violence programs.

While Nepal’s policies detail strategies and possible actions to create an enabling environment for FP access for youth, they do not include steps to address gender norms specific to youth FP. Nepal is placed in the yellow category for this indicator.

None of the policy documents reviewed for Niger include language addressing parental or spousal consent. The lack of policy language supporting youth access to FP services without these authorizations creates a potential barrier for youth in Niger interested in accessing contraception. To improve the policy environment, policymakers should consider including specific provisions for youth to access FP services without consent from a parent or spouse. Niger is placed in the gray category for this indicator.

Niger’s policy environment does not address provider authorization. Niger is placed in the gray category for this indicator.

Nigerien law recognizes the rights of all people to receive sexual and reproductive health care broadly. Article 2 of the “Loi sur la santé de la reproduction au Niger, 2006” acknowledges that reproductive health is a universal human right and should be free from discrimination, including discrimination based on age or marital status:

Article 2 - Caractère universel du droit à la santé de la reproduction. Tous les individus sont égaux en droit et en dignité en matière de santé de la reproduction. Le droit à la santé de la reproduction est un droit universel fondamental garanti à tout être humain, tout au long de sa vie, en toute situation et en tout lieu. Aucun individu ne peut être privé de ce droit dont il bénéficie sans discrimination aucune fondée sur l'âge, le sexe, la fortune, la religion, l'ethnie, la situation matrimoniale ou sur toute autre situation.

Niger is placed in the green category for this indicator.

While the “Loi sur la santé de la reproduction au Niger, 2006” makes a declarative statement supporting the rights of all people, regardless of age or marital status, to receive reproductive health care, the following article emphasizes the right of legally married couples to reproductive health:

Article 2 - Caractère universel du droit à la santé de la reproduction

Tous les individus sont égaux en droit et en dignité en matière de santé de la reproduction. Le droit à la santé de la reproduction est un droit universel fondamental garanti à tout être humain, tout au long de sa vie, en toute situation et en tout lieu. Aucun individu ne peut être privé de ce droit dont il bénéficie sans discrimination aucune fondée sur l'âge, le sexe, la fortune, la religion, l'ethnie, la situation matrimoniale ou sur toute autre situation.

Article 3 – Autodétermination

Les couples et les individus ont le droit de décider librement et avec discernement des questions ayant trait à la santé de la reproduction dans le respect des lois en vigueur, de l'ordre public et des bonnes mœurs. Les couples légalement mariés peuvent décider librement et avec discernement de l'espacement de leurs naissances et de disposer des informations nécessaires pour ce faire, et du droit d'accéder à la meilleure santé en matière de reproduction.

Additionally, while the “Planification familiale au Niger : plan opérationnel, 2018” acknowledges that the use of contraceptive methods by young unmarried women is negatively perceived by the public, it states that such a perception does not align with the country’s vision for adolescent and youth sexual and reproductive health. However, the “Planification familiale au Niger” plan opérationnel” does not offer any further details:

La jeune femme célibataire utilisant une méthode contraceptive est mal vue par la population ce qui est contraire à la vision SSRAJ (santé sexuelle et reproductive des adolescents et des jeunes) ;

This emphasis on legally married couples stands in contrast to the rest of the law, which extends reproductive rights, including FP, to all individuals. To address this discrepancy, the government should clarify policy language supporting access to FP services by married and unmarried couples and individuals, including youth. Furthermore, the government should provide specific policy language regarding its vision for adolescent and youth sexual and reproductive health, and particularly the right of young unmarried women to access and use contraceptive methods. Niger is placed in the yellow category for this indicator.

Niger’s policy environment does not discuss extending access to a full range of family planning methods to youth. Niger is placed in the gray category for this indicator.

Activity 1.1.19 of the “Planification familiale au Niger : plan d’action, 2012-2020” briefly references strengthening FP education for high school students through the home economics curriculum.

Renforcer l'enseignement de la PF au cours d'économie Familiale dans les CES [collèges d’enseignement secondaire].

Recognizing the need for FP education demonstrates a level of policy commitment on this issue. However, the policy fails to include specific guidelines on the content of the material and how the lessons should be instructed, nor coverage for young people outside of this specific course.

One of the demand-generation objectives of the “Planification familiale au Niger : plan opérationnel, 2018” aims to reinforce the adolescent and youth family life education program.

Objectif CD 3 : Renforcer le programme d'éducation à la vie familiale des adolescents et jeunes

Définition de l’Objectif : La majorité des adolescents et jeunes n’ont pas d’informations précises et approfondies sur les questions de procréation et de préparation à la gestion future de la vie familiale. Le MSP [Ministère de la santé publique] va travailler à préparer les adolescents et jeunes à la parenté responsable. Il formera les adolescents et jeunes à travers les canaux propices (mise à échelle de la formation sur les curricula en milieu scolaire, etc.). Il les sensibilisera dans les villages, au niveau des centres de promotion des jeunes, les ‘’Makarantas’’, ‘’les Fada’’, les centres de formation des jeunes pour apprendre et discuter de la PF.

The 2018 “Plan” offers more details about program approach than the 2012-2020 “Plan.” Examples of such details include a focus on preparing adolescents and youth for responsible parenting and a mention of implementation of activities in settings outside of schools (such as villages, youth promotion centers, and youth training centers). However, the policy lacks content specificity and directives for instruction.

Niger’s “Plan stratégique sectoriel de mise en œuvre de la politique nationale de jeunesse, 2011-2015” discusses several actions to raise youth awareness and use of sexual and reproductive health services, including supporting sexuality education through peer education using adapted training modules:

ACTION 22 : Appui à l’instauration de l’éducation sexuelle au sein de la famille et des groupes de jeunes :

La stratégie d’éducation par les pairs sera promue dans les quartiers, les villages, hameaux, les écoles, les structures informelles de regroupement des jeunes pour toucher le maximum des cibles (parents comme jeunes) sur la base de modules de formation adaptés qui seront définis, testés, appliqués et évalués tout le long du processus.

As the reviewed policy documents do not reference all nine of the United Nations Population Fund’s (UNFPA’s) essential components of comprehensive sexuality education (CSE), Niger is placed in the yellow category for this indicator.

The “Planification familiale au Niger : plan opérationnel, 2018” identifies youth as a priority population and includes a service access objective targeting youth.

Objectif AS 2 : Augmenter les points d’accès aux services de SR [santé reproductive] /PF pour les adolescents et jeunes en milieux scolaire et extrascolaire.

 Définition de l’Objectif : Les jeunes ont des besoins spécifiques en matière de planification familiale qui ne sont pas suffisamment pris en compte alors qu’ils sont plus exposés à des pratiques à risque en matière de santé sexuelle et de reproduction. Le MSP [ministère de la Santé publique] cherche à accroître la disponibilité de points d’accès aux services de planification familiale adaptés à leurs besoins. Il renforcera davantage les capacités des prestataires en approche jeunes à tous les niveaux pour offrir aux jeunes et aux adolescents, des services de planification familiale et des soins de santé de la reproduction de qualité.

The “Plan de développement sanitaire, 2017-2021” aims to strengthen the supply of health services for young people and adolescents by integrating youth health services into all levels of the health system:

Poursuivre l’intégration des services de santé des jeunes dans les paquets des services à tous les niveaux du système de santé. L’intégration des services de santé des jeunes et des adolescents dans les paquets d’activités à tous les niveaux du système de santé va se poursuivre pour augmenter la disponibilité et la capacité des services. Les interventions qui seront ciblées sont : la prise en charge des infections sexuellement transmissibles, le dépistage volontaire du VIH, le dépistage volontaire de la drépanocytose, la prévention de la grossesse (disponibilité des produits contraceptifs), la prise en charge des conséquences de l’avortement, etc.

…Collaborer avec les jeunes afin de définir les stratégies et interventions d’offre de services adaptés à leurs besoins ;

Both policy documents highlight the government’s commitment to increasing the availability of FP service access points tailored to the needs of youth and indicates that building the capacity of service providers in a “youth approach” will be prioritized.

Multiple news sources reference a 2007 law that guarantees free access to contraceptive methods to all women in all public facilities. In the absence of a review of the policy document, it is unclear whether youth are identified as beneficiaries. However, the reviewed policies do not mention enforcing confidentiality and audio/visual privacy or connect provider training to judgment issues. Because the policies do not adequately cover all three of the service-delivery elements of youth-friendly FP services, Niger is placed in the yellow category for this indicator.

The “Plan stratégique sectoriel de mise en œuvre de la politique nationale de jeunesse, 2011-2015” lays out sensitization activities to target parents and community leaders about teenage pregnancy and adolescent development. While the activities are part of a larger strategic plan that includes promotion of youth sexual and reproductive health and rights, these activities do not specifically target youth FP:

ACTION 15 : Sensibilisation aux conséquences néfastes des grossesses précoces et rapprochées

La persistance des grossesses précoces et rapprochées reste encore très préoccupante et, est liée à une insuffisance d’information sur les conséquences de ces pratiques. …. Elles cibleront aussi bien les jeunes que leurs parents, les leaders d’opinion et les décideurs politiques. La mise en œuvre se fera à travers l’organisation des causeries éducatives, des prêches, des caravanes, des journées de plaidoyer, la diffusion des spots radio télévisés, des sketchs, la tenue de théâtre forum.

ACTION 19 : Renforcement des capacités des parents sur la parenté responsable et la gestion de l’adolescence

La gestion de l’adolescence constitue une période critique au cours de laquelle les parents ont des difficultés pour encadrer leurs enfants. Deux campagnes de sensibilisation et d’information seront menées chaque année dans chaque commune du pays en vue d’atteindre l’objectif de deux millions six cent cinquante (2.650.000) personnes sur l’importance de la parenté responsable et la gestion de l’adolescence. Elles cibleront aussi bien les jeunes que leurs parents, les leaders d’opinion et les décideurs politiques. La mise en œuvre se fera à travers l’organisation des séances de causeries éducatives, des prêches, des caravanes, des journées de plaidoyer, la diffusion des spots radio télévisés, des sketchs, la tenue de théâtre forum. Les capacités techniques et matérielles des acteurs seront renforcées à travers des sessions de formation et ou des recyclages et la production des supports éducatifs. La stratégie de la pair-éducation sera privilégiée pour atteindre les cibles.

The “Planification familiale au Niger : plan d’action, 2012-2020” includes an FP communication intervention that targets multiple stakeholder groups, including youth, but does not provide details regarding the purpose of the communication materials or activities within the intervention:

Renforcer la communication à travers le marketing social et le partenariat avec les leaders religieux et traditionnels, les élus locaux, les ONG [organisations non gouvernementales] et associations, les groupements féminins et les jeunes chaque année dans les huit régions du pays.

The “Planification familiale au Niger: plan opérationnel, 2018” includes a demand-generation objective to increase the number of opinion leaders and champions in support of FP:

Objectif CD 1 : Augmenter le nombre de leaders d'opinion Champions de la PF

Définition de l’Objectif : Les leaders d'opinion sont des modèles pour la société. Ils pourront contribuer à la promotion de la PF en parlant publiquement de ses bénéfices pour le bien-être des communautés. Le MSP [ministère de la Santé publique] va identifier plus de leaders d'opinion afin qu'ils soutiennent activement et plaident pour les programmes de PF. Il va former les leaders et les outiller avec des données probantes sur la valeur de la PF pour en faire des Champions.

…

Action Prioritaire : Identifier et former en plaidoyer et IEC/CCC [information-éducation-communication /communication pour le changement de comportement] des champions PF au niveau des institutions, religieux, sociétés civiles, secteurs privés, jeunes

However, while both the objective and priority action  suggest an intention to increase community support for FP services, it is not evident that the focus is on increasing community support for youth access to FP services in particular.

The “Plan de développement sanitaire, 2017-2021” describes awareness-raising activities as an intervention to improve the health of young children and adolescents:

Les interventions suivantes seront mises en œuvre pour améliorer la santé du jeune enfant et de l’adolescent :

• Prévenir les grossesses précoces chez les adolescentes. Cette intervention sera menée en collaboration avec le Ministère en charge de la population, de l’enseignement secondaire, de la jeunesse, de l’emploi et de la justice. Elle consistera à la sensibilisation de la communauté, les parents et les adolescents afin de réduire les mariages précoces.
• Etendre les activités des pairs éducateurs. Les expériences réussies des pairs éducateurs vont être étendues.

…

• D’autres interventions se feront en amont en termes de communication pour le changement des comportements à la fois des jeunes et des parents. Ces interventions auront pour but d’amener les jeunes à adopter un comportement sexuel responsable et à utiliser les services de santé disponibles le cas échéant. Ces interventions nécessitent une action multisectorielle qui implique les médias, la société civile et la communauté.

While all reviewed action and operational plans include activities to sensitize communities around youth sexual and reproductive health, prevent teenage pregnancies, and create FP champions in the community,  it is unclear whether the intention is to increase demand for FP or to build a supportive environment for youth FP.

The “Politique nationale de genre, 2017” acknowledges the need for Niger to put more emphasis on policies that encourage the use of family planning to reach true gender equality, and includes a strategic goal that specifically mentions reproductive health:

Axe stratégique 1 : Amélioration de l’environnement socioculturel en lien avec la démographie, la paix et la sécurité pour plus d’équité entre les hommes et les femmes.

Cet axe concerne les changements de mentalités des hommes et des femmes, les attitudes et les pratiques propices à l’égalité de reconnaissance et de traitement envers les femmes y compris le renforcement de leurs capacités de décision et d’action. Il soutient l’accès des femmes aux services sociaux de base (Santé, Santé de la Reproduction, Education, Citoyenneté Responsable, Eau, Hygiène et Assainissement, etc.) qui sont déterminants dans la constitution des capacités et du capital humain du pays.

The goal details a list of actions to take, including promoting a sociocultural environment favorable to equity; ensuring the different reproductive health needs of women, adolescents, and men; and promoting the participation of women and young people. These activities will be carried out through a program of social mobilization and advocacy of various actors in society to reach gender equity and equality at the household and community levels.

While the policy does identify traditional chiefs and religious leaders as strategic actors who should support awareness raising and social mobilization for the desired structural changes in gender equity, no activities specifically address gender norms within youth FP.

In the absence of this information explicitly addressing efforts to build community support for FP for youth, the country is placed in the gray category, subject to updating if further policy documents provide additional information regarding the content of this intervention.

The “National Standards & Minimum Service Package for Adolescent & Youth-Friendly Health Services, 2018” protects the confidentiality of information for youth and adolescents, including from parents.

The “National Adolescent & Youth Friendly Job Aids for Service Providers in Primary Health Care Facilities in Nigeria, 2015” directs providers to allow youth and adolescents to decide how much they would like to involve their parents in their health care, and to not share any information with parents unless entrusted to by the client.

Although not yet passed, a draft version of the “National Policy on the Health and Development of Adolescents and Young People in Nigeria, 2020-2024” guarantees access to FP services without the consent of a third party:

Ensure that all adolescents age 14 years have the rights to receive ambulatory and non-surgical reproductive health services appropriate for their age and health situation – including contraceptive information, counselling and services, prevention and treatment of sexually transmitted infections, management of sexual abuse and post-abortion care – without any discrimination from health worker or request for adult/parental  consent that may pose a barrier to prompt and quality services 

While some policies of Nigeria protect confidentiality of information from parents, none of the policies or enacted laws explicitly affirm youth access to FP services without parental consent. Furthermore, there is no language in Nigerian laws or policies guaranteeing youth access to FP services without consent from spouses or partners. The ambivalence of the current legal framework on youth’s right to freely and independently access FP services creates a barrier for youth accessing such services. Nigeria is placed in the gray category for this indicator. If the National Policy—or another policy with similar language— becomes law, Nigeria’s policy environment would be supportive of youth access to FP services without parental or spousal consent.

The “National Standards & Minimum Service Package for Adolescent & Youth-Friendly Health Services, 2018” promote the right of young people to access general health services without provider discrimination:

Standard 4:

All young people who visit health service delivery facilities are treated with respect, dignity and in an equitable manner irrespective of their health, socio-demographic or political status.

What does this mean? Health care providers administer the same level of quality care and consideration to all adolescents regardless of age, sex, social status, cultural background, ethnic origin, sexual preferences, disability or any other reason.

Rationale: Being treated disrespectfully is a strong disincentive for adolescents and other young people to use health services. Also, young people are not likely to attend a point of service delivery if they feel excluded or discriminated against in any way. On the other hand, being treated equally will have a positive effect on adolescents, encouraging them to meet further appointments and recommend the service to their peers. Furthermore, the manner young people are treated contributes significantly to their sense of satisfaction with care as clients.

Input Criteria: …

Protocols/ guidelines to provide services competently in nonjudgmental, caring, considerate, gender-responsive and culturally sensitive attitude and equitable manner are in place.

While the National Standards underscore health providers’ obligation to serve youth without discrimination, they do not explicitly mention FP services or identify FP as part of the package of services. A draft version of the “National Policy on the Health and Development of Adolescents and Young People in Nigeria, 2020-2024” states that adolescents older than age 14 should be able to receive contraceptive services without discrimination from a health worker:

Ensure that all adolescents age 14 years have the rights to receive ambulatory and non-surgical reproductive health services appropriate for their age and health situation – including contraceptive information, counselling and services, prevention and treatment of sexually transmitted infections, management of sexual abuse and post-abortion care – without any discrimination from health worker or request for adult/parental  consent that may pose a barrier to prompt and quality services.

If this draft policy is passed with the current language, Nigeria’s policies would acknowledge providers’ duty to offer FP services to youth without discrimination or bias. However, Nigeria is currently placed in the gray category for this indicator.

Several key policies acknowledge clients’ rights to access sexual and reproductive health services regardless of age. The “National Reproductive Health Policy, 2017” states:

All Nigerians, irrespective of their gender and age including adolescents from age 10 years and older population, have sexual and reproductive rights, and are equally entitled to sexual and reproductive health development and care.

The “National Family Planning/Reproductive Health Service Protocols, Revised Edition, 2010” direct service providers to inform every client of his or her right to:

Access—obtain services regardless of age, sex, creed, colour, marital status, or location.

The “National Youth Policy, 2019” confirms the right of youth to access reproductive health services and alters the definition of youth from the previous youth policy from ages 18 to 35 to ages 15 to 29.

This recognition of the rights of all people to access FP services is critical to addressing the barriers women of all ages frequently face when attempting to access contraception. Nigeria is placed in the green category for this indicator.

The “National Family Planning/Reproductive Health Service Protocols, Revised Edition, 2010” direct service providers to inform every client of their right to:

Access—obtain services regardless of age, sex, creed, colour, marital status, or location.

 Nigeria is placed in the green category for this indicator.

The “National Training Manual for the Health and Development of Adolescent and Young People in Nigeria, 2011” discourages providers from recommending certain nonpermanent contraceptive method options, even though they have been deemed safe for general use by the World Health Organization (WHO):

Other methods of contraception are available, but they are often not recommended for youths who have never had children. These methods include Intra-Uterine Devices (IUD), Injectables (Depo-Provera and Noristerat), Tubal ligation, Vasectomy.

The same document further lists three methods deemed most appropriate for youth in the instructions for providers on contraceptive method counseling:

Present a brief lecture covering the three methods of contraception, which are most appropriate for young people – pills, condoms and spermicide e.g. foaming tablets.

The “National Guidelines for the Integration of Adolescent and Youth Friendly Services into Primary Health Care Facilities in Nigeria, 2013” include specific directives to provide contraceptive counseling and services as a part of all clinical preventive services targeting adolescents and youth in primary health care facilities. The list of essential drugs, however, limits contraceptive offerings to barrier methods, oral contraceptives, and emergency contraception. While an intrauterine device (IUD) kit is listed in the medical equipment addendum, this contraceptive offering is absent in the essential drug list.

