Governments around the world have made great strides in creating policies that support young people. Increasingly, countries have formalized the rights of adolescents and young people to access sexual and reproductive health services. Despite growing commitment from decisionmakers, many barriers remain for young people who want to use contraception.

A limited evidence base has hampered systematic assessment and mapping of the key policies and programs that govern young people’s ability to access family planning (FP) information, services, and commodities. Governments and their partners lack clear guidance on investing in the interventions that ensure their commitments to expanding FP use among young people are realized. Similarly, efforts by civil society to monitor the state of policy environments for youth FP are needed to understand how countries are addressing these needs and to identify areas for improvement. 

To address this evidence gap, PRB has conducted research and analysis to identify the most effective policies and program interventions to promote uptake of contraception among youth, defined as people between the ages of 15 and 24. This research has been compiled into a “Youth Family Planning Policy Scorecard” to evaluate and compare the favorability of current national policy and program environments.

Based on a review of existing evidence and expert consultations, the following indicators were selected as evidence-based interventions for inclusion in the “Youth FP Policy Scorecard”:

  • Policy barriers related to consent (parental, spousal, or service provider); age; and marital status.
  • Policies related to comprehensive sexuality education.
  • Policies supporting/inhibiting youth-friendly FP service provision.
  • Policies related to community support for youth FP services.

The scorecard is designed to allow users to quickly assess the extent to which a country’s policy environment enables and supports youth access to and use of FP through the promotion of evidence-based practices. The scorecard can be used by governments, donors, and advocates to evaluate a country’s youth FP policy environment, set policy priorities and guide future commitments, and compare policy environments across countries.

The current version of the scorecard includes data for sixteen countries: Benin, Burkina Faso, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Guinea, Kenya, Mali, Mauritania, Niger, Nigeria, Senegal, Sindh (Pakistan), Tanzania, Togo, and Uganda. 

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Introduction

Governments around the world have made great strides in creating policies that support the health and human rights of young people. Increasingly, countries have institutionalized the rights of adolescents and young people to access health services, including sexual and reproductive health (SRH), within formal laws and policies. Statements by the United Nations Population Fund (UNFPA), World Health Organization (WHO), and others have underscored the urgency for international organizations and governments to ensure that all young people have informed choice and full access to contraceptives.1

Despite growing commitment from decision-makers, many barriers remain for young people who want to use contraception. A limited evidence base has hampered systematic assessment and mapping of the key policies and programs that govern young people’s ability to access family planning (FP) information, services, and commodities. Governments and their partners lack clear guidance on supporting interventions that ensure their commitments to expanding FP use among young people are realized. Similarly, civil society needs to establish monitoring efforts to understand how countries address the needs of youth in their laws and policies and to identify areas for improvement.

To address this evidence gap, the Population Reference Bureau (PRB) has developed a “Youth Family Planning Policy Scorecard” to measure and compare countries’ youth FP policies and programming. The scorecard compiles and analyzes the evidence that identifies the most effective national policies and program interventions to promote uptake of contraception among youth, defined as people between the ages of 15 and 24. This report details the purpose of the new scorecard, describes its methodology and indicator selection process, and summarizes results for 16 countries.

In the scorecard the term “family planning” refers to contraception and related services, as is common among advocates. However, the term “family planning” is less useful when considering youth’s unique reproductive health needs, since many young people have not yet begun planning a family, although they do need access to contraception. The scorecard uses the terms “family planning,” “FP,” and “contraception” interchangeably.

Purpose

The scorecard is designed to allow quick assessment of the extent to which a country’s policy environment enables and supports youth access to and use of FP by promoting evidence-based practices. The scorecard can be used by governments, donors, and advocates to:

  • Evaluate the inclusion of evidence-based interventions and policy language shown to reduce barriers and/or increase youth access to contraception in countries’ policies.
  • Set policy priorities and guide future commitments based on gaps and areas of weakness identified by the scorecard.
  • Compare policy environments across countries.

The scorecard evaluates the status of existing youth FP policies reflected in official government documents. Policies are understood to be government-authored laws, regulations, and strategies to set priorities and/or achieve a particular objective. Specifically, the scorecard assesses a country’s policy framework (constitutions, laws, reproductive health acts, etc.) and programmatic guidelines (FP costed implementation plans, adolescent health strategies, youth development plans, etc.) that impact youth FP.

