Adolescent Girls’ Sexual and Reproductive Health Service Delivery in Uganda: Evaluating Progress in Implementation of the National Adolescent Reproductive Health Policy A presentation By Agnes Kyamulabi (Dept of Develoment Studies, Makerere University) Opesen C. Chris (Dept of Sociology & Anthropology, Mak-University) AT THE SOCIETY OF ADOLESCENT HEALTH IN UGANDA (SAHU)  4TH SYMPOSIUM OF MAKERERE-COLUMBIA (MUCU) MEETING Kampala, Uganda 29TH MARCH 2017  VENUE: HOTEL AFRICANA, UGANDA

Introduction Adolescent girls as a vulnerable group face many social change crises as they transition from childhood to adulthood Coupled with most sexual encounters in this age group being unprotected, these vulnerabilities increase their risk of getting unwanted pregnancy, engaging in an unsafe abortion, contracting STls/HIV. The National Adolescent Health Policy was hence developed in 2004 with 12 key objectives and over 20 targets partly, to promote adolescent girls SRH.

Objective of the paper On this backdrop, this paper provides a functional evaluation of the progress made in the implementation of this policy

Methodology Evidence presented is based on 2 MoH key informant interviews a realist hermeneutic review of UDHS panel data(2001, 2006, 2011 and 2016) National census data 2014 and 2002 IP ASRH reports particularly, UNICEF, UNFPA NGO reports MoH data from 2005 to 2015 vis-à-vis the 2004 policy targets. Analysis and interpretations were inductively and thematically conducted

Findings: Progress in the National ASRH Policy Indicator Targets Indicator Progress Counts (n) Per cent (%) Negative 1 3.7 No progress 2 7.4 Very low Low 4 14.8 High 5 18.5 Target Close Target exceeded No data 9 33.3 Target Not SMART Total 27 100

Findings: Progress in the National ASRH Policy Indicator Targets Negative Progress indicators: 3.7% (n=1, N=27) Harmful traditional practices(e.g. FGM) through appropriate policies, legislation and programmes reduced Target: Not stated. Status: From 0.5% (UDHS 2006) to 1% in UDHS 2012. Detailed UDHS 2016 not out. Not reported in UDHS 2001 No Progress Indicators: 7.4% (n=2, N=27) (a) Abortion law reviewed with a view to improve the services Target: Have abortion law reviewed Status: No review done since 2004 (Hansard 2017) (b) Use of emergency contraception integrated in family planning programmes targeting adolescents increased. Target: Use of emergency contraception integrated …… Status: No integration since 2004 (UDHS 2001/2017)

Findings: Progress in the National ASRH Policy Indicator Targets Very low Progress indicators: 7.4% (n=2, N=27) (a) Double contraceptive use among sexually active adolescents State of contraceptive use in 2004: 21.5% (UDHS 2006) Target 43% Status : 21.9% (UDHS 2016) (b) Raise the median age at first sexual intercourse to 18 years from 16.7 in females Median age in 2004: 16.7 years (UDHS 2006) Target 18 years Status: 16.8 years (UDHS 2012)

Findings: Progress in the National ASRH Policy Indicator Targets Low Progress Indicators: 14.8% (n=4, N=27) (a) STI management and HIV/AlDS counselling integrated in all activities at all levels of care State in 2004: 28.2% (MoH 2006) Target 100% Status: 68% (UDHS 2012) (b) Enrolment: Girl-child enrolment and retention in primary schools increased to match that of boys State in 2004: 0.95 (MoH 2006) Target: 1, Status: 0.98 (SPR 2014) (c) Enrolment: Girl-child enrolment and retention in secondary schools increased to match that of boys State in 2004: 0.79 (MoH 2006) Target: 1, Status: 0.81 (SPR 2014) (d) Reduce the % of women who have their first child below 20 years State in 2004: 59% (UDHS 2011) Target: 30%, Status: 25% (UDHS 2016)