Providers are discouraged from providing long-acting reversible contraceptives (LARCs) to youth under these policies. The “National Adolescent & Youth Friendly Job Aids for Service Providers in Primary Health Care Facilities in Nigeria, 2015” reaffirm language from previous policies that restricts method mix for young people:

Not all the modern methods of contraceptives are appropriate for adolescents. Most of the temporary methods are appropriate but not the permanent methods.

Furthermore, a national strategy to increase access to LARCs, “Increasing Access to Long-Acting Reversible Contraceptives in Nigeria: National Strategy and Implementation Plan, 2013-2015,” does not include a targeted strategy to increase uptake of LARCs among youth.

However, an earlier document, “National Family Planning/Reproductive Health Service Protocols, Revised Edition, 2010,” includes youth and nulliparous women in the eligibility criteria for short-acting and long-acting reversible contraceptive methods. The document outlines no restrictions on the provision of oral contraceptives and implants to women between menarche and 18 years old and advises providers that the advantages outweigh the risks for the provision of injectables and IUDs to women who are younger than age 18 and nulliparous. The “National Training Manual on Peer-to-Peer Youth Health Education, 2013” also acknowledges that, except for permanent methods, all methods appropriate for healthy adults are also appropriate for post-pubertal adolescents. In addition, the “National Standards & Minimum Service Package for Adolescent & Youth-Friendly Health Services, 2018” specify that the package of adolescent and youth-friendly services for sexual and reproductive health include counseling and provision of barrier methods, oral pills, emergency contraception, and LARCs as “appropriate.” The “Manual for Training Doctors and Nurse/Midwives on LARC Methods, 2015” mandates that providers use the WHO medical eligibility criteria in the provision of IUDs and contraceptive implants but does not reference age.

The inconsistency between the adolescent policies and general FP service protocols creates an opportunity for providers to differentially interpret the directives and a barrier to youth attempting to access a full range of methods. Adding a provision that explicitly supports youth access to all medically eligible contraceptive methods would strengthen Nigeria’s policies regarding youth FP and support full implementation of the “Nigeria Family Planning Blueprint, 2020-2024,” which acknowledges this ambiguity and promotes the provision of LARCs. Nigeria is placed in the red category for this indicator.

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, the “National Family Planning/Reproductive Health Service Protocols, Revised Edition, 2010,” the “Clinical Protocol for the Health and Development of Adolescent and Young People in Nigeria, 2011” and the “National Adolescent & Youth Friendly Job Aids for Service Providers in Primary Health Care Facilities in Nigeria, 2015” all include EC as a possible contraceptive method for youth.

Nigeria’s policy environment surrounding sexuality education is weak. The leading guidance on provision of sexuality education in the country is the “National Family Life and HIV Education Curriculum for Junior Secondary School in Nigeria, 2003.” This document provides a substantial overview of the family life and HIV education (FLHE) curriculum for junior secondary schools, primarily focused on human development and life skills. The component of the curriculum most relevant to contraceptive provision is HIV education. While the curriculum presents comprehensive information on sexually transmitted infections (STI)/HIV, including definitions, modes of transmission, and signs and symptoms, it falls short of informing youth on how to prevent these infections through safe sexual behavior and condom and contraceptive use. Further, there is no discussion of where or how to access sexual and reproductive health services. Rather, the guidance for preventing STI/HIV is:

• Abstain from sexual behavior.
• Avoid sharing sharp objects (such as needles, razor, clippers).
• Insist on screened blood.

The “National Guidelines on Promoting Access of Young People to Adolescent and Youth-Friendly Services in Primary Health Care Facilities in Nigeria, 2013” references peer education as a strategy to supplement in-school instruction on sexual and reproductive health to reach in-school and out-of-school youth, as well as parents and guardians. The “National Training Manual on Peer-to-Peer Youth Health Education, 2013” details a peer education session on contraception and pregnancy prevention, including a discussion emphasizing the benefits of abstinence. However, the policy also states that peer educators should discuss various contraceptives and their advantages, acknowledging that “adolescents should make contraceptive choices based on their need and whether they want to protect against pregnancy and or need to protect against STI/HIV.”

The “Nigeria Family Planning Blueprint, 2020-2024” outlines the strengthening of nationwide implementation of the FLHE curriculum and increased access to online learning materials.  Although not yet passed, a draft version of the “National Policy on the Health and Development of Adolescents and Young People in Nigeria, 2020-2024” notes the role the Ministry of Education plays in policy implementation, and that the Ministry must review and revise the FLHE curriculum to ensure it conforms to global best practices in CSE curriculum design and delivery.

Moreover, the “National Family Planning Communication Plan, 2017-2020" states that the “National Family Life and HIV Education Curriculum for Junior Secondary School in Nigeria, 2003” will be reviewed and amended “to support the goal of disseminating appropriate FP messaging to adolescents and young people.” It seeks to incorporate FP into classroom settings by disseminating information through peer educators and trained teachers. While this indicates positive language for CSE, the curriculum has yet to be amended and the current policy environment still promotes abstinence

Nigeria is placed in the red category for comprehensive sexuality education (CSE) since the country’s guidance on sexuality education refers only to abstinence. To improve the policy environment surrounding sexuality education, policymakers in Nigeria should consider including the nine United Nations Population Fund (UNFPA) essential components of CSE when updating the FLHE curriculum.

Nigeria’s “National Reproductive Health Policy, 2017” emphasizes youth-friendly service provision, although such services are not defined:

Objective 4: To increase access to quality reproductive health information and services for adolescents and young persons. Target 1: Achieve at least 50% coverage of young people who have access to comprehensive SRH [sexual and reproductive health] information and services by 2021. Target 2: Achieve at least 50% coverage of young people who have access to comprehensive youth friendly health services by 2021.

The “Nigeria Family Planning Blueprint, 2020-2024” outlines plans to develop a national FP training plan for providers to address bias and ensure nondiscriminatory care, with a specific emphasis on a rights-based approach for youth:

SD.5. Expand access to Rights based Youth Friendly FP Services.

Provider bias in service provision to youth and sexually active unmarried women remains a barrier to the delivery of a right based non-discriminatory FP services. Service provider bias as a result of training being more skill focused with inadequate emphasis on value clarification and youth-friendly services is an identified challenge in service delivery. The Quality of counselling and attitudinal skill-building will be improved by revising FP training materials/curriculum to emphasize right-based approach. IPCC [interpersonal communication and counselling] modules will be made mandatory as a component of FP trainings to ensure it is reinforced as a way of addressing provider attitude and bias as well as institutionalizing rights-based counselling.

A previous version of the Blueprint specifically identified steps to ensure privacy in youth-friendly service delivery spaces. However, while the current Blueprint notes that the national FP training plan’s rights-based approach should be based on confidentiality, it does not specifically address privacy in the provision of youth-friendly FP services.

The “National Youth Policy, 2019” outlines policy benchmarks to integrate adolescent and youth-friendly health services in primary health facilities and implement training programs for youth-friendly service delivery. The “National Training Manual for the Health and Development of Adolescent and Young People in Nigeria, 2011” lists eight competencies of a youth-centered counselor, one of which guides counselors to be aware of their own judgments:

Self awareness and self-knowledge: Develop a keen knowledge and awareness of self in terms of one’s own limitations, biases, prejudices religious and cultural beliefs and internal conflicts.

However, the same document emphasizes abstinence-only values, likely affirming some providers’ preconceived notions regarding youth’s right to access contraception. One section describing factors affecting adolescent development mentions abstinence as a positive traditional practice, and a later section describing pregnancy prevention methods emphasizes abstinence as the norm:

Sexual abstinence is the surest way of preventing STIs [sexually transmitted infections] and unwanted pregnancies. In our society where the norm is sexual abstinence, young people practicing abstinence are free of guilt of being found to have violated the norm, and fear of the consequences of sexual intercourse. Sexual abstinence could also add to the sense of self-esteem and self-worth.

The “National Standards & Minimum Service Package for Adolescent & Youth-Friendly Health Services, 2018” state that provider protocols and guidelines include nonjudgmental services and notes that young people should receive services for free or at a subsidized rate, but is not specific to family planning:

2. Protocols/ guidelines to provide services competently in nonjudgmental, caring, considerate, gender-responsive and culturally sensitive attitude and equitable manner are in place.
3. All staff undergo training in appropriate procedures to ensure respectful attitude and maintenance of the dignity of clients in their service provision to all categories of young people.…
4. Policies and procedures to provide health services to young people free of charge or at affordable prices are in place.

Multiple external documents report the existence of Nigeria’s “Free Family Planning Commodity Policy, 2011,” which states that family planning commodities should be provided free of charge to all clients in the public sector. However, a copy of this policy could not be obtained, and stakeholders note that out-of-pocket costs often offset the policy’s effectiveness.

Nigeria is placed in the yellow category for youth-friendly FP service provision. The country has the potential to move to a green categorization if policy documents include provisions to offer free or subsidized FP services to youth and further clarify steps to ensure audio/visual privacy in services.

The “National Policy on Health and Development of Adolescents and Young People in Nigeria, 2007” briefly addresses the sexual and reproductive health needs of young people. The policy acknowledges that youth face sociocultural barriers to access sexual and reproductive health services:

Negative perception about adolescent sexual and reproductive health issues and related services.

To address these barriers, the policy includes activities to link service delivery with community sensitization efforts targeting parents and mass media activities to shift social norms.

The “National Strategic Framework on the Health and Development of Adolescents and Young People in Nigeria, 2007-2011” includes two relevant objectives:

Promote awareness of reproductive health issues of young people amongst all stakeholders.

Strengthen the capacity of parents, guardians and significant others to respond positively to the needs of young people through effective IEC [information, education, and communication] approaches.

Specific activities are outlined under these objectives to engage the community through advocacy and community mobilization and promote reproductive health behaviors through information, education, and communication. The “National Family Planning Communication Plan, 2017-2020"includes plans to increase engagement of traditional and religious leaders on family planning, which may contribute further to an enabling social environment. The Communication Plan also states that campaigns will use multi-media approaches to reach the general public and specific demand generation efforts would be made for adolescents, youth and other high priority groups.

A draft copy of the “National Adolescent Health Policy, 2020-2024” declares gender equity and responsiveness as an underlying principle and value and emphasizes the need to engage gender-responsive approaches, including community interventions that address gender imbalances:

Strengthen adolescent leadership and engagement in the family and community using transformative interventions that address the power imbalance between adolescent girls and boys as well as gender-inequitable norms and practices, including gender-based violence.

Existing policies, however, do not include specific activities to address gender norms related to youth access to or use of FP services. Nigeria is placed in the yellow category for this indicator.

The “Responsible Parenthood and Reproductive Health Act of 2012, Republic Act 10354” restricts access to FP services for minors:

That minors will not be allowed access to modern methods of family planning without written consent from their parents or guardian/s except when the minor is already a parent or has had a miscarriage.

The Act continues to note that providers may waive parental consent or spousal consent in specific cases:

Section 23. Prohibited Acts. – The following acts are prohibited:

• Any health care service provider, whether public or private, who shall:

.…

(2) Refuse to perform legal and medically-safe reproductive health procedures on any person of legal age on the ground of lack of consent or authorization of the following persons in the following instances:

(i)Spousal consent in case of married persons: Provided, that in the case of disagreement the decision of the one undergoing the procedure shall prevail;

(ii) Parental consent or that of the person exercising parental authority in the case of abused minors, where the parent or the person exercising parental authority is the respondent, accused or convicted perpetrator as certified by the proper prosecutorial office of the court. In the case of minors, the written consent of parents or legal guardian or, in their absence, persons exercising parental authority or next-of-kin shall be required only in elective surgical procedures and in no case shall consent be required in emergency or serious cases as defined in Republic Act No. 8344

Section 4.07 of the “Implementing Rules and Regulations of Republic Act No. 10354, 2013” provides more details on the requirement of written consent from a parent or guardian for minors to access family planning services:

Any minor who consults at health care facilities shall be given age-appropriate counseling on responsible parenthood and reproductive health. Health care facilities shall dispense health products and perform procedures for family planning:

Provided, that in public health facilities, any of the following conditions are met:

(a) The minor presents written consent from a parent or guardian.

(b) The minor has had a previous pregnancy or is already a parent as proven by any one of the following circumstances, among others:

1. Written documentation from a skilled health professional;
2. Documentation through ancillary examinations such as ultrasound;
3. Written manifestation from a guardian, local social welfare and development officer, local government official or local health volunteer; or
4. Accompanied personally by a parent, grandparent, or guardian.

While the policy environment does not require spousal consent, the Philippines is placed in the red category for this indicator as the law requires parental consent for minors to access FP services.

The “Responsible Parenthood and Reproductive Health Act of 2012, Republic Act 10354” prohibits providers from refusing health care services and information on account of a person’s marital status, gender, age, religious convictions, personal circumstances, or nature of work. However, the act includes language that allows providers to object to services based on their religious beliefs as long as they refer the patient to another provider:

Section 23. Prohibited Acts. – The following acts are prohibited:

(a) Any health care service provider, whether public or private, who shall:

(3) Refuse to extend quality health care services and information on account of the person’s marital status, gender, age, religious convictions, personal circumstances, or nature of work: Provided, That the conscientious objection of a health care service provider based on his/her ethical or religious beliefs shall be respected; however, the conscientious objector shall immediately refer the person seeking such care and services to another health care service provider within the same facility or one which is conveniently accessible: Provided, further, That the person is not in an emergency condition or serious case as defined in Republic Act No. 8344, which penalizes the refusal of hospitals and medical clinics to administer appropriate initial medical treatment and support in emergency and serious cases;

Nevertheless, the “Family Planning Competency-Based Training, Facilitator’s Guide, n.d." and "Family Planning Competency-Based Training, Basic Course Handbook for Service Providers n.d." teach providers to use the World Health Organization (WHO) medical eligibility criteria for contraceptive use and train counselors to not impose their own values on clients, although the latter training is not specific to youth FP.

Since the laws and policies of the Philippines support the WHO medical eligibility criteria for contraceptive use but do not explicitly require providers to service youth despite personal beliefs, the country is placed in the yellow category for this indicator.

The “Family Planning Competency-Based Training, Basic Course Handbook for Service Providers, n.d” lists key policy statements that guide FP program promotion and implementation, one of which includes the provision of FP services based on voluntary and informed choice for all women and men of reproductive age regardless of age:

FP information and services will be provided based on voluntary and informed choice for all women and men of reproductive age regardless of age, number of children, marital status, religious beliefs, and cultural values.

The “Responsible Parenthood and Reproductive Health Act of 2012, Republic Act 10354” also prohibits providers from refusing to offer quality health care services based on age:

Section 23. Prohibited Acts. – The following acts are prohibited:

(a) Any health care service provider, whether public or private, who shall:

….

(3) Refuse to extend quality health care services and information on account of the person’s marital status, gender, age, religious convictions, personal circumstances, or nature of work:

The Philippines is therefore placed in the green category for this indicator.

The “Family Planning Competency-Based Training, Basic Course Handbook for Service Providers, n.d.” includes key policy statements that guide FP program promotion and implementation, one of which includes the provision of FP services for all women of reproductive age regardless of marital status:

FP information and services will be provided based on voluntary and informed choice for all women and men of reproductive age regardless of age, number of children, marital status, religious beliefs, and cultural values.

Moreover, the “Responsible Parenthood and Reproductive Health Act of 2012, Republic Act 10354” prohibits a health care service provider from refusing to provide quality health care services and information because of the person’s marital status, gender, age, religious convictions, personal circumstances, or nature of work.

The Philippines is therefore placed in the green category for this indicator.

According to the “Family Planning Competency-Based Training, Facilitator’s Guide, n.d.” and the “Family Planning Competency-Based Training, Basic Course Handbook for Service Providers, n.d.” “all contraceptives are safe for use of young people,” but the documents provide additional notes on the benefits of specific methods:

ALL CONTRACEPTIVES ARE SAFE FOR USE OF YOUNG PEOPLE

Generally, all adolescents are advised to practice ABSTINENCE until they reach the proper age to start a family.

• Fertility awareness-based methods For those adolescents who can effectively monitor body changes to determine the woman’s fertile period and able to follow the rules as to when to abstain from sex. If not able, consider other FP methods.
• Oral contraceptives Low dose COC [combined oral contraceptives] is a good choice because of high efficacy and low frequency of side effects. Emphasis is needed for consistent and proper use of the methods during counseling along with COC side effects.
• Male condoms One main advantage is its safety. Since they are readily available and accessible in different places and set up. Education and counseling are important to ensure correct and consistent condom use.
• Progestin-only injectables For those adolescents having difficulty in using COCs, progestin-only injectables are suitable alternatives.
• IUD Not a good choice for young women who are at high risk for STIs [sexually transmitted infections]. IUD [intrauterine devices] can be an option for parous adolescents who require long-term protection against pregnancy and have a low risk of STIs.

Moreover, "The Philippine Clinical Standards Manual on Family Planning, 2014” states that "all currently available modern contraceptive methods are safe for adolescents" and provides descriptions of each method—including combined hormonal contraceptives, progesterone-only contraceptives, barrier methods, IUDs, fertility-based methods, and sterilization—along with recommended reasons for use/avoidance.

Furthermore, the "Adolescent Health and Development Program: Manual of Operations 2017" requires local governments to provide basic adolescent health care services, including the purchase and distribution of family planning commodities:

LGUs [local government units] must ensure provision of basic adolescent health care services including, but not limited to, the operation and maintenance of facilities and equipment necessary for the delivery of a full range of reproductive health care services and the purchase and distribution of family planning goods and supplies as part of the essential information and service delivery package defined by DOH [Department of Health].

While the Basic Course Handbook for Service Providers does not address youth access to a full range of methods, it does state that men and women should access methods of their choice:

FP information and services will be provided based on voluntary and informed choice for all women and men of reproductive age regardless of age, number of children, marital status, religious beliefs, and cultural values.

While Filipino policies identify FP methods available to youth and acknowledge youth access to all contraceptives, they do not sufficiently state that youth have access to a full range of methods, including long-acting reversible contraceptives (LARCs), regardless of age, marital status, or parity. The Philippines is placed in the yellow category for this indicator.

The “National Policy and Strategic Framework on Adolescent Health and Development, Administrative Order No. 2013-0013” tasks the Departments of Health, Education, and Social Welfare and Development with formulating “an age- and development-appropriate Reproductive Health and Sexuality Education curriculum.”

Similarly, “The Responsible Parenthood and Reproductive Health Act of 2012, Republic Act 10354” outlines the government’s plan for age-appropriate reproductive health education:

Section 14. Age- and Development-Appropriate Reproductive Health Education.

The State shall provide age- and development-appropriate reproductive health education to adolescents which shall be taught by adequately trained teachers informal and nonformal educational system and integrated in relevant subjects such as, but not limited to, values formation; knowledge and skills in self-protection against discrimination; sexual abuse and violence against women and children and other forms of gender based violence and teen pregnancy; physical, social and emotional changes in adolescents; women’s rights and children’s rights; responsible teenage behavior; gender and development; and responsible parenthood:

Provided, That flexibility in the formulation and adoption of appropriate course content, scope and methodology in each educational level or group shall be allowed only after consultations with parents-teachers community associations, school officials and other interest groups. The Department of Education (DepED) shall formulate a curriculum which shall be used by public schools and may be adopted by private schools.