Methods

To identify policy and program interventions that have been proven to increase youth use of contraception, PRB staff conducted a literature review of 42 studies and systematic reviews (scholarly, gray, and program reports) on youth SRH published between 2000 and 2016. From this evidence base, we identified legal approaches and programmatic interventions that have proven effective in improving access to and use of contraception among youth ages 15 to 24. We did not include adolescents ages 10 to 14 in the review, due to limited data for this age group.

The evidence on what works to address youth FP needs is varied and at times contradictory, due in part to the nature of this population. Youth’s thoughts, interests, and behaviors are constantly changing and evolving, and different populations of youth (for example married, out of school, disabled) have targeted needs. Further, the impacts of youth interventions are often not observable for years after a study closes, when youth may initiate or resume sexual behavior.2 Variations in outcomes are also related to intervention design and implementation. The 2016 Lancet Commission on Adolescent Health and Wellbeing found greater effectiveness when interventions were packaged together rather than implemented individually; however, when interventions are packaged together it can be challenging to tease out the impact of specific interventions.3 Finally, the manner in which interventions are implemented varies by study.

Acknowledging these challenges, we selected policy and program interventions for which three conditions apply:

  • Evidence from low- or middle-income countries (LMIC) shows the policy or program intervention removes a barrier to or results in increased contraceptive use among youth (ages 15 to 24).
  • It is feasible for the policy or program intervention to exist or be adopted at scale at the national level in most LMIC.
  • The policy or program intervention can be compared across countries.

When selecting indicators, we chose those with supporting evidence directly linked to increased youth contraceptive use, although this choice limited the number of policy and program interventions that were ultimately included. Cash transfer programs, for example, have had an impact on decreasing pregnancies among youth and increasing age of sexual debut, but the evidence has not yet identified a direct link to contraceptive use.4

We shared two draft sets of indicators with youth SRH experts, revised the framework based on their feedback, and ultimately selected six indicators that fit the selection criteria:

  • Parental consent, spousal consent, or provider discretion.
  • Restrictions based on age.
  • Restrictions based on marital status.
  • Comprehensive sexuality education (CSE).
  • Youth-friendly FP service provision.
  • Community support for youth FP services.

We devised three color-coded categories to classify how well a country is performing for each indicator. For each indicator, the color assigned is based on the extent to which a country provides the most favorable policy environment for youth to access and use contraception:

GREEN: Strong policy environment.

YELLOW: Promising policy environment but room for improvement.

RED: Policy environment impedes youth from accessing and using contraception OR a policy addressing the indicator does not exist.

To conduct this analysis, we reviewed all potentially relevant policy documents published by each country’s government that could be accessed online. We contacted multiple government and nongovernmental stakeholders in each country to ensure that relevant policies were not inadvertently omitted and to validate our analysis. A full list of policies reviewed is provided in each country summary.

Scorecard Indicators Overview

The following table summarizes the definitions and categorizations of the six scorecard indicators, with details provided below.

Parental Consent, Spousal Consent, or Provider Discretion

  • GREEN: Law or policy exists that supports youth access to FP services free from provider discretion AND consent from a parent or spouse.
  • YELLOW: Law or policy exists that supports youth access to FP services free from one or two of the following: provider discretion, parental consent, or spousal consent, but not all three.
  • RED: Law or policy exists that requires provider discretion OR consent from a parent OR spouse for youth access to FP services. 
  • RED: No law or policy exists on provider discretion or consent from a parent or spouse to access FP services.

Many countries have taken a protectionist approach to legislating youth’s access to FP services, based on a belief that young people need to be protected from harm and that medical providers, parents, or spouses should be able to overrule their reproductive health decisions. Instead, these laws serve as barriers that inhibit youth’s access to a full range of SRH services, including FP. For example, an International Planned Parenthood Federation study in El Salvador reports that laws requiring parental consent for minors to access medical treatment create a direct barrier for youth to access FP. The study recommends: “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.”5

Global health and human rights bodies stress the importance of recognizing young people’s right to freely and responsibly make decisions about their own reproductive health and desires. The 2012 International Conference on Population and Development Global Youth Forum recommended that “governments must ensure that international and national laws, regulations, and policies remove obstacles and barriers—including requirements for parental and 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.”6

National laws should reflect open access to FP services for youth, without being subject to parental consent, spousal consent, or provider discretion. Provider discretion is understood to be any legal provision that allows a provider to determine eligibility for youth to access contraception apart from medical eligibility criteria, such as the provider’s personal belief.7

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 consent, spousal consent, or provider discretion. 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. Policies that underscore the obligation of providers to service youth without discrimination or bias are considered fully supportive of youth access to contraception and contribute to a green categorization under this indicator.