Findings: Progress in the National ASRH Policy Indicator Targets High Progress Indicators: 18.5% (n=5, N=27) (a) Lifetime risk of maternal death in age group 15-24years reduced by 50% State: 0.029 in 2005-2011(UDHS 2012) Target 0.0145 Status: 0.019 for 2009-2016 (UDHS 2016) (b) Percentage of mothers below 20 years receiving at least two doses of Tetanus Toxoid during pregnancy increased State in 2004: 56% (MoH 2004) Target: 80% Status: 74.3% (UDHS 2016) (c) HMlS desegregated data on immunization, and nutrition status or breastfeeding status obtained for children born to adolescent mothers in order to design appropriate interventions State in 2004: 48% (MoH 2004) Target: 100%, Status: 78.6% (UDHS 2016) (d) Proportion of adolescents that are comprehensively knowledgeable about STls and AlDS increased State in 2004: 29% (MoH 2004) Target: Not stated Status: 40.7% (UDHS 2016) (e) Review, enact, enforce and implement legislation that will reduce harmful traditional practices State in 2004: No FGM law Target: Not stated Status: FGM law in place (Hansard 2010)

Findings: Progress in the National ASRH Policy Indicator Targets (a) Target Close Indicators: 3.7% (n=1, N=27) Improve the proportion of mothers below 20 years delivering in a health facility State in 2004: 48% (MoH 2004) Target 80% Status: 78.6% (UDHS 2016) (b) Target Exceeded Indicators: 7.4% (n=2, N=27) Increase the practice of dual protection in sex (against both disease and pregnancy) among adolescents by 30% State in 2004: 49.8% (MoH 2004) Target 80% Status: 81.8% (UDHS 2016) Increase the perception of the risk of getting HIV/AlDS in adolescent females State in 2004: 68% (MoH 2004) Target 90% Status: 99.3% (UDHS 2012)

Findings: Progress in the National ASRH Policy Indicator Targets No Evaluation Data Indicators: 33.3.% (n=9, N=27) Ratio of girls : boys in tertiary education. the target is 1 and the SPR (2014) puts it at 0.92 but there is no bench mark data Increase the proportion of adolescents abstaining from sex before marriage by 30%.**** Pregnant school girls to continue with education system after they have delivered Proportion of orphans with HIV accessing home based care and support increased Proportion of HIV positive adolescent accessing ARVs increased (29% today-MoH 2015 but no bench mark data) Adolescent reproductive health incorporated into the curricula of all health training institutions and schools.  Increase the number of institutions providing psychosocial support services for adolescents    Number of adolescents accessing psychosocial support services for the assessment and management of mental/behavioural disorders increased    Establish psychosocial support    ****Median age for marriage in girls is 16.8 and 22.3 years in boys but there is no data measuring abstinence before marriage (UDHS 2001/2012)

Findings: Progress in the National ASRH Policy Indicator Targets Non SMART Indicators: 3.7% (n=1, N=27) Establish psychosocial support    Others not included in the computation of the proportion but are not SMART Harmful traditional practices through appropriate policies, legislation and programmes reduced Review, enact, enforce and implement legislation that will reduce harmful traditional practices Increase the number of institutions providing psychosocial support services for adolescents

Conclusion and Recommendation Progress has been made in the last 13 years but ASRH policy effectiveness is observed in only 7.4% (n=2) of the 27 target performance indicators which is very low. The state of some target performance indicators is not SMART rendering measurement of progress complex. UNFPA and UNICEF evaluations in the area of ASRH do not capture all the indicator performance targets of the National Adolescent Health Policy. This is also true of the UDHS. Recommendations To strengthen evidence based decision making. MoH, its IPS, other development partners and the UDHS should align their ASRH related evaluations to the national policy indicators to ease performance assessment efficiently and provide timely data. There is need to review the national policy indicators to be SMART.

Thank You For your valuable Attention