Adolescent health/sexual and reproductive health scenario in Bangladesh and recipe for action

There have been attempts at developing programmes and interventions to address key    challenges related to a lack of adolescent-friendly health services, limited access to age-appropriate counselling services, promotion of a healthy lifestyle, and menstrual management facilities at the school, both in the government and non-state sectors for quite some time. These programmes have mostly been on a small scale, localised and fragmented. A study has been done to fill in this knowledge gap by conducting a situation analysis on AH/SRH and identifying past and present programmes that have been highly effective and impactful.

The study adopted multiple methods for collecting data: i) a Scoping review of relevant  documents to get a ‘snap shot’ of the current situation; ii) a Qualitative study including Key Informant Interviews (KIIs) with stakeholders at district and central levels, In-depth Interviews (IDIs) with programme participants, and Focus Group Discussions (FGDs) with members of the beneficiary community; iii) Observational case studies based on field visits to selected programme sites, and iv) feedback from a deliberative workshop with the stakeholders to share and discuss findings.

Data were collected from 11 purposively selected sub-districts (of eight districts, one district per division) during Jan. – Mar. 2022. The sub-districts were selected based upon programme concentration and discussion with DGHS/DGFP of MoHFW, MoE, and MoWCA. A total of 39 IDIs, 34 KIIs, 9 FGDs, and 18 case observations were done. Finally, a stakeholder deliberative dialogue with key stakeholders at the central level was organised on 30^th May 2022 at BRAC Centre Inn Dhaka.

Here are some glimpses from the findings:

·         In the study, 28 Adolescent SRH programmes were reviewed by the study team. Findings reveal that BRAC was a pioneer in implementing programmes for adolescent girls since the ‘90s as part of its women empowerment mission, e.g., BRAC Adolescent Development Programme (1993) and APON (1998). This was followed by UNICEF at the beginning of the millennium (Kishori Abhijan, 2001) and then the government (Adolescent-friendly Health Corners, DGHS/MoHFW, 2011).

·         An attempt was made to identify some impactful (and scalable) AH/SRH programmes based on the scoping review and perspectives of the programme implementers and beneficiaries. For example, child marriage interventions improved awareness about the problems of early marriage, including the legal age of marriage for girls and its rationale. Some interventions positively affected unmarried girls’ preference for marriage at 20 years of age or later and increased their confidence in negotiating with their parents to delay marriage.

·         Menstrual hygiene management programmes helped to improve relevant knowledge and use of health products and services as intended by the programmes. Findings show that additional focus on male family members, especially fathers, was helpful to improve the utilisation of MHM products.

·         Some Nutrition programmes successfully improved nutrition practices and shifted gender dynamics at household and community levels, beside improving knowledge of nutrition and its practical implications in everyday life. Some

·         Programmes focusing on gender-based violence achieved reasonable awareness of the participants around domestic and intimate-partner violence, harassment, rape and acid throwing etc.

·         Findings show that in-school girls developed better gender-equitable attitudes than their out-of-school peers. Some programmes achieved a higher percentage of married adolescents using modern contraceptive methods.

·         Educational interventions enhanced access to AH/SRH knowledge and helped lower the barrier for adolescents to access information, counselling, and sexual and reproductive health services.

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Common enabling factors for adolescent health/SRH programmes (all countries including Bangladesh): Analysis of the data identified common factors underlying the success (based on outcome/impact) as follows: i) use of multiple platforms (schools, health facilities, community outreach) for service delivery (Bangladesh, India); ii) community engagement and participation (Bangladesh, Nepal, India); iii) regular monitoring and evaluation (Bangladesh, India, Nepal); iv)  capacity-building of programme implementers and participants (India, Nepal, Sri Lanka); v) youth engagement (Pakistan, Nepal); vi) involving peer groups to share/disseminate information (Nepal. Pakistan, India); vii) use of digital platforms (Bangladesh, Nepal, India); viii) establishing adolescent-specific service delivery outlets (Bangladesh, India, Pakistan, Sri Lanka).

·         Common challenges for adolescent health/SRH programmes (all countries including Bangladesh)

Supply-side challenges include i)  socio-cultural and religious barriers to discussing sensitive issues like SRH issues  publicly; ii)  shortage of trained/skilled service providers, including mental health counsellors; iii) poor programme documentation and regular programme M & E; iv) poor coordination among the ministries, agencies and stakeholders in the government and non-state sectors.