If a policy document mentions that youth are not subject to one or two of the following—spousal consent, parental consent, or provider discretion—but does not mention all three, the country is classified in the yellow category.

Any country that supports provider discretion beyond the WHO medical eligibility criteria for contraceptive use or requires consent from a parent or spouse is placed in the red category, indicating a legal barrier for youth to use contraception. If a country does not have a policy in place that addresses youth access to FP services without consent, it is also placed in a red category. The absence of a policy regarding consent allows for differential interpretation of youth’s rights to freely and independently access FP services and thus serves as a barrier.

Restrictions Based on Age

  • GREEN: Law or policy exists that supports youth access to FP services regardless of age, including the provision of long-acting and reversible contraceptives (LARCs).
  • YELLOW: Law or policy exists that supports youth access to FP services regardless of age but does not include provision of a full range of methods.
  • RED: Law or policy exists that restricts youth from accessing a full range of FP services based on age.
  • RED: No law or policy exists addressing age in access to FP services.

Youth seeking contraception, including long-acting and reversible contraceptives (LARCs), are frequently faced with scrutiny or denial from their provider based on their age.8 The WHO medical eligibility criteria for contraceptive use, however, explicitly states: “Age alone does not constitute a medical reason for denying any method to adolescents.”9

To overcome this barrier, countries should have in place a policy statement that legally requires health providers to offer 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 that explicitly protect access to FP regardless of age but do not explicitly protect youth access to a full range of contraceptive methods, including LARCs, are placed in the yellow category. Countries that allow youth to access LARCs but place restrictions based on parity or other characteristics that do not align with WHO medical eligibility criteria, are also 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 a full range of contraceptive methods regardless of age.

A country is placed in the red category if it has a policy in place that restricts access to FP services based on age alone or lacks any policy addressing age as a determinant to access FP services. These policies create a direct barrier for youth seeking contraception.

Restrictions Based on Marital Status

  • GREEN: Law or policy exists that supports youth access to FP services regardless of marital status.
  • YELLOW: Law or policy exists that supports access to FP services for unmarried women, but without specifying youth. 
  • RED: Law or policy exists that restricts youth access to FP services based on marital status. 
  • RED: No law or policy exists addressing marital status in access to FP services.

A 2014 systematic review identified laws and policies restricting unmarried youth from accessing contraception as an impediment to youth uptake of contraception.10 In the absence of a legal stance on marital status, health workers can justify refusal to provide contraception to unmarried youth.11 Thus, strong policies providing equal access to FP services for married and unmarried youth are necessary to promote uptake of contraceptive services among all youth.

Countries are determined to have the most supportive policy environment 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 a person’s legal right to access FP services regardless of marital status but does not specifically mention youth in this provision, it is considered to have a promising policy environment and classified in the yellow category, because the policy leaves room for interpretation. Finally, a country is placed in the red category if its policies restrict youth from accessing FP services based on marital status or if the country has no policy supporting access to FP services regardless of marital status.

Comprehensive Sexuality Education

  • GREEN: Policy supports the provision of sexuality education AND mentions all nine UNFPA essential components of CSE.
  • YELLOW: Policy supports provision of sexuality education without referencing all nine of the UNFPA essential components of CSE.
  • RED: Policy promotes abstinence-only education OR discourages sexuality education.
  • RED: No policy exists supporting sexuality education of any kind.

The WHO recommends educating adolescents about sexuality and contraception to increase contraceptive use and ultimately prevent early pregnancy and poor reproductive health outcomes.12 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.13

A growing body of evidence demonstrates that informing and educating youth about sexuality and SRH have a positive impact on their reproductive health 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.14 A study in Brazil that implemented a school-based sexual education program in four municipalities measured a 68 percent increase in participating students’ use of modern contraception during their last sexual intercourse.15 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.16

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.17 Further, these guidelines recognize gender and human rights and build on global standards discussed in the UNESCO “International Technical Guidance on Sexuality Education.”

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.

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 was ineffective in preventing negative SRH outcomes.18 In fact, some reports suggest that an abstinence-only approach increases the risk for negative SRH outcomes among youth.19 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. Additionally, the absence of any policy approach to sexuality education altogether suggests the country has not taken a stance on supporting the education of young people on SRH, including contraceptive services. The lack of such a policy places a country in the red category.