Furthermore, “Implementing Rules and Regulations of the Responsible Parenthood and Reproductive Health Act of 2012” states that private and public schools shall provide a supportive environment for youth wherein they have access to facilities for information and referral to service providers on all responsible parenthood and reproductive health concerns. The act also notes that reproductive health information provided to youth should be scientifically accurate and evidence-based information on the reproductive system.

The “Adolescent Health and Development Program: Manual of Operations, 2017” refers to a comprehensive sexuality education (CSE) activity called “Abstinence-Plus,” which focuses on abstinence as the best method to avoid an unintended pregnancy and contraception as a way to reduce risk. The Manual of Operations further states that the content of its curriculum:

- Created safe social environment for youth participants

...

- Focused narrowly on specific sexual behaviors that lead to these health goals (e.g., abstaining from sex, using condoms); gave clear messages about these behaviors; addressed how to avoid situations that might lead to these behaviors

…

- Used teaching methods that actively involved youth participants and helped them to personalize the information.

- Made use of activities appropriate to the young people’s culture, developmental level, and previous sexual experience.

While existing Filipino laws and guidelines support the provision of sexuality and reproductive health education, they do not specifically address education in the context of education for family planning. The Philippines is placed in the yellow category for this indicator and can improve by referencing the UNFPA essential components of CSE in future curricula.

“The Philippine Clinical Standards Manual on Family Planning, 2014” states that young individuals must be assured confidentiality and privacy and that reproductive health counseling services for them must be made accessible, available, affordable, and understandable in a supportive and non-judgmental environment.

“The Responsible Parenthood and Reproductive Health Act of 2012, Republic Act 10354” states that the government should guarantee affordable reproductive health services, methods, devices, and supplies to all clients. The Act notes that individuals targeted in the National Household Targeting System for Poverty Reduction shall be beneficiaries to free reproductive health services and supplies but does not specifically address youth.

The “Family Planning Competency-Based Training: Basic Course Handbook for Service Providers, n.d.” includes key policy statements that guide FP program promotion and implementation, one of which states that privacy and confidentiality should always be observed while providing services.

The “Implementing Rules and Regulations of the Responsible Parenthood and Reproductive Health Act of 2012” instructs the Department of Health to develop a curriculum to train health professionals in counseling about adolescent reproductive health, determining age- and development-appropriate methods or services.

In addition, the “Adolescent Health and Development Program: Manual of Operations 2017”—which is designed to provide recommendations and tools for health care facilities—includes a section on enhancing providers’ capacity and notes that changing providers’ attitudes, beliefs, knowledge, and practices should be carried out through sensitization and training. The document notes that sensitization should be used to persuade health professionals to view adolescent health as a public health and human rights problem and training should be used to improve providers’ knowledge and skills on adolescent-friendly services. The Manual also lays out levels of compliance to standards, which detail that health facilities should ensure audio/visual privacy in facilities and implement procedures to ensure privacy and confidentiality.

The “Adolescent Job Aid Manual, 2009” directs facility staff to “ensure that the consultation and examination are done in a place where the interaction between the health worker and the adolescent cannot be heard or seen by anyone else.” However, the manual outlines general standards for all adolescent health services and is not specific to youth FP.

While Filipino laws and policies refer to youth access to FP services, core elements youth-friendly service delivery are not explicitly detailed, such as trainings to offer non-judgmental services to adolescents and affordability in the context of FP services for youth. The Philippines is placed in the yellow category for this indicator.

The “National Policy and Strategic Framework on Adolescent Health and Development, Administrative Order No. 2013-0013” tasks the Department of Health, Department of Education, and the Department of Social Welfare and Development to:

Provide parents with adequate and relevant scientific materials on the age- appropriate topics and manner of teaching Reproductive Health and Sexuality Education to their children.

The "Responsible Parenthood and Reproductive Health Act of 2012, Republic Act 10354” directs the Department of Health and local government units to initiate and sustain a heightened nationwide multimedia campaign to raise public awareness on the protection and promotion of family planning and youth reproductive health, among other issues. It also acknowledges the role gender equity should play in the government’s reproductive health efforts:

Moreover, the State recognizes and guarantees the promotion of gender equality, gender equity, women empowerment and dignity as a health and human rights concern and as a social responsibility. The advancement and protection of women’s human rights shall be central to the efforts of the State to address reproductive health care.

While not specific to youth family planning, the National Standards for Adolescent-Friendly Services outlined in the “Adolescent Health and Development Program: Manual of Operations, 2017” include a standard to create an enabling environment:

An enabling environment exists in the community for adolescents to seek and utilize the health services that they need...

The related input criteria include procedures to communicate with adults visiting the health facility about the value of providing adolescents with services and activities—including community assemblies, meetings with parents, group meetings, and school visits—to engage community members in providing adolescent health services.

While “The Philippine Youth Development Plan, 2017-2022,” includes plans to implement “Responsible Parenthood and Family Planning classes” and increase subscription to family planning for the youth, it does not provide any detailed strategy.

The Philippines’ legal and policy environment is promising as it outlines plans to raise public awareness on youth access to sexual and reproductive health services. However, provisions of most policies do not have an explicit focus on FP services for youth. While the Youth Development Plan states specific plans to improve family planning for youth, it does not provide any details on the nature of classes or interventions for making family planning information available. Other policies also use vague language about building community support or addressing gender and social norms without identifying specific activities or interventions.

The Philippines is placed in the gray category for this indicator.

The policy documents reviewed for Senegal contain no references to parental or spousal consent. Senegal is placed in the gray category for this indicator. 

The “Plan stratégique de santé sexuelle et de la reproduction des adolescent(e)s/jeunes au Sénégal, 2014-2018” states that services must be provided to youth by providers who are nonjudgmental:

Ces services doivent être :

...

• efficaces : ils sont assurés par des prestataires disponibles, compétents, accueillants qui savent communiquer avec les jeunes sans porter de jugement de valeur.

Therefore, Senegal is placed in the green category for this indicator.

The right of youth to receive sexual and reproductive health care is written into Senegalese law. The 2005 reproductive health (RH) law, “Loi n° 2005-18 du 5 août 2005 relative à la santé de la reproduction,” includes a clear declaration allowing all people to access RH services without discrimination, including discrimination based on age. Under Articles 3 and 10, the right to RH is acknowledged as a fundamental health and human right for all people. The law further promotes access to RH for adolescents under Article 4:

Article 3 : Le droit à la Santé de la Reproduction est un droit fondamental et universel garanti à tout être humain sans discrimination fondée sur l’âge, le sexe, la fortune, la religion, la race, l’ethnie, la situation matrimoniale ou sur toute autre situation.

Article 4 : Les Soins et services de Santé de la Reproduction recouvrent : …la promotion de la santé de la reproduction des adolescents ;

Article 10 : Toute personne est en droit de recevoir tous les soins de santé de la reproduction sans discrimination fondée sur l’âge, le sexe, le statut matrimonial, l’appartenance à un groupe ethnique ou religieux.

Senegal is placed in the green category for this indicator since national laws and policy guidelines support adolescents’ access to contraception regardless of age.

The “Loi n° 2005-18 du 5 août 2005 relative à la santé de la reproduction” includes a clear declaration allowing all people to access reproductive health services without discrimination, including discrimination based on marital status:

Article 3 : Le droit à la Santé de la Reproduction est un droit fondamental et universel garanti à tout être humain sans discrimination fondée sur l’âge, le sexe, la fortune, la religion, la race, l’éthnie, la situation matrimoniale ou sur toute autre situation.

Article 4 : Les Soins et services de Santé de la Reproduction recouvrent: …la promotion de la santé de la reproduction des adolescents;

Article 10. - Toute personne est en droit de recevoir tous les soins de santé de la reproduction sans discrimination fondée sur l’âge, le sexe, le statut matrimonial, l’appartenance à un groupe ethnique ou religieux.

Because the law includes FP as a part of reproductive health care and services, Senegal is placed in the green category for this indicator.

The right to a full range of contraceptive options is explicitly outlined in the “Protocoles de services de santé de la reproduction au Sénégal, n.d.” The Protocoles de services recognize the unique sexual and reproductive health needs and interests of youth and instruct providers to offer medically appropriate contraception to adolescents, regardless of age:

En ce qui concerne la planification familiale, les adolescents peuvent utiliser n’importe quelle méthode de contraception et doivent avoir accès à un choix étendu. L’âge ne constitue pas à lui seul une raison médicale permettant de refuser une méthode à une adolescente. Si certaines inquiétudes ont été exprimées concernant l’utilisation de certaines méthodes contraceptives chez l’adolescente (par ex. l’emploi des progestatifs injectables seuls pour les moins de 18 ans), elles doivent être pesées en regard des avantages présentés par le fait d’éviter une grossesse.

Additionally, the “Protocoles de services” include long-acting reversible contraceptives in the list of available methods. Therefore, Senegal is placed in the green category for this indicator.

Although the availability of emergency contraception is not factored into the categorization of this indicator, emergency contraception is also included in the list of available methods in the “Protocoles de services.”

In the early 1990s, two family life education (FLE) programs were piloted in Senegal. In 1990, the Ministry of Education (MoE) piloted a population education curriculum in primary schools. In 1994, the MoE appointed le “Groupe pour l’Étude et l’Enseignement de la Population,” a Senegalese nongovernmental organization, to pilot an FLE program in secondary schools. In 2010, the MoE incorporated aspects of the FLE pilot programs into the national basic education curriculum; however, critical elements of comprehensive sexuality education (CSE) were omitted, including “rights, gender, personal values, interpersonal relationships, gender-based violence, skills-building related to sexual and reproductive health (SRH) (for example, negotiating condom use), and critical thinking skills to assess social norms." The MoE has facilitated efforts to refresh the national curriculum. In doing so, the policy revision should consider the nine United Nations Population Fund (UNFPA) essential components of CSE.

The “Plan stratégique de santé sexuelle et de la reproduction des adolescent(e)s/jeunes au Sénégal, 2014-2018” describes the aims of a proposed sexual health education program, including some of the essential components of CSE programs. It describes strengthening skills in critical thinking, personalization of information, and reaching across formal and informal sectors and across age groups. For example:

L'éducation à la santé sexuelle consiste à informer sur la sexualité en transmettant un certain nombre de valeurs et de recommandations aux adolescent(e)s/jeunes. En effet elle vise à… développer l'exercice de l'esprit critique, notamment par l'analyse des modèles et des rôles sociaux véhiculés par les médias.

Elsewhere, the Plan stratégique describes educating youth on human rights and gender inequalities:

Dans le cadre de l'éducation de ces derniers, les questions de genre et les conséquences néfastes de la violence basée sur le genre seront abordées afin que toute forme de violence soit prévenue. Les jeunes seront informés et sensibilisés sur les Droits Humains (le genre faisant partie intégrante des questions de droit de l'homme).

This component, however, is not included as an aim of the previously described sexual health education program. Additional components, such as providing accurate information, linking SRH services and other initiatives for young people, providing youth-friendly spaces, and strengthening youth input into SRH programming, are also acknowledged in the “Plan stratégique,” but often in the context of service delivery rather than CSE.

The “Cadre stratégique national de planification familiale, 2016-2020” includes interventions for the promotion of large-scale communication on birth spacing. In reference to communication to young people, the “Cadre stratégique national” outlines the integration of new family planning protocols into current home economics and life and earth sciences curricula and the support of peer educators within FLE clubs as interventions:

Renforcement de la communication visant les jeunes :

En matière de renforcement de la communication visant les jeunes, la DSRSE [direction de la santé de la reproduction et de la survie de l’enfant] mettra l’accent sur des initiatives visant à adapter davantage le dispositif de formation existant en formant les professeurs relais technique (PRT) et les professeurs d'économie familiale sur la PF, en appuyant l’intégration des nouveaux protocoles PF dans les curricula des professeurs d'économie familiale et de Sciences de la Vie et de la Terre en formant les leaders Elèves Animateurs (LEA), les gouvernements scolaires et autres pairs éducateurs sur les techniques de communication. Enfin, le présent plan prévoit de réaliser des investissements substantiels visant à doter les LEA de supports de communication, contractualiser avec les clubs EVF [éducation à la vie familiale] dans les écoles pour la mise en oeuvre d'un paquet d'activités et soutenir la réalisation d’activités périodiques de suivi /coordination.

The “Stratégie nationale de financement de la santé pour tendre vers la couverture sanitaire universelle, 2017” acknowledges the positive impact that sexual health education can have on informed decisions and reproductive health outcomes, but does not provide further details on the proposed education curriculum.

Senegal’s policies acknowledge CSE broadly but fall short of including all nine essential components together in a clear operational policy for CSE. Senegal has a promising policy environment for CSE, but until these policies are revised, the country will remain in the yellow category for this indicator.

The “Plan stratégique de santé sexuelle et de la reproduction des adolescent(e)s/jeunes au Sénégal, 2014-2018” includes plans to train providers to offer youth-friendly contraceptive services, with particular emphasis on good communication skills:

Pour le professionnel de santé, le dialogue et la relation de confiance noués avec l'adolescent(e)/ jeune sont des déterminants fondamentaux de la qualité de la prise en charge, qu'il s'agisse de diagnostiquer, de dépister et d'informer. En effet, il doit avoir des compétences nécessaires pour communiquer avec les adolescent(e)s/jeunes, détecter leurs problèmes de santé de façon précoce et fournir des conseils et des traitements. Il doit placer les besoins, les problèmes, les pensées, les sentiments, les points de vue et les perspectives des adolescent(e)s/jeunes, au cœur de ses activités... L'accent sera mis sur l'apprentissage et la formation continue.

Additionally, the “Plan stratégique” outlines the necessary criteria for youth-friendly services in line with the World Health Organization Quality of Care framework for adolescent service provision, including that services must be accessible (and affordable), acceptable, equitable, effective (and without any value judgments), appropriate, efficient, and comprehensive:

Ces services doivent être :

• accessibles : ils sont disponibles au bon endroit, au bon moment, à un bon prix (gratuit si nécessaire).
• acceptables : ils répondent à leurs attentes et garantissent la confidentialité.
• équitables : ils sont offerts à tous sans distinction de sexe, d'âge, de religion, d'appartenance ethnique, de handicap, de statut social ou de toute autre nature.
• efficaces : ils sont assurés par des prestataires disponibles, compétents, accueillants qui savent communiquer avec les jeunes sans porter de jugement de valeur.
• appropriés : les soins essentiels sont fournis d'une manière idéale et acceptable dans un environnement sécurisé.
• efficients : les soins de qualité sont dispensés au coût le plus faible possible.
• complets : la prestation de soins couvre tous les aspects de la prise en charge et la référence est assurée en cas de besoin.

The “Plan d’action national de planification familiale, 2012-2015” further references the provision of FP services to youth and identifies the need for discretion, confidentiality, and tailored service provision:

L’accent sera mis sur la qualité du service et du counseling tout en assurant la disponibilité du matériel et des consommables. Un focus particulier sera mis sur l’amélioration de l’accès aux services de Planification Familiale pour les jeunes en leur assurant la discrétion, la confidentialité et un service adapté.

Similarly, the “Protocoles de services de santé de la reproduction au Sénégal, n.d.” include a direct reference to the provision of FP services for youth and recognize the rights of youth to receive services, including their right to information, access, privacy, and dignity.

Les protocoles définis doivent être respectés pour les différents services. Cependant du fait de la spécificité et de la vulnérabilité de cette cible, une attention particulière doit être apportée aux droits à l’information, à l’accès, à l’intimité et à la dignité de ces adolescent(e)s et jeunes.

Across these policies, all three service delivery elements of adolescent-friendly contraceptive service provision are addressed. Therefore, Senegal is placed in the green category for this indicator.

The “Plan d’action national de planification familiale, 2012-2015” highlights the need to inform youth and their communities regarding FP. One of the strategic actions under the communication plan is to roll out a mass media campaign aimed at young people. This strategic action has three main activities:

Bâtir une campagne participative pour les jeunes

Renforcer les centres d'écoute pour les jeunes et centres d'informations

Utilisation des réseaux sociaux et nouvelles technologies pour informer les jeunes sur la PF (facebook, sms, blogs)

The “Plan stratégique de santé sexuelle et de la reproduction des adolescent(e)s/jeunes au Sénégal, 2014-2018” includes plans to use information and communications technology and media to reach youth and the broader community.

Une campagne nationale médiatique de sensibilisation sur la SRAJ [santé reproductive des adolescents et des jeunes] sera également menée. De même il serait judicieux d'utiliser des radios communautaires qui représentent un moyen de mobilisation important, pour garantir la participation de la communauté.

The “Plan stratégique” also discusses how gender will be addressed in youth reproductive health programs:

6.4.2.1 Sur le plan social et organisationnel

Des actions à mener pour l'amélioration de l'environnement social/organisationnel sont indispensables pour l'atteinte des objectifs de la SRAJ...

 • Prise en compte des questions de Genre

La dimension genre sera prise en compte dans l'élaboration des projets et programmes de SRAJ ainsi que dans 1'éducation et la formation des adolescent(e)s/jeunes. Dans le cadre de l'éducation de ces derniers, les questions de genre et les conséquences néfastes de là violence basée sur le genre seront abordées afin que toute forme de violence soit prévenue.

Les jeunes seront informés et sensibilisés sur les Droits Humains (le genre faisant partie intégrante des questions de droit de l'homme).

Since these plans include detailed steps to build an enabling social environment among youth and communities for FP services, Senegal is placed in the green category for this indicator.

The “Reproductive and Healthcare Rights Act, 2013,” a law applicable across Pakistan, signals increased political acknowledgment of the reproductive rights of women, in an effort to curtail maternal mortality and morbidity. While the Act provides increased legal protection for women overall, it ignores the particular reproductive health (RH) rights of young women.

The Act does not include any provision for youth. Further, under Line B, Article 4, the right of parents to educate their children is prioritized as a means of promoting RH care information. The acknowledgment of parental responsibility without subsequent recognition of youth’s rights to FP services creates an opportunity for interpretation that favors parental rights over children’s RH decisions.

Article 4: Promotion of reproductive healthcare rights:

1. The right to reproductive healthcare information can be promoted,...

(b) through the exercise of parental responsibility which assures the right of parents as educators.

The Sindh policies reviewed do not provide further guidance on youth’s right to access FP services without parental consent, leaving ambiguity in the requirement of parental consent for FP services.

The “Manual of National Standards for Family Planning, 2009” and the “Manual of Standards for Family Planning Services, Sindh, Revised, 2017” include identical guidance to providers on preventing barriers to contraceptive use, including the discouragement of requiring spousal consent:

Eligibility requirements that needlessly limit the use of certain methods based on a woman’s age, parity, or lack of spousal consent.

The national and provincial standards advise providers to follow the World Health Organization’s medical eligibility criteria when offering contraception to women. While the policies address spousal consent, they fail to sufficiently address parental consent for youth to access FP services. Sindh is placed in the yellow category for this indicator.

The “Manual of National Standards for Family Planning, 2009” and the “Manual of Standards for Family Planning Services, Sindh, Revised, 2017”—both of which include youth access to FP as part of their standards—identify unjustified medical barriers, including provider bias:

What Are Unjustified Medical Barriers?

• Practices derived (at least partly) from a medical rationale.
• Non-evidence-based barriers that result in denial of contraception.
• Eligibility restrictions, based on providers’ limitations/personal biases.

These policies urge providers to follow the medical eligibility criteria to discern eligibility for contraceptive services. Sindh is placed in the green category for this indicator.

