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Mainstreaming Adolescent Reproductive Health (ARH) and Gender in HIV/AIDS Programs, Addressing HIV/AIDS Among the Young People

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Title: Mainstreaming Adolescent Reproductive Health (ARH) and Gender in HIV/AIDS Programs, Addressing HIV/AIDS Among the Young People


1
Mainstreaming Adolescent Reproductive Health
(ARH) and Gender in HIV/AIDS Programs, Addressing
HIV/AIDS Among the Young People
  • A Study Report for a Policy Dialogue,
  • The WORLD BANK
  • Jointly with
  • WAO/PMO, MoH, HAPCO, and MoYSC
  • Addis Ababa, 2 June 2004

2
Study objectives
  • To increase understanding of the linkages between
    Adolescent Reproductive Health (ARH), Gender and
    HIV/AIDS,
  • To review policy frameworks, institutional
    arrangements and identify implementation gaps
  • To improve the visibility and participation of
    young people and vulnerable groups in HIV/AIDS
    programming,  

3
Study objectives
  • to identify and disseminate promising approaches
    for scaling-up (policies and actions, tools, good
    practices, lessons learned) and identify
    challenges and implementation gaps, and
  • to increase the commitment and collaboration
    among partners and countries working on ARH,
    gender and HIV/AIDS programs. 

4
Methodologies
  • Review of key documents and resources,
  • Dialogue with policy makers, program
    managers/implementers and key informants,
  • Use of applicable tools (SWOT, ranking, matrix),
  • Identification of promising approaches and
    challenges/gaps,
  • Field visits,
  • Focus groups discussion, and
  • Facilitated Learning Dissemination sessions.

5
Criteria for Measuring Promising Approaches and
Gaps
  • Effectiveness degree of response to local needs
    critical issues of the country,
  • Linkages/coordination with multi-sectoral
    dimensional applications and outcomes/impact
    (ARH, gender HIV/AIDS),
  • Youth Focused with increased Male involvement
    and Female empowerment,

6
Criteria for Measuring Promising Approaches and
Gaps
  • 4. Efficiency cost effective, systemic,
    tracking/reporting change (ME, reports,
    indicators),
  • 5. Transferable with clear steps and can be
    transferred/adapted to another setting/situation,
  • 6. Visionary Strategic Direction Strong
    leadership with long term, coordinated
    sustainable results, and
  • 7. Sustainability Community participation and
    ownership and public acceptance.

7
Who are the Stakeholders of ARH, Gender and
HIV/AIDS?
  • Government (Key)
  • Ministry of Youth, Sport and Culture (MoYSC),
  • Womens Affairs Office (WAO/PMO),
  • Ministry of Health (FHD),
  • HIV/AIDS Prevention and Control Office (HAPCO)
  • Government (others)
  • Ministry of Education, youth at school,
  • Ministry of Agriculture (MoA), Rural Youth,
  • Ministry of labor and Social Affairs (MoLSA), out
    of school and vulnerable youth, a
  • Ministry of Finance and Economic Development
    (MoFED NoP, CSA, Federal Planning SDPRP, MDGS,
  • Ministry of Justice (MoJ), and
  • Media (ETV and Walta

8
Who are the Stakeholders of ARH, Gender and
HIV/AIDS?
  • Others
  • NGOs, both indigenous and international,
  • Youth and womens groups and clubs,
  • Community Based Organizations (CBOs) and
    traditional structures,
  • Civil Society Organizations (CSOs), religious,
    learning, professional, advocacy groups, etc.
  • Private Sector (labor union, employers, youth
    associations),
  • Development partners and donors WB, UN agencies,
    EU, bilateral (USAID, SIDA, CIDA, Netherlands,
    Norwegian, Irish, etc.)

9
International Regional Instruments committed
  • 1981, Convention for the Elimination of All Forms
    of Discrimination Against Women (CEDAW), signed
    in 1981 (periodic report is presented to the
    United Nations),
  • 1991, Children Summit, New York, Convention on
    the rights of the Child (1984),
  • 1992, Earth Summit, Rio,
  • 1994, International Conference on Population and
    Development (ICPD) Program of Action,

10
International Regional Instruments committed
  • 1995, Womens Conference, Beijing Platform for
    Action,
  • 1995, Social Summit (Copenhagen),
  • 2000 Millennium Summit, Millennium Development
    Goals (MGDs),
  • 2002, Abuja Declaration on HIV/AIDS, TB and other
    infectious diseases,
  • 2002, The ILO Code of Practices in HIV/AIDS, and
  • 2003, The African Charter on Human Rights and
    Peoples Right on the Right of Women in Africa
    (Mozambique)

11
Millennium Development goals (MDGs) and Targets
by 2015 (specific to the study)
  • Goal 3 Promoting Gender Equality and
  • empower women
  • Eliminate gender disparities in education
  • Goal 5 Reduce Maternal Mortality
  • Reduce by 3/4the MMR
  • Goal 6 Combat HIV/AIDS, malaria and other
    diseases
  • Halt and reverse the spread of HIV/AIDS

12
HIV/AIDS Among the Youth
  • In Ethiopia, more than half of young people, aged
    between 15 and 19 years, and two in five women,
    aged between 20 and 24 years, have no knowledge
    of sexually transmitted infections (STIs) (DHS
    2000). STIs are fueling HIV/AIDS.
  • Over 85 percent of HIV/AIDS transmissions in SSA
    are a result of heterosexual and reproductive
    acts mainly casual and unsafe sex and mother to
    child transmission.