The nine UNFPA essential components for CSE are:

A basis in the core universal values of human rights.
An integrated focus on gender.
Thorough and scientifically accurate information.
A safe and healthy learning environment.
Linking to SRH services and other initiatives that address gender, equality, empowerment, and access to education, social, and economic assets for young people.
Participatory teaching methods for personalization of information and strengthened skills in communication, decisionmaking, and critical thinking.
Strengthening youth advocacy and civic engagement.
Cultural relevance in tackling human rights violations and gender inequality.
Reaching across formal and informal sectors and across age groups.

Youth-Friendly FP Service Provision

  • GREEN: Policy mentions all seven core elements of adolescent-friendly contraceptive services AND explicitly mentions the provision of a full range of contraceptive methods to youth.
  • YELLOW: Policy references targeting youth in provision of FP services but mentions fewer than seven of the core elements of adolescent-friendly contraceptive services.
  • RED: No policy exists targeting youth in the provision of FP services.

The WHO “Guidelines on Preventing Unintended Pregnancies and Poor Reproductive Outcomes Among Adolescents in Developing Countries” recommend that policymakers make contraceptive services adolescent-friendly to increase contraceptive use among this population.20 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 LMIC found that three out of seven interventions that increased contraceptive use involved a component of contraceptive provision.21

Additional evaluations show that when SRH services are tailored to meet the specific needs of youth, youth are more likely to use these services and access contraception.22 The scorecard uses the seven core elements identified in High-Impact Practices in Family Planning (HIPs), “Adolescent-Friendly Contraceptive Services” as the framework for assessing the policy environment surrounding FP service and contraceptive provision.23 This review identified seven common elements in adolescent-friendly FP service provision that contributed to increased use of contraception among this age group.

A critical component of this indicator is explicitly tracking whether a full range of contraceptive methods, including LARCs, is offered. Provision of LARCs as part of an expanded method mix is particularly effective. One of the studies identified in the 2016 systematic assessment provided implants as an alternative contraceptive option for young women seeking short-acting contraceptives in 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.24 However, many youth 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 LARCs (specifically, 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 policymakers, 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 nonhealth benefits of contraceptive options, including LARCs, for sexually active adolescents and youth who want to avoid, delay, or space pregnancy.25

Many countries have adolescent-friendly health initiatives, but for a country to be placed in the green category, its policies must specifically reference providing FP services and contraception to youth. A country is placed in the green category for this indicator if its policy documents reference all seven adolescent-friendly contraceptive service elements as defined above and specifically mention provision of the full range of contraceptive services to youth. Simply referencing the provision of FP services to youth, but not adopting the full elements of adolescent-friendly contraceptive services, indicates a promising but insufficient policy environment, and the country is placed in the ellow category.

Countries that do not have a policy that promotes contraceptive service provision to youth are placed in the red category. In the absence of such policies, youth may have great difficulty accessing the contraception they desire.

Several service provision-related barriers to youth contraceptive use are captured in other indicators in the scorecard: parental consent, spousal consent, and provider discretion; restrictions based on age; and restrictions based on marital status. Since these barriers are already captured in other indicators, they are not included again in this indicator’s red category to avoid over-penalizing countries. Additional programmatic barriers to youth accessing contraceptive services exist, such as lack of privacy and confidentiality and cost of services. These and other barriers are addressed in the seven common elements of adolescent-friendly FP service programs outlined above.

The seven elements are:

Train and support providers to offer adolescent-friendly contraceptive services.
Enforce confidentiality and audio/visual privacy.
Offer a wide range of contraception.
Provide no-cost or subsidized services.
Build an enabling legal and political environment.
Link service delivery with activities that build support in communities.
Address gender and social norms.

Community Support for Youth FP Services

  • GREEN: Policy outlines a detailed strategy to build community support for youth FP services, including one or more of the following approaches: mass media/multimedia, community engagement, awareness campaigns. 
  • YELLOW: Policy references engaging the community to support youth access to FP, but does not include specific intervention activities. 
  • RED: No policy exists to build community support for youth FP services.

The final indicator addresses demand-side factors, specifically efforts to make youth access to and use of a full range of contraceptive methods more 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 among 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 SRH service packages.26

Group engagement activities that mobilize communities through dialogue and action, rather than only targeting individuals, are considered to be a promising practice to change social norms around SRH, including contraceptive use.27 Group engagement can be useful to change the discourse around youth sexuality and address misconceptions about contraception within communities.

This indicator is intentionally broad and can manifest in many ways within country policies. Since the evidence is still emerging on which community engagement initiatives are most effective in promoting contraceptive use among youth, the scorecard uses a broad approach to categorizing policy commitments. This indicator focuses on efforts to build support for youth FP within the communities that influence their ability to access services. Often, this includes activities targeting adult gatekeepers, such as parents and religious leaders. Policy initiatives exclusively targeting youth to build support for FP are not factored into categorization of this indicator.