The “Costed Implementation Plan on Family Planning for Sindh, 2015” includes “Family Planning 2020: Rights and Empowerment Principles of Family Planning” as an annex. This list states that age and marital status should not determine access to FP services:

Quality, accessibility, and availability of information and services should not vary by non-medically indicated characteristics i.e. age, location, language, ethnicity, disability, HIV status, sexual orientation, wealth, marital or other status.

This declaration references the right of all people to access services regardless of age, placing Sindh in the green category for this indicator.

Sindh policy documents are contradictory regarding the right to access FP services regardless of marital status. The “Costed Implementation Plan on Family Planning for Sindh, 2015” references the right of all women, regardless of marital status, to access FP information and services, as does the “Manual of Standards for Family Planning Services, Sindh: Revised, 2017”:

Right to Access: All individuals in the community have a right to receive services from FP programmes, regardless of their social status, economic situation, religion, political belief, ethnic origin, marital status, geographical location, or any other group identity.

However, the “Sindh Population Policy, 2016” narrows the scope of access to FP services to married young people:

The Population Welfare Department will provide information, education and counseling on population issues and make available services for birth spacing to young married couples to minimize high risk fertility behaviours.

The latter policy references sociocultural beliefs surrounding young people’s reproductive health behaviors as justification for the focus on married youth. As such, the Population Policy overlooks the FP needs of unmarried youth, creating a barrier to access to services. Further, the Manual of Standards contradicts its own language on marital status cited above by stating:

Adolescents who are married need access to safe and effective contraception.

Because Sindh’s policy language favors married couples’ access to family planning but does not restrict unmarried youth from accessing services, Sindh is placed in the yellow category for this indicator.

The “Manual of National Standards for Family Planning, 2009” and the “Manual of Standards for Family Planning Services, Sindh: Revised, 2017” discuss the special contraceptive and counseling needs of adolescents, ultimately encouraging providers to offer a full range of methods to youth:

Adolescents who are married need access to safe and effective contraception. Many adolescents use no contraception or use a method irregularly, so they are at high risk of unwanted pregnancy, unsafe abortion, and STIs [sexually transmitted infections]. In general, adolescents are eligible to use any method of contraception. Services should avoid unnecessary procedures that might discourage or frighten teenagers, such as requiring a pelvic examination when they request contraceptives.

These policies align with the World Health Organization’s medical eligibility criteria and classify all short- and long-acting reversible methods as “use method in any circumstance” or “generally use method” for post-menarche women under age 18 and nulliparous women. Sindh is placed in the green category for this indicator. 

Although the availability of emergency contraception (EC) is not factored into the categorization of this indicator, it is worth noting that the “Manual of National Standards” includes women of reproductive age in the eligibility requirement for EC and acknowledge youth vulnerability to sexual assault, which warrants the provision of this method: 

While all women in situations of conflict are vulnerable to sexual assault, young female adolescents may be the group most in need of EC services. Adolescent refugees are often targeted for sexual exploitation and rape, yet there are relatively few programmes that address the specific reproductive health needs of young people, and even fewer that provide EC.

The “National Vision for Coordinated Priority Actions to Address Challenges of Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition, 2016-2025” acknowledges the role that the national government can play in overseeing integration of reproductive health and family planning across sectors. The National Vision includes sexuality education for adolescents as one of the measures the Ministry of Health can support:

Focus on sexual & reproductive health education among adolescents, both boys and girls in school and out of school, is an important step that needs to be taken in a culturally sensitive manner.

However, the “Sindh Population Policy, 2016” limits the provision of sexuality education to married couples, using sociocultural beliefs as a justification. Under the “Focusing on Youth and Adolescents” section, the Population Policy emphasizes marriage as a precursor to parenthood, suggesting an abstinence-only educational approach:

Similar move would be initiated to support education of adolescents as their reproductive health issues are significant in urban and rural areas. However, this will be approached within the acceptable socio-cultural framework of the province and in conductive settings. As such, the Policy endorses that adolescents and youth may be equipped with knowledge about healthy and happy marital life leading to responsible parenthood.

Additional activities support educating older youth regarding life skills. Sindh addresses FP education for youth at the university level under Activity 5.4.1 of the “Costed Implementation Plan on Family Planning for Sindh, 2015”:

Consultations held with Department of Education, Health Education Commission, professional colleges to include life skills into the curriculum

Although the Costed Implementation Plan recognizes the provision of sexuality education, the scope is limited to college-age students. However, the “Sindh Reproductive Healthcare Rights Act, 2019” has provisions on reproductive health education in the curriculum at secondary and higher secondary school levels.

The “Sindh Youth Policy, 2018” indicates support for youth access to RH information. It incorporates short-term and mid-term strategies for education and communication activities at the school level and long-term strategies, including a “Youth Helpline” for counseling adolescents on SRH. The Youth Policy also affirms that the youth would be entitled to gender responsive and age-appropriate life skills-based education, both in school and out of school. However, further details of how the strategies would be implemented are not provided.

While some policies support youth access to information, other policies limit comprehensive sexuality education to married couples and focus on an abstinence-only educational approach, limiting the ability of youth to make positive sexual and reproductive health decisions. Sindh is placed in the red category for this indicator.

The provision of contraception to youth is highlighted as a special area of focus in the “Sindh Health Sector Strategy, 2012-2020”:

Strategy 3.4: Re-defining links with DoPW (Department of Population Welfare) with shift of contraceptive services through district and urban PHC [primary health care] systems and aimed at birth spacing in younger couples

The strategy includes an activity to integrate FP service provision with maternal care, which states that contraceptives should be provided at no cost to younger couples:

Integrating contraception provision: Provision of free contraceptives and training by DOPW to all DOH [Department of Health] facilities for birth spacing. Integration of services with pregnancy care to reach out to couples and supported by community-based BCC [behavior change communication].

The “Manual of Standards for Family Planning Services, Sindh: Revised, 2017” defines YF services and provides a checklist for facility observation that includes whether services are free or affordable to young people and whether several provisions to ensure privacy and confidentiality are in place.

The “Costed Implementation Plan on Family Planning for Sindh, 2015” identifies youth as a vulnerable segment of the population and acknowledges that strategies to reach this group include comprehensive and nonjudgmental contraceptive counseling and service provision. The Costed Implementation Plan includes activities to train health providers in YF service provision:

During the training of providers and community-based workers on FP, youth-friendly services and engagement will be added as a compulsory element of training (in-service and pre-service). Such an orientation of providers to the principles of youth-friendly services will allow existing facilities and community-based workers to incorporate ownership of providing services to meet the needs of young people.

The “Sindh Reproductive Healthcare Rights Act, 2019” includes language guaranteeing privacy during the provision of reproductive health services and ensuring the confidentiality of personal information:

(g) training of reproductive health care providers to be gender sensitive and to reflect user perspective to the right to privacy and confidentiality and also training in interpersonal and communication skills;

...

(k) provision of reproductive healthcare services to persons in privacy and ensuring personal information given thereof is kept confidential; .

Because these policies emphasize youth-friendly FP services and includes the three service-delivery elements—cost, privacy and confidentiality, and provider training—Sindh is placed in the green category for this indicator.

The “Costed Implementation Plan on Family Planning for Sindh, 2015” highlights reaching youth as a key concern and priority area. As a part of the discussion on reaching youth, the plan recognizes the importance of engaging the community to support youth access to FP:

Engagement with key gatekeepers and community leaders to foster an enabling environment for service uptake.

However, additional guidance on how this activity will be implemented, as well as discussion of approaches to address gender norms, are missing. While the “Sindh Youth Policy, 2018” includes a medium/ long-term strategy to sensitize youth groups regarding gender equality, it does not address gender norms specific to youth family planning.

Sindh is placed in the yellow category for this indicator.

The right of young people and adolescents to freely access family planning services without requiring consent from a parent or spouse is situated prominently in the “National Family Planning Guidelines and Standards, 2013”:

Decisions about contraceptive use should only be made by the individual client. No parental or spousal consent is needed for an individual to be given family planning information and services, regardless of age or marital status.

Given this clear declaration protecting youth autonomy in sexual and reproductive health decisionmaking, Tanzania is placed in the green category for this indicator.

The “National Standards for Adolescent Friendly Reproductive Health Services, 2004” affirm the rights of youth to access FP services and providers’ obligation to adhere to youth rights:

All adolescents are informed of their rights on sexual and reproductive health information and services whereby these rights are observed by all service providers and significant others.

The “National Family Planning Guidelines and Standards, 2013” provide specific guidance to providers to deliver respectful, competent, and non-judgmental services to youth:

Standard 5.4: Service providers in all delivery points have the required knowledge, skills, and positive attitudes to effectively provide sexual and reproductive health services to young people in a friendly manner.

The service providers exhibits the following characteristics:

• Has technical competence in adolescent-specific areas.
• Respects young people.
• Keeps privacy and confidentiality.
• Allows adequate time for client/provider interaction.
• Is non-judgmental and considerate.
• Observes adolescent reproductive health rights.

The “National Adolescent Health and Development Strategy, 2018-2022” highlights provider bias and attitude as key barriers to youth access to family planning (FP) services, defining adolescent-friendly services as those that include:

Providers who are non-judgmental and considerate, easy to relate to and trustworthy [;] provide information and support to enable each adolescent to make the right free choices for his or her unique needs.

Taken together, these statements supporting youth access to sexual and reproductive health services free from provider judgment or bias indicate a supportive and favorable policy environment. Therefore, Tanzania is placed in the green category for this indicator.

The “National Standards for Adolescent Friendly Reproductive Health Services, 2004” makes a clear age-based statement protecting the rights of youth to access FP services:

All adolescents are informed of their rights on sexual and reproductive health information and services whereby these rights are observed by all service providers and significant others.

The “National Family Planning Guidelines and Standards, 2013” also directly mention the right of youth to receive FP services:

Like persons of other age groups, young people have the rights to decide if and when they want to have children, be informed and obtain information about family planning services, and access a full range of contraceptive methods.

Tanzania is placed in the green category for this indicator because its policies explicitly acknowledge young people’s right to FP services.

Standard 5.3 of the “National Family Planning Guidelines and Standards, 2013” recognizes the right of all young people to receive FP services, regardless of marital status:

Young people are able to obtain family planning services without any restrictions, regardless of their marital status.

With a clear recognition of married and unmarried youth’s right to FP services, Tanzania is placed in the green category for this indicator.

The “National Family Planning Guidelines and Standards, 2013” affirm the right of young people to access a full range of FP methods and direct providers to offer FP services in accordance with the World Health Organization’s medical eligibility criteria:

Contraceptives should be provided to clients in accordance with nationally approved method-specific guidelines, as defined by the World Health Organization (WHO) Medical Eligibility Criteria (MEC).

In addition to stating the right for youth to access family planning services, the “Guidelines and Standards” further acknowledges that youth have the right to access a full range of methods and references the “National Family Planning Procedure Manual, n.d.,” which details the WHO’s medical eligibility criteria allowing young people to access long-acting reversible contraceptives. Tanzania is therefore placed in the green category for this indicator.

Although the availability of emergency contraception is not factored into the categorization of this indicator, note that emergency contraception is included in the package of contraceptive offerings listed in the Procedure Manual.

The Ministry of Education and Culture in Tanzania has taken a broad stance on the form of sexuality education to offer to youth. The Ministry developed the “Guidelines for Implementing HIV/AIDS/STDs and Life Skills Education in Schools and Teachers’ Colleges, Version 2, 2002” as a response to increased HIV transmission among youth. As a result, the directives focus primarily on the prevention of HIV and sexually transmitted infections. Comprehensive sexuality education (CSE), specifically, is not referenced and accordingly not defined.

The Guidelines describe the national approach to sexual education as:

The content of HIV/AIDS/STIs control education shall aim at developing and promoting knowledge, skills positive and responsible attitudes such as assertiveness, effective communication, negotiation, informed decision making and provide motivational support as a means to responsible sexual behaviour.

These guidelines were developed in 2002, prior to the publication of international guidance on CSE. This framing is not comprehensive and limits the provision of information on sexuality, safe sexual behaviors, sexual and reproductive health (SRH) care, and gender.  To promote a holistic approach to life skills education, including self-awareness, relationship skills, cognitive skills, and SRH education, Tanzania developed the “National Life Skills Education Framework, 2010.” The Framework notes that despite concerns from stakeholders who contributed to the content, health-based life skills would be covered in biology and governance entrepreneurship courses, and that life-skills education will be “de-linked from an exclusive emphasis on SRH and HIV/AIDS.” The education would have a “strong gender orientation” and will ensure that “students get a sufficient ‘dose’ of SRH/HIV education [but] they will also be taught to apply life skills to other areas in sufficient depth to have an impact.”

Additional policies implicitly acknowledge the limitations of the current policy environment for CSE. The “National Adolescent Health and Development Strategy, 2018-2022” recommends:

Promote a comprehensive curriculum which makes sexual and reproductive health, nutrition, life skills and empowerment compulsory topics to be included in secondary school and non-formal education packages.

The “National Family Planning Costed Implementation Plan 2019-2023” supports the adoption of policies that improve youth access to contraceptive information and services and integrates a CSE program into the national curriculum. One of the Costed Implementation Plan's strategic outcomes is to adopt and implement policies that improve access to high-quality FP information for in-school youth:

OUTCOME 2: Adopt and implement policies that improve equitable and affordable access to high-quality FP services and information

…

Stakeholders identified two opportunities to reach in-school youth: 1) reviewing and rolling out an evidence-based national comprehensive sexual education curriculum to ensure that the content on contraception is strong and evidence-based and 2) revising the National School Health Programme guidelines and strategy to include FP information.

…

Output EE 4: Policies supporting young people’s access to contraceptive information and services adopted and implemented.

Activity 1: Include strong, evidence-based FP content into Comprehensive Sexuality Education (CSE), currently integrated in national school-based curricula for primary and secondary schools.

The Costed Implementation Plan’s strategic outcome to increase total demand for contraception also acknowledges the need to tailor communication materials and channels to reach target audiences, namely youth, with FP information. The Costed Implementation Plan aims for these messages to focus on providing accurate and relevant information about FP methods, promoting the availability of FP services and the importance of healthy timing and spacing of births, and ensuring that audiences are aware of their rights related to FP services.

While the Costed Implementation Plan activity includes sub-activities detailing the necessary steps for the adoption of a new CSE curriculum, including stakeholder workshops and costing for drafting, revision, and dissemination of the policy, it does not include guidelines that are fully aligned with the United Nations Population Fund’s (UNFPA’s) essential components. To improve upon existing guidelines, the Ministry of Education and Culture should consider including the nine essential components for CSE in any future curricula revisions. Tanzania is placed in the yellow category for this indicator.

The “National Road Map Strategic Plan to Improve Reproductive, Maternal, Newborn, Child, and Adolescent Health in Tanzania, 2016-2020 (One Plan II)” prioritizes adolescent and youth-friendly (YF) family planning services, setting a target to increase the proportion of adolescent and YF health services from 30%to 80%by 2020. The “National Family Planning Costed Implementation Plan, 2019-2013” includes provider training and ensures confidentiality and privacy within its activities to improve availability and access to quality YF services:

OUTPUT SD4: Number of facilities offering quality youth-friendly services according to established national youth-friendly service standards increased

Reflecting strategic priority 4, activities in this output focus on improving services for young people at both the facility and community levels. First, an assessment will be conducted with youth of different profiles (e.g., different age groups, married versus unmarried, in- versus out-of-school) to collect information regarding barriers they face in accessing contraceptive services. Findings will be shared with CHMTs [Council Health Management Teams] and facility managers as part of advocacy to prioritise funding for structural changes, including infrastructure improvements to ensure privacy and confidentiality, changes in hours of service, and signage to publicise facilities that have undertaken efforts to become adolescent-friendly. Facilities will be identified for improvement and for training needs via routine supervision. In collaboration with the Adolescent and Reproductive Health Unit, at least one trainer per region will be trained in YFCS [youth-friendly contraceptive services]. At least two providers per facility across the country will be trained to offer contraceptive services to youth without bias or barriers; these trainings will also include private facilities or pharmacies and ADDOs [accredited drug dispensing outlets] that youth are likely to frequent. In addition, operators of the youth-focused toll-free help line will also be trained in YFCS. In addition to showing visible signs that identify them as meeting requirements for YFCS, facilities will be included in a YFCS directory that can be disseminated through FP stakeholder meetings, trainings, and zonal meetings and through the toll-free help line. Efforts will also be made to reach young people with services outside of facilities, including outreach from facilities to places where youth gather frequently (e.g., youth clubs, youth corners). The quality of YFCS offered by both facility- and community-based providers will be assessed during routine supportive supervision visits conducted under Output SD1.

The Tanzania “National Family Planning Guidelines and Standards, 2013” recognize the unique FP needs of young people as a group deserving special consideration:

All family planning service-delivery points—whether in a facility, community, or outreach setting—should incorporate youth-friendly services, as further described in Section II: Standards. Services are youth-friendly if they have policies and attributes that attract youth to the services, provide a comfortable and appropriate setting for serving youth, meet the needs of young people, and are able to retain their young clients for follow-up and repeat visits. 

This document further details specific directives for the provision of YF services (Standard 5.1.-5.6.), provider training, and free contraceptives for all FP clients in the public sector.

Together, these policies address each of the three service-delivery core elements that improve adolescent and youth uptake of contraception. Therefore, Tanzania is considered to have a supportive and favorable policy environment surrounding service provision and is placed in the green category for this indicator.

The “National Family Planning Costed Implementation Plan, 2019-2023” outlines activities to lead to positive shifts in social norms and attitudes, with the goal of fostering healthier behavior and beliefs around contraception:

Given that the FP Goals Model identified improving social norms related to FP as a major contributor to future mCPR [modern contraceptive prevalence rate] growth, specific attention will be paid to identifying and subsequently addressing and shifting social norms. The foundation activity will be an assessment to identify social norms that currently impede FP use in the priority 18 regions, the findings of which will inform subsequent activities in this and other outputs. … Developed messages will be tailored to address specific norms relevant for the specific regions and groups, including messages targeted to health care providers to normalise FP services for all age groups. The messages and tools will be integrated into community-sensitisation activities run by CHWs [community health workers] and shared with local FP champions. CHWs who underwent the government’s one-year training for CHWs, and who will be identified through mapping conducted under the service delivery thematic area, will receive refresher training and support to conduct community-mobilisation activities using updated content to change social norms and attitudes (i.e., module 1 of the FP refresher training curriculum). A message development guide and tailored messages will be part of the service delivery supervision conducted monthly by nearby health facilities. Also, in collaboration with a media consultant, messages that address social norms will be developed for local radio, while messages that address ‘shared’ norms (across regions) will also be aired through national radio.

While not specific to contraceptive services, the “National Adolescent Health and Development Strategy, 2018-2022” emphasizes community engagement and efforts to overcome gender norms:

Misinformation among gatekeepers is a potential drawback to adolescents’ access to health services as parents, guardians and local leaders are critical information channels for adolescents… By empowering families and the community in general, demand for adolescent friendly health services can be significantly improved.

Among its top priorities and recommendations, the Strategy aims to:

Create strong linkages with community groups, community-based organizations [CBOs] and faith-based organizations [FBOs] to promote positive socio-cultural norms.

The Strategy also notes gender norms’ impact on adolescent health:

Gender norms have an influence on the health of adolescents, which manifests through discrimination of both male and female adolescents, leading to marginalization… Contradictory gender norms from family and society can shape sexual expectations with implications on engagement in unsafe sexual behaviors.