Demand-side challenges include i) resistance emerging from traditional norms and tribal culture, parents and xcommunity gate-keepers, religious leaders etc. while disseminating sensitive information; ii) economic barriers to access AH/SRH services by the adolescents; iii) lack of support from the family and community due to poor awareness of the parents on AH/SRH issues; iv) Social and psychological barriers emerging from shyness and relative loneliness of the adolescents; v) negative perception of the parents and others on mental health counselling; vi) outreach for the school dropouts and out-of-school adolescents.

·         Based on evidence generated through the study, we summarise what worked and did not work during the implementation of these programmes to inform the future design of a comprehensive AH/SRH programme:

o   a) What worked: Enabling factors

Evidence generated through the study identified the following common enabling factors for the success of the AH/SRH programmes in the studied countries, including Bangladesh: use of the health facility, school and community-based platforms in combination for service delivery, buying in the social gate-keepers including religious leaders, engaging the community to participate in co-designing the interventions, continuous M & E using measurable indicators, supply and demand-side capacity building, incorporation of life-skills and income generation activities in the AH/SRH programme, and peer-to-peer approach for building awareness on relevant issues.

o   b) What did not work: challenges to be addressed

Some common challenges identified through the study across the selected countries, including Bangladesh are: lack of coordination among various ministries/implementing organisations and poor integration of services, limited implementation capacity, shortage of resources, including trained human resources, lack of motivation of field staff, infrastructural challenges, absence of age-specific customized programme design, poor programme documentation, non-inclusiveness and frequent dropouts of adolescents, cultural and religious barriers raised by the family/society/community, gender insensitivity, time-bound project nature of the programmes without sustainability plans etc.

·         Current gaps in AH/SRH programmes in Bangladesh

Some of the gaps in the AH/SRH programmes in Bangladesh identified through the study are: limited geographical coverage and age-specific intervention;  lack of programme inclusivity for disadvantaged adolescents, AH/SRH component strategically bundled with other interventions; younger adolescents (10-14 years), unmarried girls and adolescent boys are less covered in the current programmes; limited programme documentation and poor and irregular M & E,  experiences of scale-up not documented to inform future programme modifications; lack of sustainability plans once current funding stops; frequent dropout of field level staffs, volunteers, adolescent participants; lack of model effectiveness testing initiatives etc.

·         Based on evidence generated from the study, the following recommendations are made for developing a comprehensive AH/SRH programme in Bangladesh:

·         Build coordination and collaboration among the ministries and agencies involved in implementing AH/SRH interventions and with the non-state sectors to expand outreach and avoid duplication and overlaps.

·         Strategic partnership with sectors beyond health as the diverse needs of adolescents cannot be addressed by the health sector alone. Synergistic action with other sectors and stakeholders such as education, social welfare and media is crucial, especially for vulnerability reduction and ‘leaving no one behind’.

·         Ensure equity and inclusivity to reach the hitherto un-reached adolescent groups such as disabled, marginalised population, LGBT and transgender community, CSWs, street-dwellers, remote and hard-to-reach areas, tea-garden etc. The programme design needs to be flexible to accommodate the different needs of these diverse groups.

·         The interventions need to be gender-sensitive; the programme design should be such that it can address the different needs of the two sexes. For example, ensuring female physicians for female adolescents especially married adolescents. Ensure privacy and confidentiality while providing services.

·         Increase demand for AH/SRH services by ensuring an adolescent-friendly service environment in the AFHCs; Instead of the AFHC-based approach, think of a life-course approach to deliver age-specific integrated services to overcome fragmentation and provide ‘one-stop’ services.

·         Use multiple platforms, including digital platforms, for service delivery to target adolescents for maximum impact;  ensure active engagement of the adolescents, the catchment community and its gatekeepers, including religious leaders, in programme design and implementation.

·         It is also necessary for the non-state sectors to establish relations and communication with relevant formal institutions and govt. agencies, civil society organisations and regulatory authorities for programme buy-in from the early phase of programme designing.

·         Enhance capacity of the service providers across with necessary skills and training to deliver integrated services at scale. Training informal CTC (Close-to-Community) providers and developing strategies to enable better links and coordination between this community-embedded cadre and the formal health sector has the potential to reduce service costs and improve the availability of quality SRH (and other) care at the community level.

·         Develop mental health workforce for different tiers e.g., clinical psychologists, and clinical social psychiatrists, to fill in the gaps in counselling services. 

·         Ensure proper programme documentation and programme M & E to inform future course correction as needed for being relevant. Monitoring of AH service utilisation based on the indicators used in DHIS 2.

·         Ensure sustainability beyond programme duration by increasing investment in adolescent health/SRH programmes, and establishing linkages with mainstream health systems for integrated service delivery and sustainability.