Countries that outline specific interventions to build support within the larger community for youth FP are considered to have a strong policy environment and are placed in the green category. Countries that include a reference to building community support for youth FP, without providing any specific plan for doing so, are placed in the yellow category. Countries without any reference to an activity to build support for youth FP among the community are placed in the red category.

Limitations And Recommendations

A desk review of electronically-accessible policy documents, supplemented with documents not available online that were provided by local experts, returned over 150 relevant policy documents across the 16 countries. However, additional policy documents relevant to the scorecard likely exist. Future iterations of the scorecard might supplement these findings with further collection of primary data, in the form of key informant interviews or questionnaires, from local stakeholders.

Many LMIC are moving towards a decentralized government structure, including several of the countries analyzed here, most notably Pakistan. Inevitably, approaches to health service delivery will vary at the subnational level under these governance structures. However, with the exception of Pakistan, we did not conduct a search of subnational policies. Additionally, the scorecard does not capture the efforts of donors, nongovernmental organizations, and implementing partners to address youth FP needs, and may not fully represent the state of youth FP programming in the country that falls outside of governments’ purviews.

Finally, the purpose of the scorecard in its current form is to characterize the state of youth FP policy commitments in specific countries. The scorecard does not measure the extent to which a country has implemented youth FP policies. Countries with strong policy environments surrounding youth FP may not sufficiently allocate funding nor implement youth FP programs as outlined in their policies. Thus, an analysis of a country’s policy environment is only one component of understanding youth FP programs. To further understand the nuanced policy environment surrounding youth FP needs, policy implementation assessments would deepen the analysis of existing policies and programs.

Discussion of Results

The majority of the countries reviewed—Benin, Burkina Faso, Côte d’Ivoire, DRC, Guinea, Ethiopia, Kenya, Nigeria, Tanzania, and Uganda—have either a general adolescent and youth health strategy or a tailored adolescent and youth SRH strategy. The age range of adolescents and youth cited in these strategies generally follows the WHO’s definition, ages 10 to 19 and ages 15 to 24, respectively. Ethiopia expands the definition of youth to ages 15 to 30, aligning with the definition of youth in the national constitution. The policies reviewed do not always specify which FP services will be provided to which cohorts of adolescent and youth.

Tanzania and Kenya recognize the unique needs of very young adolescents (ages 10 to 14) as a vulnerable subpopulation of adolescents and youth. Kenya provides the most comprehensive instruction for service provision to very young adolescents in its “National Guidelines for Provision of Adolescent and Youth Friendly Services,” which outline strategies to reach very young adolescents, including offering a routine health visit for young girls, linking FP services with schools or nearby referral systems, and providing community-based FP services for newly married girls.

Overall, results are most promising for the FP service-provision and community-support indicators. Fifteen of the sixteen countries, excluding Niger, have included youth-specific service provision of FP in their policies. While Burkina Faso, Côte d’Ivoire, Ethiopia, Kenya, Mali, Senegal, and Tanzania have the most supportive policy environment around youth access to a full spectrum of FP methods, Benin, DRC, Guinea, Mauritania, Niger, Nigeria, Sindh, Togo, and Uganda have room for improvement.Specifically, these countries should consider the inclusion of all seven elements of adolescent-friendly contraceptive services discussed in the HIPs “Adolescent-Friendly Contraceptive Services” in future policies and provision of a full range of contraception to youth.

Eleven of the sixteen countries, excluding DRC, Mali, Mauritania, Niger, and Sindh, outline detailed steps to build community support for youth FP in their policies. Approaches included in this indicator generally call upon a common social and behavior change communication intervention to inform and educate the general community, community leaders, and parents about the importance of youth FP services. As the evidence for engaging communities evolves, the results for this indicator will likely show greater differentiation and prioritization of approaches.

Discussion of CSE in policies is frequently vague and difficult to assess. Generally, countries mention sexuality education in their reproductive health policies but do not provide additional guidance on the components of a sexuality education curriculum nor how to implement it. Côte d’Ivoire has the most comprehensive sexuality education program. The country recently shifted its family life education program into a CSE program that includes all nine of the UNFPA essential components of CSE. Nigeria’s family life and HIV education curriculum is another comprehensive document addressing sexuality education in schools. While quite robust in discussions of human development, social norms, relationships, gender, and life skills, the policy takes a weak stance on SRH. In fact, the curriculum avoids discussion of FP services and promotes abstinence-only education.