Gender norms are briefly referenced within the Strategy’s strategic recommendations, which include a call to raise the minimum age at marriage to 18:

CBOs and FBOs should also address gender norms, roles and relationships that may be harmful… Cash transfer interventions can particularly help adolescent girls take fewer risks in their sexual relationships.

The “National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn, and Child Deaths in Tanzania, 2016-2020 (One Plan II)” includes several activities to use community support for adolescent and youth sexual and reproductive health, including:

Activity 5.5: Support utilization of existing community structures (religious leaders, parents, community and government leaders) to reach young people with age-appropriate sexual and reproductive health information and link them to services.

Tanzania is placed in the green category for this indicator since its strategies not only acknowledge the importance of engaging the community in the provision of FP services to youth, but also identify interventions to build community support for youth-friendly FP services and address gender norms.

Togo’s policy environment does not explicitly prohibit parental or spousal consent. Togo is placed in the gray category for this indicator.

The “Protocoles de santé de la reproduction ; santé de la mère, santé de l’enfant, santé des jeunes et adolescents(es), santé des hommes ; tome I ; 2ème édition, 2009” make clear that providers should be nonjudgmental of youth:

1.2- Ce qu’il ne faut pas faire

…

• S’imposer d’emblée lorsqu’on engage une discussion avec les jeunes.
• Ridiculiser les jeunes.
• Juger les jeunes.
• Être négatif ou pessimiste lorsqu’on travaille avec les jeunes.
• Sous-estimer la capacité des jeunes.

Comment les adolescents et jeunes aimeraient être traités?

• Les acceptez tels qu’ils sont, ne pas leur faire de la morale et ne pas les démoraliser
• ...Ne pas les juger.

The “Loi n° 2007-005 sur la santé de la reproduction, 2007” guarantees the right of reproductive health to adolescents without discrimination. Similarly, the “Politique et normes en santé de la reproduction, planification familiale et infections sexuellement transmissibles de Togo, 2009” state that providers should withhold judgment when counseling clients on FP methods:

2- LES CLEFS D’UN BON COUNSELING

CHAPITRE 2 : LE COUNSELING EN PF…

- Montrer du respect et de l’amabilité envers le (la) client(e) par son approche sans jugement,

- Ecouter activement les préoccupations du (de la) client(e),

- Présenter l’information sans partie pris dans le respect du sentiment du (de la) client, …

CHAPITRE 2 : LE COUNSELING EN PF….

3.4- Choix/ Décision

- Aider le (la) client(e) à choisir la méthode qui lui convient,

- Rester neutre,

- Discuter des critères d’éligibilité du (de la) client(e),

- S’assurer que le (la) client(e) est bien informé (e),

Because Togo’s policies explicitly state that providers must avoid judgment of youth when providing FP, Togo is placed in the green category for this indicator.

The “Loi n° 2007-005 sur la santé de la reproduction, 2007” states that reproductive health services should be available to all individuals regardless of age or marital status and further guarantees adolescents’ right to reproductive health without discrimination:

Art. 7 - En matière de santé de la reproduction, tous les individus sont égaux en droit et en dignité sans discrimination aucune fondée sur l'âge, le sexe, le revenu, la religion, l'ethnie, la race, la situation matrimoniale ou sur toute autre situation touchant à l'état de la personne.

Art. 9 - Le droit à la santé de la reproduction est reconnu, sans discrimination aucune, à tout individu, personne du troisième âge, adulte, jeune, adolescent et enfant.

Similarly, the “Politique et normes en santé de la reproduction, planification familiale et infections sexuellement transmissibles de Togo, 2009” state that youth-friendly services are based on the principle that adolescents have the right to health services regardless of age:

Le respect des droits humains et en particulier le droit des adolescents/jeunes à l’accès aux services de santé de qualité sans discrimination aucune liée à leur âge, leur sexe, leur religion ou condition sociale

Togo is placed in the green category for this indicator.

The “Loi n° 2007-005 sur la santé de la reproduction, 2007” guarantees the right to reproductive health services—including FP—regardless of age or marital status and further guarantees the right to reproductive health to adolescents without discrimination:

Art. 7 - En matière de santé de la reproduction, tous les individus sont égaux en droit et en dignité sans discrimination aucune fondée sur l'âge, le sexe, le revenu, la religion, l'ethnie, la race, la situation matrimoniale ou sur toute autre situation touchant à l'état de la personne.

Art. 9 - Le droit à la santé de la reproduction est reconnu, sans discrimination aucune, à tout individu, personne du troisième âge, adulte, jeune, adolescent et enfant.

The “Programme national de lutte contre les grossesses et mariages chez les adolescents en milieux scolaire et extrascolaire au Togo, 2015-2019” includes a focus on access to improving sexual and reproductive health services and targets both married and unmarried youth:

Axe stratégique 3 : Accès à l’information et aux services de santé sexuelle et de la reproduction adaptés aux adolescents

Résultat d’effet 3.1
Un plus grand nombre d’adolescentes utilisent de services contraceptifs.

• % d’adolescentes (15 à 19 ans) mariées utilisant une méthode moderne de contraception
• % d’adolescentes (15 à 19 ans) non-mariées utilisant une méthode moderne de contraception

Togo is placed in the green category for this indicator because its policy environment protects youth access to family planning regardless of marital status.

The “Standards de services de santé adaptés aux adolescents et jeunes de Togo, 2009” describe the package of minimum services for adolescents at each level of the health system, which includes all methods of contraception, including long-acting reversible contraceptives (LARCs). The “Protocoles de santé de la reproduction du Togo ; composantes communes, composantes d’appui ; tome II ; 2ème edition, 2009” include a full range of contraceptive options for youth in FP services and acknowledge the importance of providing contraception to sexually active youth. However, the policy states that abstinence should be strongly recommended to adolescents. It includes restrictions for recommending intrauterine devices (IUDs) to adolescents based on parity, frequency of sexual activity, and number of partners:

Appliquer la conduite à tenir :  « convient à ou ne convient pas à » en tenant compte des caractéristiques de l’adolescent et de son choix

...

7- PROGRAMMER LES VISITES SELON LA METHODE CHOISIE

…

N.B. Une sexualité précoce augmente le risque de cancer du col. L’abstinence devrait être fortement recommandée chez un adolescent

The “Plan d’action national budgétisé de planification familiale du Togo, 2017-2022” includes as one of its main objectives offering a varied and complete range of contraceptive methods, with a focus on youth:

Objectif 2 : Garantir l’offre et l’accès à des services de PF de qualité en renforçant la capacité des prestataires publics, privés et communautaires et en ciblant les jeunes dans les zones rurales et les zones enclavées par le biais de l’élargissement de la gamme des méthodes, y compris la mise à l’échelle des MLDA [méthode à longue durée d’action], la PFPP [planification familiale post-partum] et l’amélioration des services destinés aux jeunes.

While some Togolese policies support youth access to a full range of methods, the existence of the “Protocoles de santé de la reproduction: tome II, 2009” restricting the provision of LARCs to youth places Togo in the red category. Future protocols for provider provision of LARCs for adolescents should be updated based on the most recent World Health Organization medical eligibility criteria for contraceptive use.

Although the availability of emergency contraception is not factored into the categorization of this indicator, note that the “Protocoles de santé” include emergency contraception in the general list of contraceptive methods, but not in the adolescent-specific section on sexual and reproductive health. Thus, it is not clear whether the policy intends for emergency contraception to be accessible to youth.

The “Loi n° 2007-017 portant code de l'enfant, 2007” guarantees every child the right to information on reproductive health:

1. Le droit de tout enfant d'avoir des informations sur la santé de la reproduction.

The “Loi n° 2007-005 sur la santé de la reproduction, 2007” states that everyone has the right to information and education on sexual and reproductive health:

Art. 13 - Tout individu a droit à l'information, à l'éducation utile à sa santé sexuelle et reproductive et aux moyens nécessaires lui permettant d'évaluer les avantages et les risques pour un choix judicieux.

The “Plan national de développement sanitaire, 2017-2022” lists comprehensive sexuality education (CSE) and information, advice, and services for sexual and reproductive health, including commodities, as priority interventions for adolescent health and development.

Orientation stratégique : Promotion de la santé et le développement de l’adolescent

Renforcement du cadre de concertation intersectoriel en matière de promotion de la santé des adolescents ; …

• Éducation sexuelle complète ;
• Informations, conseil et services pour une santé sexuelle et génésique complète, contraception incluse ;

The “Plan d’action budgétisé de la planification familiale au Togo, 2017-2022” includes activities to reach youth in formal and informal settings, which is one of the essential components of CSE:

CD2-A4. Harmonisation des curricula d’enseignement sur l’éducation sexuelle complète dans les systèmes éducatifs (formel et informel)

Actualiser les connaissances sur la SRAJ [santé reproductive des adolescents et des jeunes dans les écoles grâce aux nouveaux modules d’éducation sexuelle complète dans les curricula de formation. Des enseignants expérimentés seront formés pour être des formateurs. Ils animeront ensuite des sessions de formation des formateurs chaque année. Ces derniers assureront l’éducation sexuelle complète des adolescents et jeunes.

Similarly, the “Programme national de lutte contre les grossesses et mariages chez les adolescents en milieux scolaire et extrascolaire au Togo, 2015-2019” includes specific activities for introducing CSE to youth, particularly girls, in and out of school:

Axe stratégique 2 : Accès et maintien des adolescentes dans le système éducatif et accès à l’éducation sexuelle complète

…Il vise également l’accès à l’éducation sexuelle complète (ESC) pour toutes les adolescentes en milieux scolaire et extrascolaire. L’ESC est reconnue globalement comme une stratégie efficace pour prévenir les grossesses précoces et renforcer l’autonomisation des adolescentes.

Résultats d’effet 2.2 : La qualité et la couverture de l’éducation sexuelle complète sont renforcées dans les établissements scolaires, dans les centres de formations professionnelles et pour les portefaix, les domestiques et les serveuses dans les bars

As part of its gender approach, the “Politique et normes en santé de la reproduction, planification familiale et infections sexuellement transmissibles de Togo, 2009” includes a plan to incorporate gender into population education for youth, another of the essential components of CSE:

… En matière d'éducation des enfants, des adolescents et des jeunes, il s'agira d'introduire des modules d'approche genre dans l'EPD [éducation en matière d'environnement et de population pour un développement humain durable] / SR [santé de reproduction]..

The "Plan d’action pour le repositionnement de la planification familiale au Togo, 2013-2017" includes strategies for improving communication on family planning services to adolescents and young people. While strategies include using new technologies such asradio and television broadcasts to target adolescents and young people in school and out of school, the “Plan d’action” does not clarify whether the communication will include essential components of CSE.

Togo’s policy environment is supportive of CSE but does not reference all nine of the United Nations Population Fund’s (UNFPA’s) essential components of CSE. Togo is placed in the yellow category for this indicator.

The “Plan d’action pour le repositionnement de la planification familiale au Togo, 2013 -2017” includes a strategy to improve the supply of FP services for adolescents and young people in and out of school through capacity building of providers.

Stratégie O6 : Amélioration de l’offre des services de PF [planification familiale] offerts en direction des adolescents et jeunes

Mieux intégrer les spécificités des adolescents et des jeunes à travers des interventions mieux adaptées à leurs besoins en matière de SSR [santé sexuelle et de reproduction] /PF, qu’il s’agisse des jeunes scolarisés ou des jeunes non scolarisés. Ceci nécessite le renforcement de la capacité des prestataires et la mise en place d’une ligne verte accessible aux adolescents et aux jeunes.

Activité O6.1 : Renforcement des capacités des prestataires de 25% des FS [formations sanitaires] pour offrir les services de PF adaptés aux adolescents et aux jeunes.

Renforcer les capacités des prestataires de 25% des FS (168 FS sur 674 FS offrant déjà la PF) pour offrir les services de PF adaptés aux adolescents et aux jeunes de 34 FS (à raison de 2 personnes à former par FS) par année de 2013 à 2017.

- Recensement des FS appropriées pour la prise en charge des adolescents et jeunes

- Adaptation des manuels de formation en prise en charge des jeunes et adolescents dans les FS

- Organisation de 3 sessions de formation de 2 personnes par FS pendant 5 jours en prise en charge des jeunes chaque année de 2013 à 2017

- Suivi des activités de formation

The “Protocoles de santé de la reproduction ; santé de la mère, santé de l’enfant, santé des jeunes et adolescents(es), santé des hommes ; tome I ; 2ème edition, 2009” describe the necessary characteristics of provider interactions with adolescents, such as respecting their moral principles, establishing a climate of trust, and ensuring confidentiality:

Ils ont besoin d’attention et de compréhension, d’où la nécessité de développer une approche amicale avec eux dans le but d’établir un climat de confiance, de dialogue confidentiel et de respect de leurs principes moraux et de créer un service adapté à leur prise en charge.

The “Plan d’action national budgétisé de la planification familiale du Togo, 2017-2022” includes plans to train providers in youth-friendly FP service provision and specifically targets removing the obstacle of negative provider attitudes:

OA1-A12. Mise en place des services de SR [santé de la reproduction /PF adaptés aux jeunes et les adolescents, indépendamment de leur statut et lieu de résidence

Sur la base du diagnostic de la PF au niveau des jeunes, il s’agit de mieux intégrer les spécificités des adolescents (es) et jeunes à travers des interventions mieux adaptées à leurs besoins en matière de contraception, qu’il s’agisse des jeunes scolarisés ou non scolarisés, du milieu rural ou urbain. Ceci nécessite le renforcement de la capacité des prestataires, le renforcement des lignes vertes intégrant le volet PF et accessibles aux adolescents (es) et jeunes ainsi que la promotion d’activités intégrées de PF, de lutte contre le VIH et le sida voire de prise en charge des des IST [infections sexuellement transmissibles] chez les jeunes...

OA2-A5. Renforcement des capacités des prestataires des FS en offre de services conviviaux et adaptés de SRAJ [santé reproductive des adolescents et des jeunes] y compris la contraception

Renforcer les capacités des prestataires de 10% des FS publiques (soit 77 FS sur 768 FS offrant la PF) par an dans le domaine de l’offre des services de PF adaptés aux adolescents et jeunes. Ceci permettra de lever l’obstacle lié à l’attitude inappropriée des prestataires face aux adolescents et jeunes qui se présentent dans les centres de santé pour adopter les méthodes de PF. Elle sera réalisée à travers la formation, l’aménagement des structures de soins, la supervision et le suivi des prestations.

The “Plan d’action” aims to offer free FP services during national family planning weeks and youth days at health facilities. The “Standards de services de santé adaptés aux adolescents et jeunes de Togo, 2009” aim to improve the financial accessibility of youth-friendly services, and the “Programme national de lutte contre les grossesses et mariages chez les adolescents en milieux scolaire et extrascolaire au Togo, 2015-2019” includes an activity to pilot a contraceptive subsidy program for adolescents. The most recent “Plan national de développement sanitaire, 2017-2022” includes the development of FP services specific to young people and adolescents as a priority intervention.

Togo is placed in the green category for this indicator because all three youth-friendly service-delivery elements are addressed.

One of the five standards in “Standards de services de santé adaptés aux adolescents et jeunes de Togo, 2009” seeks community support for health services adapted to youth:

Standard 4 : Les membres de la communauté et les associations communautaires y compris les adolescents et les jeunes sont organisés en vue de faciliter l’utilisation des services de santé par les adolescents et les jeunes

The “Programme national de lutte contre les grossesses et mariages chez les adolescents en milieux scolaire et extrascolaire au Togo, 2015-2019”, which explicitly aims to extend youth access to contraception, includes activities for building community support for preventing adolescent pregnancies. These activities include engaging community leaders and community-based organizations:

Résultat d’effet 4.2 : Les parents, les communautés et les leaders traditionnels et religieux s’engagent dans la lutte contre les grossesses et mariages des adolescentes

Résultats d’effet 4.3 : Les OSC [Organisations de la Société Civile]/OBC [Organisations de Base Communautaire] sont plus aptes à intervenir efficacement dans la prévention et la prise en charge des grossesses et mariages chez les adolescentes

The “Politique nationale pour l'equité et l'égalité de genre du Togo, 2011” plans to raise awareness of gender issues among health stakeholders and to integrate a gender approach into sexual and reproductive health services for men, women, and adolescents:

Objectif 3.2. Assurer la prise en compte des besoins différenciés en santé de la reproduction des femmes, des adolescent(e)s et des hommes

• Intégration effective de l’approche genre dans la conception la planification, la budgétisation des interventions en santé et SR [santé de la reproduction]
• Mener des activités de sensibilisation et de plaidoyer des acteurs du secteur santé sur les questions de genre et leurs manifestations sur la santé et la SR des femmes et des hommes et des adolescent(e)s

Togo is placed in the green category for this indicator because its policies include a detailed strategy for building an enabling social environment.

Uganda’s policy environment supports youth access to FP services without authorization by a third party. The “National Policy Guidelines and Service Standards for Sexual and Reproductive Health and Rights, 2006” explicitly affirm the right of all people, including youth, to access FP services without parental or spousal consent:

No verbal or written consent is required from parent, guardian or spouse before a client can be given family planning service except in cases of incapacitation (intellectual disability). Clients should give written consent to long-term and permanent family planning methods.

Uganda is placed in the green category for this indicator.

The “Uganda Clinical Guidelines 2016: National Guidelines for Management of Common Conditions” instructs providers to counsel clients to make voluntary, informed FP choices. Providers are directed to explain each method using the medical eligibility criteria:

Help client choose appropriate method using family planning medical eligibility criteria wheel

The medical eligibility criteria for contraception in Uganda specify that youth are eligible for short-term methods and long-acting reversible contraceptives. This provides a promising policy environment for provider authorization of youth FP services, but it would be strengthened with explicit guidance to providers to withhold personal judgment when offering these services. Uganda is placed in the yellow category for this indicator.

The “National Policy Guidelines and Service Standards for Sexual and Reproductive Health and Rights, 2006” explicitly mention the right of all Ugandans, regardless of age, to access family planning services:

Every individual who is sexually active can receive family planning and contraceptive services irrespective of age or mental status.

The acknowledgement of individuals’ right to receive sexual and reproductive health services, regardless of age, signals a strong policy environment and warrants categorization the green category for this indicator.

The “National Policy Guidelines and Service Standards for Sexual and Reproductive Health and Rights, 2006” explicitly mention the right of all Ugandans to access FP services:

Every individual who is sexually active can receive family planning and contraceptive services irrespective of age or mental status.

While inclusive of all people, the policy does not explicitly recognize marital status as a criterion for provision or refusal of FP services. Providers and clients may differentially interpret this statement, potentially creating a barrier for youth desiring access to contraception. To strengthen the eligibility criteria, the guidelines eligibility statement should specifically recognize segmented parts of the population, such as married and unmarried youth. Because no policy exists addressing marital status in access to FP services, Uganda is placed in the gray category for this indicator.

The “National Policy Guidelines and Service Standards for Sexual and Reproductive Health and Rights, 2006” state that all sexually active Ugandans are eligible for family planning services:

All sexually active males and females in need of contraception are eligible for family planning services provided that:

They have been educated and counseled on all available family-planning methods and choices;

Attention has been paid to their current medical, obstetric contra-indications and personal preferences.

The eligibility criteria state that women of reproductive age, including adolescents, and nulliparous women can generally use each short-term (contraceptive pill and injectable) and long-acting reversible (intrauterine device and implant) methods. The same medical eligibility criteria are reinforced in the “Uganda Clinical Guidelines 2016: National Guidelines for Management of Common Conditions.” Uganda is placed in the green category for this indicator.