The majority of the countries, with the exception of Benin and Tanzania, fail to fully address the barriers presented by parental, spousal, and/or provider authorization. Future policies focused on youth SRH should use clear language prohibiting provider discretion and parental and spousal consent for youth contraceptive provision.

Results are fairly mixed for the indicators on restrictions based on age and on marital status. In regard to age restrictions, many countries have laws and policies that support reproductive health services regardless of age and/or offer a full range of contraception to women, but do not clearly protect youth access to a full range of contraception, including LARCs, regardless of age.

All Ouagadougou Partnership (OP) countries, with the exception of Côte d’Ivoire, have a reproductive health law that outlines the rights of individuals and couples to reproductive health information and services. Mauritania’s law is the most recent, passed in 2017. A reproductive health law is currently being drafted in Côte d’Ivoire. Recent FP policies in Côte d’Ivoire discuss the need to pass a reproductive health law, since the law that had previously been drafted in the early 2000s was not ratified due to conflict. There are many similarities in the language of these laws across OP countries, but they vary in important ways. In Benin, the law includes language that prohibits parental and spousal consent for SRH services. In Burkina Faso, Mauritania, Senegal, and Togo, the laws explicitly mention adolescents and protect their right to family planning regardless of age or marital status. Future updates to these RH laws should explicitly extend RH rights to adolescents. Overall, the policy environments in several of the OP countries are promising and the poor adolescent RH outcomes that these countries face have the potential to improve if these policies are successfully implemented.

Gender norms that promote boys’ sexuality and stigmatize girls’ have been identified in HIPs “Adolescent-Friendly Contraceptive Services” as key barriers to adolescents’ access to FP services.28 Countries frequently identify gender inequalities and gender norms as challenges for youth, particularly girls and young women who wish to access contraception, and promote various approaches to address gender. Benin has an objective to engage youth to reduce gender-based violence and forced and early marriages within its youth SRH strategy. Burkina Faso recognizes the importance of girls’ education and creating an environment conducive to gender equality. Côte d’Ivoire’s CSE program includes a module in which youth learn about the impact of gender norms on SRH, and a gender module is planned for Togo’s population education program. Ethiopia addresses gender through community engagement actions by engaging men and gatekeepers to improve women’s decisionmaking power. Kenya and Uganda include initiatives to mainstream gender responsiveness across youth SRH approaches, while Nigeria specifically includes gender sensitivity in service-delivery protocols. Togo also aims to raise awareness of gender issues among health stakeholders and to integrate a gender approach into SRH services for men, women, and adolescents. Mali includes an activity to address the economic empowerment of adolescent girls to improve their ability to make SRH decisions. Addressing gender norms as a barrier to youth accessing contraception is a key consideration for CSE and youth-friendly FP service provision.

Several country policies describe activities to engage youth directly in the design and implementation of youth-friendly health services, and often SRH services specifically. Benin describes the important role that youth organizations play in mobilizing young people to advocate for SRH services and plans to strengthen the involvement of youth in SRH planning, decisionmaking, implementation, and monitoring and evaluation. In Burkina Faso, emphasis is placed on empowering youth to participate and speak up in their families and communities to improve their decisionmaking power in addition to involving youth in the provision of SRH services. Côte d’Ivoire notes the importance of building the capacity of youth to be both grass-roots actors and to help manage programs throughout all stages in order to ensure their sustainability. In Ethiopia, a number of activities support youth participation, such as building the capacity of youth organizations, involving their members in decisionmaking and strategic planning, and expanding youth representation in working groups and task forces. Guinea has similar goals to engage youth in the development and implementation of health programs. Kenya identifies adolescent participation as a cross-cutting issue and aims to institutionalize the process of incorporating youth input into the RH research agenda and program implementation. Nigeria recognizes a rights-based approach in which youth have the right to participate in the development and implementation of policies and programs that affect their well-being.

Analysis of selected FP reference data shows potential connections between evidence-based policy approaches and resulting health outcomes. Further analysis of additional countries is needed to explore the potential associations. For example, the East African countries with the most-supportive policy environments for youth-friendly service provision—Ethiopia, Kenya, and Tanzania—also have the highest rate of modern contraceptive use (mCPR) among young married women between ages 15 to 19 and ages 20 to 24 among all 16 countries reviewed. In Ouagadougou Partnership countries with the most-supportive policy environments for service provision—Burkina Faso, Mali, and Senegal—the connection to mCPR is less clear. Mali has a supportive policy environment for service provision but low mCPR among married women between ages 15 to 19 and 20 to 24 compared to other OP countries. Togo has a high mCPR among married women ages 15 to 19 and 20 to 24 compared to other OP countries, but is placed in the yellow category for youth-friendly services due to non-medical restrictions on youth who access LARCs. Niger has both the least-supportive overall policy environment for youth, including an antiquated law penalizing the distribution of contraception, and the highest adolescent birth and teenage pregnancy rate.

Many policies reviewed were close to the end of their stated timeline or had already expired. This scorecard provides recommendations to improve the overall policy environment and may be useful as decisionmakers update strategies and policies surrounding youth FP.

Country Results

This edition of the scorecard includes analysis for 16 countries: Benin, Burkina Faso, Côte d’Ivoire, Democratic Republic of the Congo (DRC), Ethiopia, Guinea, Kenya, Mali, Mauritania, Niger, Nigeria, Sindh (Pakistan), Senegal, Tanzania, Togo, and Uganda.

The scorecard also includes selected quantitative reference data related to youth FP outcomes. These data contextualize the policy indicators to provide initial insight on whether the strength of a country’s policy environment
aligns with FP outcomes among youth.

GREEN: Strong policy environment.
RED: Policy environment impedes youth from accessing and using contraception OR a policy addressing the indicator does not exist.
YELLOW: Promising policy environment but room for improvement.


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References

1. Pathfinder International, Evidence 2 Action (E2A), Population Services International (PSI), Marie Stopes International, FHI 360, “Global Consensus Statement: Expanding Contraceptive Choice for Adolescents and Youth to Include Long-Acting Reversible Contraception,” (2015), accessed at www.familyplanning2020.org/resources/10631, on Jan. 31, 2017; United Nations Population Fund (UNFPA), The Power of 1.8 Billion: Adolescents, Youth, and the Transformation of the Future (New York: UNFPA, 2014); and World Health Organization (WHO), “Preventing Early Pregnancy and Poor Reproductive Outcomes Among Adolescents in Developing Countries: WHO Guidelines,” (Geneva: WHO, 2011).
2. Allison Glinski, Magnolia Sexton, and Suzanne Petroni, Adolescents and Family Planning: What the Evidence Shows (Washington, DC: International Center for Research on Women, 2016).
3. George Patton et al., “Our Future: A Lancet Commission on Adolescent Health and Wellbeing,” 387, no. 10036 (2016): 2423-78.
4. Michelle J. Hindin et al., “Interventions to Prevent Unintended and Repeat Pregnancy Among Young People in Low- and Middle-Income Countries: A Systematic Review of the Published and Gray Literature,” Journal of Adolescent Health 59, no. 3 (2016): S8-S15.
5. Kara Apland, “Over-Protected and Under-Served: A Multi-Country Study on Legal Barriers to Young People’s Access to Sexual and Reproductive Health Services—El Salvador Case Study,” (July 2014), accessed at www.ippf.org/sites/default/files/ippf_coram_el_salvador_report_eng_web.pdf, on Aug. 10, 2016.
6. UNFPA, “Follow-Up to the Implementation of the Programme of Action of the International Conference on Population and Development Beyond 2014—Bali Global Youth Forum, Bali, Indonesia 4-6 December 2012,” (April 2013), accessed at www.unfpa.org/, on Oct. 1, 2016.
7. Sexual Rights Initiative, “Sexual Rights Database,” (2016), accessed at http://sexualrightsdatabase.org/, on July 1, 2016; Provider discretion is understood to be “any situations where the decision is left to the provider, including: mature minor exceptions, determination of whether a person is in ‘need’ of contraception or is sexually active, determination of maturity, etc.”
8. Akinrinola Bankole and Shawn Malarcher, “Removing Barriers to Adolescents’ Access to Contraceptive Information and Services,” Studies in Family Planning 41, no. 2 (2010): 117-24; and R. Rivera et al., “Contraception for Adolescents: Social, Clinical and Service-Delivery Considerations,” International Journal of Gynecology & Obstetrics 75, no. 2 (2001): 149-63.
9. WHO, “Medical Eligibility for Contraception Use, 5th Edition,” (Geneva: WHO, 2015).
10. Venkatraman Chandra-Mouli et al., “Contraception for Adolescents in Low- and Middle-Income Countries: Needs, Barriers, and Access, Reproductive Health 11, no. 1 (2014).