Although the availability of emergency contraception is not factored into the categorization of this indicator, note that the latter document includes adolescents in the eligibility for emergency contraception:

Emergency contraception indications: All women and adolescents at risk of becoming pregnant after unprotected sex.

The “National Sexuality Education Framework, 2018” aims to streamline the delivery of sexuality instruction in formal education settings by providing young people with “age-appropriate values and skills-based information about their sexuality in accordance with Uganda’s national, religious, and cultural values.”

The framework promotes sexual abstinence outside of marriage and restricts sexual and reproductive health (SRH) information to students, in part due to religious opposition. The document also avoids any discussion of contraceptive use or family planning methods as a way to prevent unwanted pregnancies.

Strategic Priority Policy Goals and Outcomes for NSEF [National Sexuality Education Framework]: 3) To promote health behaviors such as sexual abstinence and health-seeking behaviors.

Since the current framework does not include the exact messaging that will be provided in schools, an opportunity exists for the National Curriculum Development Center to elaborate on important SRH information as the associated curriculum, textbooks, and messages are developed. However, the exclusion of critical sexuality education material and promotion of abstinence-only practices in this Framework suggests that the current policy environment creates a barrier to youth accessing care.

The “National Child Policy, 2020,” which addresses the welfare of Ugandans under age 18, discusses the provision of comprehensive SRH education as a priority action under their adolescent-friendly health services strategy:

Strategy 5: Improve provision of and access to Adolescent-Friendly Health Services (AFHS)

…

c) Promote behaviour change among adolescents through comprehensive sexual and reproductive health education, and life skills education through school and community-based interventions.

The policy includes another strategy to “improve access to SRHR [sexual and reproductive health and rights] education, HIV prevention, care, and treatment services for children and adolescents” but fails to include any priority actions that provide further detail on the content of SRHR education and how it would be provided.

New policies and future curricula should continue to incorporate the nine United Nations Population Fund (UNFPA) essential components of comprehensive sexuality education and must address or replace the emphasis on abstinence currently found in the Framework. Thus, Uganda is placed in the red category for this indicator.

Youth-friendly FP service provision features prominently across Uganda’s policy documents. While none of the policies detail clear action steps aligned with all three service-delivery core elements of adolescent-friendly contraceptive services, each recognizes the need to tailor services to youth.

The “Health Sector Strategic Plan III, 2010/11-2014/15” specifically targets adolescents and youth in the sexual and reproductive health (SRH) services strategy. The strategy proposes the following activities to strengthen adolescent SRH services and the policy environment surrounding SRH:

Strengthen adolescent sexual and reproductive health services:

• Integrate and implement adolescent sexual and reproductive health in school health programmes; and
• Increase the number of facilities providing adolescent friendly sexual and reproductive health services.
• Strengthen the legal and policy environment to promote delivery of SRH services.
• Review SRH and related policies and address institutional barriers to quality SRH services.
• Review SRH policies, standards, guidelines and strategies as need arises.

The “Uganda Family Planning Costed Implementation Plan, 2015-2020” includes a FP service delivery activity targeting youth:

SD9. Youth-friendly services are provided in clinics. To increase the availability of youth-friendly services, youth-friendly corners will be established, and health workers will be trained on youth-friendly services. In addition, FP service delivery hours will be increased to include outside school hours to accommodate youth.

The “National Multi-Sectoral Coordination Framework for Adolescent Girls, 2018-2022” outlines key interventions to train service providers to offer adolescent-friendly information:

Build capacity of service providers (health workers, teachers, community development officers, welfare officers) and institutions to offer adolescent responsive services including providing age appropriate information to adolescents, parents, caregivers and communities on nutrition, immunization, personal hygiene, general health seeking behavior and relevant pathways for referral.

Both activities mention providing training to providers on YF services but do not reference training providers to withhold personal beliefs, bias, or judgment when offering contraception services to youth.

Altogether, the strategies generally address providing youth-friendly FP services to youth but do not sufficiently incorporate all three service-delivery elements of adolescent-friendly contraceptive services, placing Uganda in the yellow category for this indicator. To bolster the policy environment supporting youth-friendly FP service provision, future guidelines should consider including the remaining service-delivery elements of adolescent-friendly contraceptive provision.

The “Uganda Family Planning Costed Implementation Plan, 2015-2020” includes comprehensive actions to create demand for FP services among youth, including elements of building community support:

DC3. Young people, 10-24 years old, are knowledgeable about family planning and are empowered to use FP services: To increase the knowledge and empowerment of young people, peer educators will be engaged and supported; media (print and online) targeting youth will be disseminated; and “edutainment” community events will provide the opportunity for knowledge exchange amongst young people and empower adults to help youth avoid teenage pregnancy.

The Plan's proposed steps not only target youth in awareness and mass media campaigns, but also seek to engage gatekeepers in additional community engagement activities:

Empower parents, caregivers, and teachers to help their children to avoid teen pregnancy, including improving parent-child communication on sexual issues.

The “National Child Policy, 2020” includes increasing access to and improving provision of reproductive and maternal health care services as one of its strategic actions aimed at preventing child mortality and promoting children’s health; children are defined in this policy as those under age 18. Within this strategic action, the policy lays out multiple priority actions that link service delivery with activities that build support in communities and address gender norms but are not specific to family planning:

5.1.1 Strategies and priority actions

Strategy 1: Increase access to and improve provision of reproductive and maternal health care services…

c) Promote sexual reproductive health among young people…

h) Strengthen family and community based support for women seeking appropriate care before and during pregnancy, delivery, and postpartum period.

i) Promote male involvement in positive social norm change, maternal and child health service planning and delivery

j) Advance community mobilization efforts to build capacity of women, families, and communities to actively engage with each other and with health providers and managers to improve the quality of services, and to hold health systems accountable.

The inclusion of a detailed strategic initiative to build community support among youth and adults for youth FP services in the Costed Implementation Plan indicates a promising policy environment, placing Uganda in the yellow category for this indicator. Outlining additional activities to address gender norms specific to family planning in future policies would make youth access to and use of contraception more acceptable and appropriate within their communities.

The “Zambia Family Planning Guidelines and Protocols, 2006” list specific strategies for incorporating family planning into adolescent reproductive health issues. The strategies acknowledge that current legislation allows youth FP access without parental and spousal consent but encourages spousal and parental counseling:

Facilitate access, especially for young girls, to all types of services dealing with RH [reproductive health] concerns and specifically FP, without consent of spouses, parents/guardians or relatives as allowed by current legislation. Spousal/guardian counselling, however, is strongly recommended. Special concern has to be given to the counselling of adolescents under 16 years of age. When, after counselling, young adolescents are unwilling to involve their parents/guardians, special care should be taken to ensure that these adolescents under 16 have the mental maturity to understand what is involved in their decision along with its possible consequences.

Zambia is placed in the green category for this indicator as its policies support youth access to family planning services without consent from parents and spouses.

The “Zambia Family Planning Guidelines and Protocols, 2006” lay out service delivery requirements for quality of care in family planning and notes that providers must not interfere in method choice with their personal opinions or preconceived biases:

Choice of Methods

All women, men, and young people shall be provided with the FP methods they request, subject to them meeting the agreed eligibility criteria, without the interference of personal opinions or preconceived biases of the service providers.

The Guidelines and Protocols go on to detail principles of a client-provider relationship and although not specific to youth, note that providers should:

• Ensure that providers communicate with clients effectively and in culturally appropriate ways.
• Treat all clients with respect and dignity.
• Provide quality services in a way that does not infringe upon the client's rights.
• Personalize care so that it is responsive to the client's needs and is not influenced by personal biases.
• Assure privacy and confidentiality.

Zambia is placed in the green category for this indicator as its policies address provider authorization for FP services.

The age of consent for various sexual and reproductive health (SRH) services has been identified as an ongoing issue in Zambia, with policies and legal frameworks providing conflicting information.

The “Adolescent Health Strategy, 2017-2021” acknowledges this weakness in the policy environment and notes the unavailability of adolescent-responsive SRH health services in all health institutions, with access to existing services limited to ages 16 and above. The strategy identifies review and alteration of the age of consent “from the current 16 to lower” and sets aside funding for age-of-consent policy and guideline development:

Activity: Policy and Guidelines development

Costing Estimates per activity (US$): Review of policy and development of guidelines

Estimated Cumulative Calculation: $20,000 for review and development and dissemination of policy guidelines on age of consent and access to SRH services

Total Expansion Districts & Health Center (H/C) or by Frequency: $20,000 for review and revision of guidelines for care and support for adolescents to transition from pediatric to adult clinical care

Total over 5 years: $40,000

Zambia’s policies do not have a unifying policy statement on access to family planning regardless of age. Therefore, Zambia is placed in the gray category for this indicator.

The “Gender Equity and Equality Act, 2015” declares that women have the right to adequate sexual and reproductive health services, including the right to access FP services and choose an appropriate method of contraception. It further elaborates that health care workers must:

(a) respect the sexual and reproductive health rights of every person without discrimination;

(b) respect the dignity and integrity of every person accessing sexual and reproductive health services;

(c) provide family planning services to any person demanding the services, irrespective of marital status or whether that person is accompanied or not accompanied by a spouse;

Because the law supports access to FP services regardless of marital status, Zambia is placed in the green category for this indicator.

The “Zambia Family Planning Guidelines and Protocols, 2006” lays out service delivery requirements for quality of care in family planning. Among the basic principles of quality of care, the Guidelines and Protocols note, is providing and ensuring a broad range of FP methods:

Choice of Methods

All women, men, and young people shall be provided with the FP methods they request, subject to them meeting the agreed eligibility criteria, without the interference of personal opinions or preconceived biases of the service providers.

The Guidelines and Protocols include a section that details each FP method currently available in Zambia, along with their mechanisms, advantages and disadvantages, side effects, service provision, and eligibility. While the eligibility criteria are derived from the World Health Organization medical eligibility criteria for contraceptive use, the Guidelines and Protocols were published in 2006 and therefore rely on outdated criteria. Even so, young people are not specifically forbidden from using any method. While some methods have no restrictions on youth based on age (i.e., progesterone only pills, injections, and implants have no restrictions for those over age 16; intrauterine devices have no restrictions for those over 20), younger individuals can use those methods with precautions.

As Zambia’s FP guidelines do not have a clear policy statement that requires health providers to offer short-acting and LARC methods, Zambia is placed in the yellow category for this indictor.

Although emergency contraception (EC) eligibility is not factored into this indicator’s rating, the Guidelines and Protocols state that while no age restrictions are listed for EC eligibility, EC should only be used in the case of rape or for clients with a history of ectopic pregnancy and other cardiovascular and chronic conditions.

The “Zambia Family Planning Guidelines and Protocols, 2006” include provision of sexual and reproductive health (SRH) information to youth as one of its key strategies to integrate family planning into adolescent reproductive health:

Provide information, education, and skills training to enable young people to deal with their RH decisions in a mature way. Do this in a variety of locations, including health services, schools, clubs, recreation centres and employment-based services.

The Guidelines and Protocols continue to stress the importance of strengthening adolescent education on reproductive health in schools:

Strengthen family education, for example. understanding of the physiology of RH system and how it works, responsible parenthood. the importance of building relationships and maintaining human values and dangers and risks associated with early sexual activities in all schools. Such information will need to be completed by appropriate service for students of reproductive age.

In 2013, the Ministry of Education and Curriculum Development Center reviewed the existing school curriculum and eventually passed the “Comprehensive Sexuality Education Framework, 2014,” which organizes the curriculum by six themes: relationships; values, attitudes, and skills; culture, society, and human rights; human development; sexual behavior; and sexual and reproductive health. The curriculum breaks down the topics, content, and outcomes for each theme along every grade level from grades 5 through 12 and includes all nine of the essential United Nations Population Fund (UNFPA) components of comprehensive sexuality education (CSE). While the curriculum encourages and discusses abstinence as a pregnancy-prevention mechanism throughout, SRH content includes contraceptives as an effective method of preventing unintended pregnancies starting in grade 9.

For example, the CSE program includes an integrated focus on gender that evolves from learning about the role of gender in society in grade 5 to the impact of gender norms on FP in grade 12:

GRADE 5

3. Culture, Society, and Human Rights

5.3.3 Social Construction of Gender

5.3.3.1 Gender Roles

Specific Outcomes:  

5.3.3.1.1 Identify roles that have traditionally been assigned to males and females in society.

5.3.3.1.2 Discuss the effects of promoting gender roles.

Knowledge:

• Gender roles for females: household chores, nurturing, empathetic, emotional, childcare, elder care
• Gender roles for males: Breadwinners, leaders, protectors, initiators
• Effects of promoting gender roles: overworking of other family members, low productivity in the home

Skills: Critical thinking about the gender roles

Values: Appreciation of sharing gender roles equitably

GRADE 12

5. Culture, Society, and Human Rights

5.3.3 Social Construction of Gender

5.3.3.1 Gender Roles

Specific Outcomes:  12.3.3.1.1 Explain gender equality in sexual behavior and family planning

Knowledge: Gender equality in sexual behavior and family planning: when to have babies, collective agreements, family size, when to have sex, openness to partner

Skills: Effective communication about gender equality in sexual behavior and family planning

Values: 

• Appreciation of gender equality in sexual behavior and family planning
• Assertiveness on gender equality on sex

The CSE program also includes components on improving communication skills and decision-making in SRH. In addition to specific decision-making skills identified throughout each of the six components, decision-making is a topic in the second theme of “Values, Attitudes and Skills.”

The curriculum notes that it is designed to expose potential risks to young people so that they can make informed decisions. It also explains that the curriculum is meant to be delivered in a safe and healthy learning environment:

The teachers shall ensure that all the outcomes covered here are shared with the learners so that while in school and out of school later, the learners will feel safe in life to face sexuality issues as individuals and severally too. What is expected in here is that teachers should be counselors of the clients in their hands, the learners. The teaching approaches should be highly learner-centered. Since the information is in core subjects to be taken by every learner; through natural sciences and social sciences, teachers are requested to find joy in noticing that as a result of this Comprehensive Sexuality Education Framework, learners will be in a better position to make informed decisions on issues relating to sexuality.

Newer health policy documents, including the “Adolescent Health Strategy, 2017-2021,” discuss the importance of continuing to scale-up CSE for adolescents in and out of school as a strategy to increase their awareness and utilization of health services.

Zambia has a strong policy environment for CSE, including reference to all nine UNFPA essential components of CSE, and is placed in the green category for this indicator.

The “Zambia Family Planning Guidelines and Protocols, 2006” note the importance of supportive behaviors over judgement when incorporating family planning into adolescent reproductive health programs:

Encourage of all people in contact with adolescents to have a supportive attitude toward them, instead of sanctions and negative reinforcement.

The Guidelines and Protocols also lay out service delivery requirements for quality of care in family planning. Among the basic principles of quality of care is providing convenient and accessible services that meet clients’ needs. The Guidelines and Protocols ensure privacy and confidentiality of clients seeking FP services, although outside of referencing separate service hours, it does not specifically reference youth:

In order to ensure privacy, FP service provider should observe the following measures:

• Inform the client in advance if a physical exam is going to be undertaken. Ensure that he/she is comfortable with this.
• Make every effort to ensure privacy, for example, by rearranging furniture, if there are no separate rooms to use for examinations.
• Ask client to undress only if necessary. Do not ask the client to undress and then leave him/her waiting for a long time.
• Provide a screen if there is no dressing room.
• Any person who does not have a role in the examination room should leave during the examination. If health staff must be present, limit their number, explain the reason for their presence and ask for the client's permission.

In order to ensure confidentiality, FP service providers must observe the following measures:

• Assure the client that any information he/she provides, or the details of services received will not be communicated to others without his/her consent. Never talk about the client in the presence of other clients. Never discuss client outside of the service delivery room. If talking to colleagues about the client, include the client in the conversation. If the client prefers to leave his/her card at the health facility, file the client's records immediately after completion. Control unauthorized access to client records.

In order to provide anonymity if required, FP service providers shall:

• Retain the clients' cards at the health facility. Arrange separate service hours for young adults, men, and couples. Offer services in workplaces or the community.

The Guidelines and Protocols also outline the content of trainings that all service providers involved in FP should receive. The content includes an “IEC [Information, Education, and Communication]/Counselling” Skill Set with content on family planning and adolescent health; a Communication Skill Set with content focused on the sensitive, unbiased, open, and interactive communication process;” and a Technical Skill Set that covers “FP technologies, procedures, requirements for care and follow-up" as well as a focus on adolescent health issues.

After assessing current gaps in family planning in Zambia, the “Integrated Family Planning Scale-Up Plan, 2013-2020” identified targeting and serving quality and accessible adolescent sexual and reproductive health information and services as one of its six strategic priorities. The Scale-Up Plan reaffirms that all family planning is free at public facilities, free at nongovernmental organization (NGO) outreach sites, and provided at low or no-cost at NGO fixed sites. To meet its strategic priorities, the Scale-Up Plan also includes activities that address adolescents and youth:

SDA4. Train current health providers in comprehensive FP with emphasis on LARCs [long-acting reversible contraceptives] . Dedicated FP providers will be recruited and trained; nurses and midwives currently working where dedicated FP providers do or will do outreach will be trained and subsequently receive mentoring by the dedicated FP providers

…

SDA12. Provide targeted services and education to adolescents and youth. Youth-friendly service points will be established in each district in existing government buildings such as sports complexes and administrative blocks. The rooms will be refurbished with FP materials and necessary supplies. Peer educators trained to dispense pills and condoms will staff the service points.

The “Adolescent Health Strategy, 2017-2021” details a strategy to move away from adolescent-friendly projects to adolescent-responsive health systems, and includes specific activities on financing youth health services in all facilities:

Financing: Transitions are required in the way that resources are allocated and purchasing of services is designed, so as to meet the need of adolescents. The following actions may facilitate this transition:

• removing (or at least reducing) the need for adolescents to pay for services at the time of use by maximizing the number of adolescents covered by effective prepaid pooling arrangements, with adequate subsidization of vulnerable adolescents and their families;

The ”Reproductive, Maternal, Newborn, Child and Adolescent Health and Nutrition Communication and Advocacy Strategy, 2018-2021” notes that adolescents and youth face many barriers when seeking FP services, including the negative attitude of health workers toward adolescents and youth, and outlines essential actions to “provide capacity building and simple job aids to providers to facilitate counseling of adolescents on reproductive health/FP issues” and “train health providers and peer educators in counseling skills and sensitize them to adolescent perspectives and empathetic attitudes.”

Finally, the “National Standards and Guidelines for Adolescent Friendly Health Services, n.d.” also include patient privacy and provider training to foster non-judgmental and respectful attitude toward adolescents as two requirements for service provision standards.

The policies reviewed clearly address the need to train and support providers to offer adolescent-friendly contraceptive services, as well as provide confidentiality and audio/visual privacy and free FP services. Zambia is placed in the green category for this indicator.

The “Gender Equity and Equality Act, 2015” declares that the Ministry of Health shall take appropriate measures to ensure that women access family planning information and services on an equal standing as men.

The “Zambia Family Planning Guidelines and Protocols, 2006” include three strategies for family planning, the first of which is to better integrate family planning with other reproductive health programs. The strategy specifically outlines activities to increase male involvement and address existing gender norms:

• Improve communication between couples about decisions regarding fertility and FP that would reflect the needs and desires of both men and women.
• Provide men with needed information that would enable them to participate responsibly in FP decision-making. They can get information and learn more about FP by accompanying their partners on clinic visits and by taking advantage of special clinic hours for men where available.
• Organize services for FP for men either through STI [sexually transmitted infection]/HIV prevention and control clinics or allocating special times in MCH [maternal and child health]/FP clinics when they could receive appropriate information and private services.

…

• Allow men to participate in the design and implementation of FP and RH [reproductive health] services and to express ways in which they can be encouraged to take more responsibility.

The Guidelines and Protocols' second strategy is to expand access to family planning through private delivery systems. This strategy includes information, education, and communication (IEC) activities to improve understanding of RH and FP rights and to change attitudes regarding FP/RH, but does not specifically connect the activities to community support of youth access to FP.

The “Adolescent Health Strategy, 2017-2021” details a strategy to move away from adolescent-friendly projects to adolescent-responsive health systems, and includes specific community-based activities:

Service delivery: A transition is needed from “adolescent-friendly” projects to programmes that strengthen mainstream capacity at primary and referral levels to respond to the priority health and development needs of adolescents. A number of actions would facilitate this transition:

…

• raising awareness about the health needs of adolescents and generating community support for the delivery of the adolescent health care package and for its uptake.

Preventive care: Transitions are required to create opportunities for all adolescents to make contact with primary care services for individual preventive services. Countries’ experiences179 180 suggest that actions to facilitate this might include:

…

• undertaking community-based initiatives for demand creation through peers, community health workers, lay counselors and others.

The Health Strategy also identifies cultural and religious values and norms as a gap that prevents parents and communities from addressing SRH for adolescents and young people, including the promotion of contraception. It outlines two proposed interventions and activities:

Identified Gap/s

Some cultural and religious values and norms prevent parents, communities and schools from addressing HIV education and SRH&R for adolescents and young adults.

(i.e. Cultural issues – where parents do not talk to their children about sexuality and teachers are culturally constrained in teaching HIV and SRH)

Religious values and norms preventing parents, communities and schools from addressing HIV and SRH & R (i.e. assumptions that the promotion of contraceptives is promoting sex before marriage, etc.).

Proposed Intervention 1

Development and deploy an advocacy strategy targeting parents, communities, church and traditional leaders, school teachers and the adolescents

Indicative Activities [for Intervention 1]

-Develop and adopt an HIV/ASRH&R [adolescent sexual and reproductive health and rights] Programme approach to reach parents, community leaders, church leaders and school teachers on risk and vulnerabilities of adolescent girls and young women (AGYW)

- Develop and implement an innovative advocacy strategy targeting key bottlenecks and stakeholders.

-Under the national adolescent health (ADH) strategy mobilize communities, parents, teachers and adolescents on the availability of responsive health services.

- Undertake HIV and SRH awareness raising briefings for PTAs [parent-teacher associations] and faith-based organizations on social norms which inhibit adolescent girls and young women (AGYW) access to relevant HIV and SRH information and services.

- Review and revise training materials for health and school-based counsellors and social workers to ensure AGYW issues are prioritized (Utilize existing structures)

- Review the curricula for the alangizi (traditional teachers on SRH and HIV) to ensure AGYW issues are being addressed.

Proposed Intervention 2 

Development of communication campaigns with innovative approaches and tools to promote AGYW health seeking behaviours and increase their knowledge on sexual health and development opportunities.

Indicative Activities [for Intervention 2]

- Launch sustained national mass and interpersonal communication campaigns on what has changed, what we can do & how we can do it.

- Information dissemination through sensitization workshops for traditional leaders (paramount chiefs, chiefs, sub chiefs, indunas, headmen

- Identify of key champions (political, traditional, civil society, youths, church leaders) to use in the change campaigns

- Develop, print and disseminate targeted HIV and SRH IEC materials (posters, brochures, leaflets, etc.) for opinion leaders, parents and different groups of AGYW (in local languages)

- Review and revise and re-develop innovative and adaptive life skills, CSE [comprehensive sexuality education] and peer education modules for use by different cadre (teachers, CBO [community-based organization] volunteers, health and youth workers, community volunteers, peer educators, etc.)

The “Reproductive, Maternal, Newborn, Child and Adolescent Health and Nutrition Communication and Advocacy Strategy, 2018-2021” acknowledges parents’ discomfort around talking to their children about FP and that many community leaders embrace “cultural and traditional beliefs which impact negatively on the acceptance of modern contraceptives by women and young girls.” The Communication and Advocacy Strategy outlines multiple communication tasks and essential actions that can be taken to improve parents’ comfort discussing FP with their children and reach an increased number of community leaders that support youth and adolescents seeking FP and health services.

Moreover, the “Zambia Integrated Family Planning Costed Implementation Plan and Business Case, 2021-2026" includes a sub-activity to produce standard communication materials to be used by all stakeholders for different groups, including adolescents. It also outlines other activities to create an enabling social environment for the youth:

FP coordinators to support adolescents and youth to promote FP among peers

Design and implement FP information materials and service delivery infrastructure for adolescents,...

Zambia’s policies outline specific interventions to build support within the larger community for youth FP and address gender norms. Therefore, Zambia is placed in the green category for this indicator.

• National Communication Strategy for Family Planning and Reproductive Health, 2008.
• National Education Policy, 2010.
• Clinical Contraception Services Delivery Programme Operational Plan, 2011-2016.
• National Children Policy, 2011.
• National Women Development Policy, 2011.
• Bangladesh Population Policy, 2012.
• National Urban Health Strategy, 2014.
• Bangladesh Essential Health Service Package (ESP), 2016.
• Comprehensive Social and Behavior Change Communication Change, 2016.
• Eighth Five Year Plan, 2020-2025.
• Health, Nutrition and Population Strategic Investment Plan (HNPSHIP), 2016-2021.
• Community-Based Health Care Operational Plan, 2017-2022.
• Lifestyle and Health Education and Promotion- Operation Plan, 2017-2022.
• Maternal, Neonatal, Child, and Adolescent Health Operational Plan, 2017-2022.
• National Plan of Action for Adolescent Health Strategy, 2017-2030.
• National Strategy for Adolescent Health, 2017-2030.
• Costed Implementation Plan for National Family Planning Program in Bangladesh, 2020-2022.

POLICY DOCUMENTS IN DRAFT, REVIEWED

• National Youth Policy, 2017.

POLICY DOCUMENTS FOUND IN BANGLA, NOT REVIEWED

• National Health Policy, 2011.
• National Plan of Action for Implementation of the National Youth Policy, 2017.

POLICY DOCUMENTS THAT COULD NOT BE LOCATED

• Adolescent and School Health Program, 2017-2022.

• Politique nationale de la jeunesse, 2001.
• Loi n° 2003-04 du 03 mars 2003 relative à la santé sexuelle et à la reproduction.
• Document de stratégie nationale de réduction de la mortalité maternelle et néonatale au Bénin, 2006-2015.
• Stratégie nationale pour la sécurisation des produits de santé de la reproduction, 2006-2015.
• Politique nationale de promotion du genre du Bénin, 2008.
• Stratégie nationale multisectorielle de santé sexuelle et de la reproduction des adolescents et jeunes au Bénin, 2010-2020.
• Programme national de santé de la reproduction, 2011-2015.
• Stratégie de croissance pour la réduction de la pauvreté, 2011-2015.
• Stratégie nationale de repositionnement de la planification familiale au Bénin, 2011-2015.
• Plan d’action national budgétisé pour le repositionnement de la planification familiale au Bénin, 2014-2018.
• Loi n° 2015-08 portant code de l'enfant en république du Bénin.
• Plan stratégique intégré de la santé de la reproduction, de la mère, du nouveau-né, de l’enfant, de l’adolescent et jeune (SRMNEAJ), 2017-2021.
• Plan stratégique de sécurisation des produits de santé de la reproduction et de programmation holistique des préservations au Bénin, 2017-2021.
• Plan national de développement sanitaire, 2018-2022.
• Plan opérationnel de reduction de la mortalité maternelle et néonatale au Bénin, 2018-2022.
• Stratégie nationale multisectorielle de la santé sexuelle et de la reproduction des adolescents et jeunes, 2018-2022.
• Plan opérationnel : Stratégie nationale multisectorielle de la santé sexuelle et de la reproduction des adolescents et jeunes, 2018-2022.
• Plan d’action national budgétisé de planification familiale du Bénin, 2019-2023.

• Politique nationale de population du Burkina Faso, 2000.
• Plan stratégique de santé des jeunes, 2004-2008.
• Loi portant santé de la reproduction, 2005.
• Directives nationales sur la santé scolaire et universitaire au Burkina Faso, 2008.
• Politique nationale de jeunesse, 2008.
• Protocoles de santé de la reproduction, 2009.
• Document de la politique nationale genre du Burkina Faso, 2009.
• Politiques et normes en matière de santé de la reproduction au Burkina Faso, 2010.
• Politique nationale de santé, 2011.
• Plan national de développement sanitaire, 2011-2020.
• Troisième programme d’action en matière de population, 2012-2016.
• Plan national de relance de la planification familiale, 2013-2015.
• Plan stratégique santé des adolescents et des jeunes, 2015-2020.
• Plan national d’accélération de planification familiale du Burkina Faso, 2017-2020.
• Décret n° 2019-0040/PRES/PM/MS/MFSNF/MFPTPS/MATD/MINEFID portant gratuité des soins et des services de planification familiale au Burkina Faso.
• Compte rendu du Conseil des ministres du mercredi 26 décembre 2018.
• Loi n° 025-2018 portant code pénal.

POLICY DOCUMENTS IN DRAFT, REVIEWED

• Plan national d’accélération de planification familiale du Burkina Faso, 2021-2025.

• Politique nationale de la jeunesse, 1998.
• Politique nationale de la santé de la reproduction, 2007.
• Plan national de développement sanitaire, 2011-2015.
• Normes des services de santé de la reproduction, 2012.
• Directives de mise en place et de fonctionnement d'un centre de santé ami des Jeunes, 2014.
• Stratégie nationale de la santé des adolescents au Burundi, 2015.
• Plan d’accélération de la planification familiale, 2015-2020.
• Politique nationale de santé, 2016-2025.
• Loi n° 1/012 du 30 mai 2018 portant code de l’offre des soins et services de santé au Burundi.
• Plan stratégique national de la santé de la reproduction, maternelle, néonatale, infantile et des adolescents, 2019-2023.
• Module de formation des prestataires de soins en santé sexuelle et reproductive des adolescents et des jeunes, 2020.
• Standards, normes et procédures en soins reproductifs, maternels, néonatals, infantiles et de l’adolescent, 2020.

POLICY DOCUMENTS THAT COULD NOT BE LOCATED

• Normes et protocoles en matière d’offre de service de santé sexuelle et reproductive des adolescents et des jeunes au Burundi, 2009.

• Plan stratégique national de la santé de reproduction, maternelle, néonatale et infantile 2014-2020.
• Programme national multisectoriel de lutte contre la mortalité maternelle, néonatale et infanto-juvénile au Cameroun : Plan stratégique, 2014-2020.
• Plan stratégique national de la santé des adolescents et des jeunes au Cameroun, 2015-2019.
• Plan opérationnel de planification familiale, 2015-2020.
• Plan national de développement sanitaire, 2016-2020.
• Health Sector Strategy, 2016-2027.
• Protocoles et algorithmes en SR-PF au Cameroun, 2017.
• Dossier d’investissement pour l’amélioration de la santé de la reproduction, santé de la mère, du nouveau-né, de l’enfant et de l’adolescent/jeune au Cameroun, 2017-2020.
• Normes et standards en SR-PF au Cameroun, 2018.
• National digital health strategic plan, 2020-2024.

Policy documents that could not be located:

• Politique nationale de la santé de la reproduction.

• Plan national d’action de l’éducation pour tous, 2003-2015.
• Loi n°06.005 du 20 juin 2006 bangayassi relative à la santé de reproduction.
• Plan national de développement sanitaire, 2006-2015.
• Cadre stratégique national de lutte contre le VIH et le sida, 2012-2016.
• Plan stratégique national de sécurisation des produits de santé de la reproduction et de programmation holistique des préservatifs en république Centrafricaine, 2013-2017.
• Politique nationale de la santé de la reproduction, 2015.
• Plan stratégique nationale de promotion de la santé des adolescents et jeunes, 2020-2024.
• Education sexuelle complète des adolescents et des jeunes : manuel de référence de la République centrafricaine à l’usage des formateurs des formateurs, n.d.
• Standards des services de santé adaptés aux adolescents et aux jeunes en RCA, n.d.

• Loi n°006/PR/2002 du 15 avril 2002 portant promotion de la santé de reproduction.
• Politique nationale du genre, 2011.
• Politique stratégique de santé communautaire, 2015-2018.
• Politique nationale de santé, 2016-2030.
• Plan national de développement sanitaire, 2018-2023.
• Plan d’actions quinquennal de mise en œuvre de la politique nationale genre, 2019-2023.

• Programme d'orientation sur la santé des adolescents destiné aux prestataires de soins de santé, 2006.
• Document de politique de la santé scolaire et universitaire, 2007.
• Stratégie nationale de développement basée sur la réalisation de l'OMD version 4, 2007-2015.
• Document de politique nationale de la santé de la reproduction et de planification familiale (2ème édition), 2008.
• Feuille de route pour accélérer la réduction de la morbidité et de la mortalité maternelles, néonatales et infantiles Côte d’Ivoire, 2008-2015.
• Plan stratégique de la santé de la reproduction, 2010-2014.
• Cadre d’accélération de l’objectif 5 du millénaire pour le développement (OMD 5) : améliorer la santé maternelle, 2012.
• Plan stratégique de la planification familiale, 2012-2016.
• Plan accéléré de réduction des grossesses à l'école, 2013-2015 - campagne zéro grossesse à l'école en Côte d'Ivoire.
• Politique nationale de population, 2015.
• Plan d’action national budgétisé de planification familiale, 2015-2020.
• Plan national de développement, 2016-2020.
• Plan national de développement sanitaire, 2016-2020.
• Plan stratégique national de la santé des adolescents et des jeunes, 2016-2020.
• Politique nationale de la jeunesse et les stratégies, 2016-2020.
• Politique nationale de santé des adolescents et des jeunes, 2016-2020.
• Programme national de l’éducation sexuelle compléte de Côte d’Ivoire, 2016-2020.
• Micro plan de communication de masse pour le changement social et de comportement en faveur de la planification familiale en Côte d’Ivoire, 2018-2019.
• Politique nationale de délégation des tâches en santé de la reproduction/planification familiale, 2019.
• Politique nationale de la santé sexuelle, reproductive et infantile, 2020.
• Protocole des services de la santé de la reproduction, n.d.
• Standards des services de santé adaptés aux adolescents et aux jeunes en Côte d’Ivoire, n.d.

• Codes larcier de la République démocratique du Congo, tome I droit civil et judiciaire, 2003.
• Loi n° 06/015 du 12 juin 2006 autorisant l’adhésion de la République démocratique du Congo au protocole à la charte africaine des droits de l’homme et des peuples, relatif aux droits de la femme en Afrique.
• Politique nationale de la santé de la reproduction, 2008.
• Normes de la zone de santé relatives aux interventions intégrées de santé de la mère, du nouveau-né et de l’enfant en République démocratique du Congo : Interventions de santé adaptées aux adolescents et jeunes, 2012.
• Politique nationale santé de l’adolescent 2013 and Paquet d’activités PNSA dans la zone santé.
• Standards des services de santé adaptés aux adolescents et jeunes, 2014.
• Democratic Republic of Congo Family Planning National Multisectoral Strategic Plan, 2014-2020.
• Plan stratégique national de la santé et du bien-être des adolescents et des jeunes, 2016-2020.
• Loi n°18/035 du 13 décembre 2018 fixant les principes fondamentaux relatifs à l’organisation de la santé publique.
• Plan national de développement sanitaire recadré pour la période 2019-2022 : Vers la couverture sanitaire universelle.

• Education Sector Policy and Strategy on HIV & AIDS, Responding to the Challenges of HIV & AIDS in Ethiopia, 2009.

• Costed Implementation Plan for Family Planning in Ethiopia, 2015-2020.
• Education Sector Development Programme V, 2015/16-2019/20.
• National Adolescent and Youth Health Strategy, 2016-2020.
• National Health Promotion and Communication Strategy, 2016-2020.
• National Reproductive Health Strategy, 2016-2020.
• Adolescent and Youth Health for Health-Care Service Providers Participant’s Manual, 2017.
• Adolescent and Youth Health Standards, Implementation Guideline and Minimum Service Delivery Package, 2017.
• School Health Program Framework, 2017.
• Adolescent and Youth Engagement Guideline, 2018-2025.
• National Guideline for Family Planning Services in Ethiopia, 2020.
• National Costed Roadmap to End Child Marriage and FGM/C, 2020-2024.
• Health Sector Transformation Plan II, 2020/21-2024/25.
• Standards on Youth Friendly Reproductive Health Services & Minimum Service Delivery Package on YFRH Services: Service Delivery Guideline, n.d.

POLICY DOCUMENTS THAT COULD NOT BE LOCATED

• National Child Policy.

• Code de santé public, 1997.
• Loi portant la santé de la reproduction, 2000.
• Plan stratégique de développement sanitaire, 2001.
• Feuille de route nationale pour accélérer la réduction de la mortalité maternelle, néonatale et infanto-juvénile, 2012-2016.
• Standards de services de santé adaptés aux adolescents et aux jeunes, 2013.
• Document de stratégie de réduction de la pauvreté DSRP III, 2013-2015.
• Politique nationale de santé, 2014.
• Plan de relance du système de santé, 2015-2017.
• Plan stratégique en santé et développement des adolescents et des jeunes en Guinée, 2015-2019.
• Plan national de développement sanitaire, 2015-2024.
• Normes et procédures en santé de la reproduction, 2016.
• Plan stratégique national de la santé maternelle, du nouveau-né, de l’enfant, de l’adolescent et des jeunes, 2016-2020.
• Plan d’action national budgétisé de planification familiale de la Guinée, 2019-2023.

• Manuel de normes en planification familiale et en soins maternels, 2009.
• Politique nationale de promotion de la santé, 2009.
• Politique nationale de santé, 2012.
• Plan stratégique national de santé de la reproduction et planification familiale, 2013-2016.
• Plan stratégique national de santé des jeunes et adolescents, 2014-2017.
• Plan stratégique national de santé sexuelle et reproductive, 2019-2023.

• National Population Policy, 2000.
• Reference Manual for Doctors: Contraceptive Updates, 2005.
• Facilitator’s Guide: Contraceptive Updates, 2005.
• Implementation Guide on RCH II Adolescent Reproductive Sexual Health Strategy, 2006.
• Standards for Female and Male Sterilization Services, 2006.
• IUCD Reference Manual for Medical Officers, 2007.
• Guidelines for Administration of Emergency Contraceptive Pills by Health Care Providers, 2008.
• Handbook for Reproductive, Maternal, Neonatal, and Child Health (RMNCH) Counsellors, 2012.
• A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health in India, 2013.
• Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) Strategy, 2013.
• Training and Resource Materials: Adolescence Education Programme, 2013.
• National Youth Policy, 2014.
• Rashtriya Kishor Swasthya Karyakram Operational Framework: Translating Strategy into Programmes, 2014.
• Rashtriya Kishor Swasthya Karyakram Strategy Handbook, 2014.
• National Programme for Youth and Adolescent Development Scheme Guidelines, 2014-15.
• Reference Manual for Injectable Contraceptive (DMPA), 2016.
• Implementation Guidelines Rashtriya Kishor Swasthya Karyakram (RKSK), 2018.
• Operational Guidelines on School Health Programme under Ayushman Bharat, 2018.
• Adolescence Education Programme Advocacy Manual: Role of Schools, Principals, & Facilitators, n.d.
• Adolescence Education Programme Life Skills Development Facilitators’ Guide, n.d.
• Facilitator's Guide: Orientation Programme for ANMs/LHVs to Provide Adolescent-Friendly Reproductive and Sexual Health Services (n.d.).
• Facilitator’s Guide: Training Manual for Medical Officers, n.d.
• Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (RGSEAG)-SABLA, n.d.