11. Chandra-Mouli et al., “Contraception for Adolescents in Low- and Middle-Income Countries.”
12. Venkatraman Chandra-Mouli, Alma Virginia Camacho, and Pierre-André Michaud, “WHO Guidelines on Preventing Early Pregnancy and Poor Reproductive Outcomes Among Adolescents in Developing Countries,”  Journal of Adolescent Health 52, no. 5 (2013): 517-22.
13. UNESCO, International Technical Guidance on Sexuality Education: An Evidence-Informed Approach for Schools, Teachers, and Health Educators (Paris: UNESCO, 2009).
14. Virginia A. Fonner et al., “School-Based Sex Education and HIV Prevention in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis,” PloS One 9, no. 3 (2014); K.G. Santhya and Shireen J. Jejeebhoy, “Sexual and Reproductive Health and Rights of Adolescent Girls: Evidence From Low- and Middle-Income Countries,”  Global Public Health  ١٠, no. ٢ (٢٠١٥): ١٨٩-٢٢١; and Chioma Oringanje et al., “Interventions for Preventing Unintended Pregnancies Among Adolescents,” Cochrane Database Systematic Review< 4, no. 4 (2009).
15. Heloísa Helena Siqueira Monteiro Andrade et al., “Changes in Sexual Behavior Following a Sex Education Program in Brazilian Public Schools,”  Cadernos de Saúde Pública< ٢٥, no. ٥ (٢٠٠٩): ١١٦٨-٧٦.
16. Patton et al., “Our Future.”
17. UNFPA, “UNFPA Operational Guidance for Comprehensive Sexuality Education: A Focus on Human Rights and Gender,” (December 2014), accessed at www.unfpa.org/publications, on July 15, 2016.
18. Patton et al., “Our Future.”
19. Santhya and Jejeebhoy, “Sexual and Reproductive Health and Rights of Adolescent Girls.”
20. Chandra-Mouli, Camacho, and Michaud, “WHO Guidelines on Preventing Early Pregnancy and Poor Reproductive Outcomes Among Adolescents in Developing Countries.”
21. Hindin et al., “Interventions to Prevent Unintended and Repeat Pregnancy Among Young People in Low- and Middle-Income Countries.”
22. Venkatraman Chandra-Mouli, Catherine Lane, and Sylvia Wong, “What Does Not Work in Adolescent Sexual and Reproductive Health: A Review of Evidence on Interventions Commonly Accepted as Best Practices,”  Global Health: Science and Practice 3, no. 3 (2015): 333-40; Allison Glinski et al., Adolescents and Family Planning; and Lindsey B. Gottschalk and Nuriye Ortayli, “Interventions to Improve Adolescents’ Contraceptive Behaviors in Low- and Middle-Income Countries: A Review of the Evidence Base,” Contraception 90, no. 3 (2014): 211-25.
23. Jill Gay et al., High-Impact Practices in Family Planning (HIPs), Adolescent-Friendly Contraceptive Services: Mainstreaming Adolescent-Friendly Elements Into Existing Contraceptive Services (Washington, DC: USAID, 2015), accessed at www.fphighimpactpractices.org/afcs, on Sept. 20, 2016.
24. David Hubacher et al., “Preventing Unintended Pregnancy Among Young Women in Kenya: Prospective Cohort Study to Offer Contraceptive Implants,” Contraception ٨٦, no. ٥ (٢٠١٢): ٥١١-١٧
25. Pathfinder et al., “Global Consensus Statement.”
26. Patton et al., “Our Future.”
27. Kate Ploude et al., High-Impact Practices in Family Planning (HIPs), Community Group Engagement: Changing Norms to Improve Sexual and Reproductive Health (Washington, DC: USAID, 2016), accessed at www.fphighimpactpractices.org/, on Oct. 21, 2016.
28. Jill Gay et al., High-Impact Practices in Family Planning (HIPs), Adolescent-Friendly Contraceptive Services
29. Katie Chau et al., “Scaling Up Sexuality Education in Senegal: Integrating Family Life Education Into the National Curriculum,”  Sex Education ١٦, no. ٥ (٢٠١٦): ١-١٧.
30. UNESCO Office in Dakar, “Senegal Is Updating its Curricula by Reinforcing Reproductive Health Education,” (2016), accessed at www.unesco.org/new/en/dakar/about-this-office/single-view/news/senegal_is_updating_its_curricula_by_reinforcing_reproductiv/, on Oct. 21, 2016.
31. Jonathan Cohen and Tony Tate, “The Less They Know, the Better: Abstinence-Only HIV/AIDS Programs in Uganda,” Reproductive Health Matters 14, no. 28 (2006): 174-78.