• National Reproductive Health Policy, 2007.
• The Constitution of Kenya, 2010.
• Kenya Health Policy, 2012-2030.
• Education Sector Policy on HIV and AIDS, Second Edition, 2013.
• National Adolescent Sexual and Reproductive Health Policy, 2015.
• National Family Planning Guidelines for Service Providers, 6th Edition, 2016.
• National Guidelines for Provision of Adolescent and Youth Friendly Services in Kenya, 2016.
• The Health Act, 2017.
• National Family Planning Costed Implementation Plan, 2017-2020.
• National Adolescent Sexual Reproductive Health Policy Implementation Framework, 2017-2021.
• Kenya Youth Development Policy, 2019.
• Children Act, No. 8 of 2001, Revised Edition, 2019.
• National School Health Policy, 2019.

DRAFT POLICY DOCUMENTS, NOT REVIEWED

• Reproductive Healthcare Act, 2019.

• Décret n° 93-447 portant reconversion et redéfinition des missions des centre d’animation et de promotion de la jeunesse ainsi que leur organisation et leur fonctionnement, 1993.
• Loi n ° 2004-028 du 09 septembre 20047 portant politique nationale de la jeunesse.
• Loi n° 2011-002 du 15 juillet portant code de la santé publique.
• Loi n° 2015 – 038 modifiant et complétant certaines dispositions de la loi n°2004-028 du 09 septembre 2004 portant politique nationale de la jeunesse.
• Politique nationale de santé, 2016.
• Plan d’action national budgétisé en planification familiale à Madagascar, 2016-2020.
• Loi n° 2017-043 fixant les règles générales régissant la santé de la reproduction et la planification familiale.
• Normes et procédures en santé de la reproduction, 2017.
• Politique nationale de santé communautaire à Madagascar, 2017.
• Stratégie nationale de lutte contre le mariage des enfants, 2017-2024.
• Manuel de référence pour la formation des prestataires de services en santé des adolescents et jeunes, 2018.
• Plan stratégique national en santé de la reproduction des adolescents et des jeunes, 2018-2020.
• Plan sectoriel de l’éducation, 2018-2022.
• Politique nationale de santé des adolescents et des jeunes, 2019.
• Plan de développement du secteur santé, 2020-2024.
• Plan stratégique intégré en planification familiale et en sécurisation des produits de santé de la reproduction, 2021-2025.

POLICY DOCUMENTS THAT COULD NOT BE LOCATED

• Free family planning policy, 2006.

POLICY DOCUMENTS IN MALAGASY FOR WHICH AN ENGLISH/FRENCH VERSION COULD NOT BE LOCATED

• Tahirinkevitra hanofanana mpiantsehatra ifotonymahakasika ny fahasalaman’ny zatovo sy tanora, 2018 [Young People’s Health Training Guide].
• Boky torolalana hanofanana ireo mpiantsehatra ifotony mahakasika ny fahasalaman ny zatovo sy ny ttaannoorra, n.d. [A Handbook for Training Basic Actors in Adolescent and Adult Health].

• National Standards Youth Friendly Health Services, 2007.
• National Plan of Action for Scaling up SRH and HIV Prevention Initiatives for Young People, 2008-2012.
• National Sexual and Reproductive Health and Rights Policy, 2009.
• National Strategic Plan for Early Childhood Development, 2009-2014.
• Preservice Education Family Planning Reference Guide, 2010.
• Guidelines for Family Planning Communication, 2011.
• National Population Policy, 2012.
• Gender Equality Act, 2013.
• National Youth Policy, 2013.
• Malawi National Reproductive Health Service Delivery Guidelines, 2014-2019.
• Malawi National Condom Strategy, 2015-2020.
• National Gender Policy, 2015.
• National Health Communication Strategy, 2015-2020.
• National Youth Friendly Health Services Strategy, 2015-2020.
• Malawi Costed Implementation Plan for Family Planning, 2016-2020.
• Constitution of 1994 with Amendments through 2017.
• National Health Policy, 2017.
• Health Sector Strategic Plan II, 2017-2022.
• National Sexual and Reproductive Health and Rights Policy, 2017-2022.

• Déclaration de la politique nationale de population du Mali, 1991.
• Loi n° 02-044 relative à la santé de la reproduction, 2002.
• Guide for Constructive Men’s Engagement in Reproductive Health, 2008.
• Plan stratégique national pour le renforcement du système de santé (PSN/RSS), 2009-2015.
• Loi n° 2011-087 du 30 décembre 2011 portant code des personnes et de la famille.
• Politique nationale genre du Mali, 2011.
• Plan d’action national de planification familiale du Mali, 2014-2018.
• Plan stratégique de la santé de la reproduction, 2014-2018.
• Programme de développement socio-sanitaire, 2014-2018.
• Reduction de la mortalité maternelle néonatale et infanto-juvénile : plan stratégique, 2014-2018.
• Plan décennal de développement sanitaire et social, 2014-2023.
• Plan d’action multisectoriel santé des adolescents et des jeunes, 2017-2021.
• Plan stratégique de sécurisation des produits de la santé de la reproduction (SPSR) au Mali, 2017-2021.
• Politique et normes des services de santé de la reproduction, 2019.
• Politique, normes et procédures en santé de la reproduction, 2019.
• Plan d’action national budgétisé de planification familiale du Mali, 2019-2023.

POLICY DOCUMENTS THAT COULD NOT BE LOCATED

• Politique cadre de développement de la jeunesse, 2012-2016.
• Plan stratégique de sécurisation des produits de la reproduction et des produits sanguins au Mali, 2014-2018.
• Plan stratégique de santé et de développement des adolescents et des jeunes, 2017-2021.
• Politique nationale santé scolaire et universitaire et le plan stratégique de santé.

DRAFT POLICY DOCUMENTS, NOT REVIEWED

• Plan stratégique de la reproduction, 2019-2023.

• Déclaration nationale de politique de population, 1995.
• Cadre stratégique national de lutte contre les IST/VIH/Sida, 2003-2007.
• Stratégie définissant la politique nationale de la jeunesse, 2004.
• Déclaration nationale de politique de population, 2005.
• Politique nationale de santé et d’action sociale, 2006-2015.
• Programme national de santé de la reproduction : projet de plan d’action, 2007.
• Guide de planification familiale — espacement des naissances, édition révisée en avril, 2008.
• Programme national de santé de la reproduction : plan stratégique SR, 2008-2012.
• Plan national de développement sanitaire, 2012-2020.
• Déclaration nationale de politique de population, 2014.
• Guide de la pratique sage-femme en Mauritanie, 1ère édition, 2014.
• Politique nationale de santé, 2017.
• Projet de loi relative à la santé de la reproduction, 2017.
• Plan national de développement sanitaire, 2017-2020.
• Politique nationale de santé à l’horizon 2030, 2017.
• Plan d’action national budgétisé en faveur de l’espacement des naissances de la Mauritanie, 2019-2023.

• Second Long-Term Health Plan, 1997-2017.
• National Reproductive Health Strategy, 1998.
• National Safe Motherhood and Newborn Health Long Term Plan, 2006-2017.
• National Strategy for Family Planning Services, 2068, 2011.
• National Reproductive Health Commodity Security Strategy, 2015.
• National Family Planning Costed Implementation Plan, 2015-2020.
• Nepal Health Sector Strategy, 2015-2020.
• Nepal Health Sector Strategy Implementation Plan, 2016-2021.
• National Adolescent Health and Development Strategy 2075, 2018.
• Safe Motherhood and Reproductive Health Rights Act, 2018.
• National Female Community Health Volunteer (FCHV) Strategy 2076, 2019.
• National Health Policy 2076, 2019.
• National List of Essential Medicines Nepal, 2021.
• Nepal Safe Motherhood and Newborn Health Roadmap 2030.

POLICY DOCUMENTS AVAILABLE IN NEPALI FOR WHICH ENGLISH VERSIONS COULD NOT BE LOCATED

• Family Health Division Implementation Guidelines 2073-2074, 2017-2018.
• Service Providers Orientation Guide, n.d.

• Loi sur la santé de la reproduction au Niger, 2006.
• Recueil de legislation sanitaire, 2008.
• Plan stratégique sectoriel de mise en œuvre de la politique nationale de jeunesse, 2011-2015.
• Planification familiale au Niger : plan d’action, 2012-2020.
• Politique nationale de genre, 2017.
• Plan de développement sanitaire, 2017-2021.
• Planification familiale au Niger : plan opérationnel, 2018.

POLICY DOCUMENTS THAT COULD NOT BE LOCATED

• Plan stratégique en santé des adolescents et des jeunes, 2011-2015.
• Politique nationale de santé, 2015.
• Law guaranteeing free contraceptives.

• National Family Life and HIV Education (FLHE) Curriculum for Junior Secondary School in Nigeria, 2003.
• National Policy on Health and Development of Adolescents and Young People in Nigeria, 2007.
• National Strategic Framework on the Health and Development of Adolescents and Young People in Nigeria, 2007-2011.
• Action Plan for Advancing Young People’s Health and Development in Nigeria, 2010-2012.
• National Family Planning/Reproductive Health Service Protocols, Revised Edition, 2010.
• Clinical Protocol for the Health and Development of Adolescent and Young People in Nigeria, 2011.
• National Training Manual for the Health and Development of Adolescent and Young People in Nigeria, 2011.
• Increasing Access to Long-Acting Reversible Contraceptives in Nigeria: National Strategy and Implementation Plan, 2013-2015.
• National Guidelines for the Integration of Adolescent and Youth Friendly Services Into Primary Health Care Facilities in Nigeria, 2013.
• National Guidelines on Promoting Access of Young People to Adolescent and Youth-Friendly Services in Primary Health Care Facilities in Nigeria, 2013.
• National Training Manual on Peer-to-Peer Youth Health Education, 2013.
• National Health Act, 2014.
• Manual for Training Doctors and Nurse/Midwives on LARC Methods, 2015.
• National Adolescent & Youth Friendly Job Aids for Service Providers in Primary Health Care Facilities in Nigeria, 2015.
• National Health Policy, 2016.
• National Family Planning Communication Plan, 2017-2020.
• National Reproductive Health Policy, 2017.
• Investment Case for Reproductive, Maternal, Newborn, Child, Adolescent Health, and Nutrition, 2017-2030.
• National Standards & Minimum Service Package for Adolescent & Youth-Friendly Health Services, 2018.
• National Health Promotion Policy, 2019.
• National Youth Policy, 2019.
• Nigeria Family Planning Blueprint, 2020-2024.

DRAFT POLICY DOCUMENTS

• National Adolescent Health Policy, 2020-2024.
• National Policy on the Health and Development of Adolescents and Young People in Nigeria 2020-2024.

POLICY DOCUMENTS THAT COULD NOT BE LOCATED

• Free Family Planning Commodity Policy, 2011.

• Adolescent & Youth Health Policy, 2000.
• Reproductive Health Policy, 2000.
• Adolescent Job Aid Manual, 2009.
• The Responsible Parenthood and Reproductive Health Act of 2012, Republic Act 10354.
• Implementing Rules and Regulations of Republic Act No. 10354, 2013.
• National Policy and Strategic Framework on Adolescent Health and Development, Administrative Order No. 2013-0013.
• The Philippine Clinical Standards Manual on Family Planning, 2014.
• Adolescent Health and Development Program: Manual of Operations, 2017.
• National Family Planning Costed Implementation Plan, 2017-2020.
• National Objectives for Health, Philippines, 2017-2022.
• Peer Education Training Manual on Adolescent Sexuality and Reproductive Health, 2017.
• Philippine Development Plan, 2017-2022.
• Philippine Youth Development Plan, 2017-2022.
• Family Planning Competency-Based Training, Facilitator’s Guide, n.d.
• Family Planning Competency-Based Training, Basic Course Handbook for Service Providers, n.d.
• National Family Planning Program, n.d.

• Loi n° 2005-18 du 5 août 2005 relative à la santé de la reproduction.
• Stratégie nationale en santé des adolescentes/jeunes au Sénégal, 2005.
• Loi n° 2010-03 du 9 avril 2010 relative au VIH/Sida.
• Plan d’action national de planification familiale, 2012-2015.
• Programme d’amélioration de la qualité, de l’équité et de la transparence, 2013-2025.
• Plan stratégique de santé sexuelle et de la reproduction des adolescent(e)s/jeunes au Sénégal, 2014-2018.
• Cadre stratégique national de planification familiale, 2016-2020.
• Stratégie nationale d’equité et d’egalité de genre, 2016-2026.
• Stratégie nationale de financement de la santé pour tendre vers la couverture sanitaire universelle, 2017.
• Réduction de la mortalité marternelle, néonatale, infanto-juvénile, des adolescents et des jeunes : dossier d’investissement, 2019.
• Plan national de développement sanitaire et social, 2019-2028.
• Protocoles de services de santé de la reproduction au Sénégal, n.d.

• Pakistan National Population Policy, 2002.
• Manual of National Standards for Family Planning, 2009.
• National Program for Family Planning and Primary Health Care, “The Lady Health Workers Programme”, 2010-2015.
• Sindh Health Sector Strategy, 2012-2020.
• Reproductive and Healthcare Rights Act, 2013.
• Costed Implementation Plan on Family Planning for Sindh, 2015.
• Sindh Population Policy, 2016.
• National Vision for Coordinated Priority Actions to Address Challenges of Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition, 2016-2025.
• Sindh Youth Policy, 2018.
• Manual of Standards for Family Planning Services, Sindh: Revised, 2017.
• The Sindh Reproductive Healthcare Rights Act, 2019.

POLICY DOCUMENTS IN DRAFT, NOT REVIEWED

• Pakistan National Population Policy 2017.

NOTE

Pakistan’s decentralized government structure necessitates evaluation of policies at the subnational level. In 2010, the government of Pakistan passed the 18th Constitutional Amendment, which devolved planning, administrative, financial, implementation, and regulatory powers of the Ministry of Health and Population Welfare Department to provincial governments. Issues related to FP are now featured in provincial health sector strategies and population and development plans, rather than in national policies.

Instead of reviewing national policies, the Scorecard analyzes the policy environment for youth FP in the province of Sindh, which is currently the focus of increased attention for FP advocacy and policy. Some national documents that influence province-level policies and programs are included. Overall categorizations, however, are specific to Sindh’s policy environment.

• Guidelines for Implementing HIV/AIDS/STDs and Life Skills Education in Schools and Teachers’ Colleges, Version 2, 2002.
• National Health Policy, 2003.
• National Standards for Adolescent Friendly Reproductive Health Services, 2004.
• National Population Policy, 2006.
• National Youth Development Policy, 2007.
• National Life Skills Education Framework, 2010.
• National Adolescent Reproductive Health Strategy, 2011-2015.
• National Family Planning Guidelines and Standards, 2013.
• National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn, and Child Deaths in Tanzania, 2016-2020 (One Plan II).
• National Adolescent Health and Development Strategy, 2018-2022.
• National Family Planning Costed Implementation Plan, 2019-2023.
• Health Sector Strategic Plan, 2021-2026.
• National Family Planning Procedure Manual, n.d.

POLICY DOCUMENTS IN DRAFT, NOT REVIEWED

• National Health Policy 2018.
• Gender and Women Development Policy.

• Politique nationale de jeunesse, 2007.
• Loi n° 2007-017 portant code de l'enfant, 2007.
• Loi n° 2007-005 sur la santé de la reproduction, 2007.
• Plan stratégique pour la santé des adolescents et jeunes au Togo, 2008-2012.
• Loi portant code de la santé publique de la république Togolaise, 2009.
• Protocoles de santé de la reproduction ; santé de la mère, santé de l’enfant, santé des jeunes et adolescents(es), santé des hommes ; tome I ; 2ème édition 2009.
• Protocoles de santé de la reproduction du Togo ; composantes communes, composantes d’appui ; tome II ; 2ème édition 2009.
• Politique et normes en santé de la reproduction, planification familiale et infections sexuellement transmissibles de Togo, 2009.
• Standards de services de santé adaptés aux adolescents et jeunes de Togo, 2009.
• Politique nationale de santé ; loi d’orientation décennale, 2010-2015.
• Politique nationale pour l'équité et l'égalité de genre du Togo, 2011.
• Plan d’action pour le repositionnement de la planification familiale au Togo, 2013-2017.
• Référentiel des services de santé de la reproduction adaptés aux adolescents et aux jeunes en milieux scolaires, universitaires et extrascolaires, 2014.
• Programme national de lutte contre les grossesses et mariages chez les adolescents en milieux scolaire et extrascolaire au Togo, 2015-2019.
• Plan d’action national budgétisé de planification familiale du Togo, 2017-2022.
• Plan national de développement sanitaire, 2017-2022.

POLICY DOCUMENTS IN DRAFT, NOT REVIEWED

• Politique nationale de la jeunesse, 2020.

POLICY DOCUMENTS THAT COULD NOT BE LOCATED

• Plan d’action pour le passage à grande échelle de la distribution à base communautaire des produits contraceptifs y compris les injectables, 2017-2018.

• National Policy Guidelines and Service Standards for Reproductive Health Services, 2001.
• National Policy Guidelines and Service Standards for Sexual and Reproductive Health and Rights, 2006.
• Health Sector Strategic Plan III, 2010/11-2014/15.
• National Adolescent Health Strategy, 2011-2015.
• Adolescent Health Policy Guidelines and Service Standards, 2012.
• National Condom Programming Strategy, 2013-2015.
• National Strategy for Girls’ Education in Uganda, 2015-2019.
• Health Sector Development Plan, 2015-2020.
• Uganda Family Planning Costed Implementation Plan, 2015-2020.
• Uganda Clinical Guidelines 2016: National Guidelines for Management of Common Conditions.
• National Sexuality Education Framework, 2018.
• Demographic Dividend Roadmap, 2018.
• National Multi-Sectoral Coordination Framework for Adolescent Girls, 2018-2022.
• National Child Policy, 2020.

POLICY DOCUMENTS IN DRAFT, REVIEWED

• National Population Policy, 2018.

POLICY DOCUMENTS IN DRAFT, NOT REVIEWED

• National Sexual and Reproductive Health Policy.
• National Adolescent Health Policy.
• Family Planning Costed Implementation Plan, 2021-2024.

• Penal Code Chapter 87 of the Laws of Zambia.
• Zambia Family Planning Guidelines and Protocols, 2006.
• Integrated Family Planning Scale-Up Plan, 2013-2020.
• Comprehensive Sexuality Education Framework, 2014.
• Curriculum on Adolescent-Friendly Health Services and Health Voucher Mechanisms: Facilitator’s Training Manual, 2015.
• National Gender Policy, 2014.
• The Gender Equity and Equality Act, 2015.
• National Youth Policy, 2015.
• Comprehensive Sexuality Education Curriculum for Out of School Young People, 2016.
• Adolescent Health Strategy, 2017-2021.
• Zambia National Health Strategic Plan, 2017-2021.
• Reproductive, Maternal, Newborn, Child and Adolescent Health and Nutrition Communication and Advocacy Strategy, 2018-2021.
• Zambia Integrated Family Planning Costed Implementation Plan and Business Case, 2021-2026.
• National Standards and Guidelines for Adolescent Friendly Health Services, n.d.