13
HIV/AIDS Prevalence Ratio in Select SSA
Countries by GenderYouth 15 24 years (UNFPA
2003)
14
Estimated HIV Prevalence in Ethiopia, 1996 to
2004 (Source BSS Ethiopia, 2002)

15
The HIV/AIDS Policy Instruments Tools
  • HIV/AIDS Policy (1998), HIV/AIDS Prevention and
    Control Offices (HAPCO/NAC 2002) mandate
    serving as the secretariat under the Prime
    Ministers Office (PMO) to coordinate and
    facilitate the implementation of HIV/AIDS
    programs,
  • National HIV/AIDS Council (NAC)/ HAPCO
    (policies)
  • Policy on HIV/AIDS of the Federal Democratic
    Republic of Ethiopia (August 1998),
  • Strategic Framework for National Response to
    HIV/AIDS in Ethiopia (2001/2005),

16
The HIV/AIDS Policy Instruments Tools
  • HAPCO instruments tools for Implementation
  • Guideline for Project Holders (Funding)
  • National ME framework for Multi-Sectoral
    Response to HIV/AIDS in Ethiopia, (2003)
  • Mainstreaming Guideline on HIV/AIDS Interventions
    in Federal Ministries and organizations in
    Ethiopia (DRAFT, 2004)

17
The HIV/AIDS Policy Instruments Tools
  • MoH HIV/AIDS instruments and Tools
  • Policy on Anti Retroviral Drugs Supply and Use
    (July 2002),
  • Guideline for the Use of Anti Retroviral Drugs in
    Ethiopia (Feb 2003),
  • National Guideline on the prevention of Mother To
    Child Transmission (PMTCT) of HIV in Ethiopia
    (November 2001),
  • STI Syndromic Case Management,
  • Adult and pediatric HIV/AIDS case management,
  • VCT Guideline and Training Manual,
  • Manual on Community Home Based Care (CHBC), and
  • National HIV/AIDS Communication Framework and
    Guidelines.

18
Institutional Arrangements for Implementing
HIV/AIDS Policies
  • At Federal level the National HIV/AIDS Council,
    HAPCO to coordinate and facilitate implementation
    of programs, reporting to NAB,
  • At Regional level Regional HAPCO reporting to
    the Regional Council,
  • At Woreda level Woreda HAPCO reporting to the
    Woreda Council, and
  • At Kebele (local) level Kebele HIV/AIDS
    committee, reporting to the Kebele Council.

19
Implementation Gaps and Challenges for HIV/AIDS
  • No clear targeted national action plans and
    programs addressing the identified high risk
    vulnerable groups with welfare safety net
    indicators, particularly for adolescent gender,
  • ARH is not given emphasis,
  • Mostly vertical initiatives, weak linkages of
    HIV/AIDS with A/RH and Gender,
  • Inadequate community participation and input,

20
Implementation Gaps and Challenges for HIV/AIDS
continued.
  • Regions and Woredas not familiar with the
    policies, instruments and tools
  • Inadequate communication and dissemination of
    policies)
  • Delay in developing instruments to implement
    policies
  • Inadequate of capacity to take policy to action,
    (human/skills, facilities, finance, materials,
    etc.)
  • Weak coordination

21
Proposed Recommendations and Actions
  • Strengthen the institutional and human capacity
    of HAPCO at all levels
  • Appoint Gender and Youth focal points, positioned
    at higher decision making levels
  • HAPCO to develop specific mechanism to ensure
    incorporation of youth, gender and ARH issues in
    sectoral annual plans/programs, with specific
    targets and indicators,

22
Gender Issues in Ethiopia
  • Gender based violence and harmful practices are
    high,
  • Gender disparities in education, higher in
    secondary and tertiary levels, and high girls
    drop out of school
  • Early marriage, rape and abduction are prominent,
    with girl-child marriage even at the age below 10
    years
  • Access to resources and services is inadequate
  • Multiple roles and heavy work load for women
  • Ethiopia has the second largest population in
    SSA, the lowest percentage of its population with
    access to safe water (only 25 percent) and uses
    the least amount of electric power per person
    (22.1 Kwh per capita) 2. The underdeveloped
    infrastructure (water, power/electricity and
    others) creates more workload, contributing to
    the poor health of women.

23
Comparative Data on A/RH, Gender and HIV/AIDS
(15 24 years of age), UNFPA 2003
24
Gender and Women Related Policy Instruments and
tools
  • National Women Policy (1993), Womens Affairs
    Sector accountable to/in the Prime Minister
    Office, mandate coordination, facilitation and
    monitoring of womens affairs activities at
    national level, with
  • The Constitution of Ethiopia, FDRE (1995),
  • National Policy on Ethiopian Women (1993),
  • The Family Law of Ethiopia (2003), and
  • Others
  • Program to Promote Girls education/ESDP
  • Womens Affair standing committee in Parliament
  • Revision of Legal and policy instruments to
    address gender issues.

25
Institutional Arrangements for Implementing
Gender Policies
  • At Federal level
  • the Womens Affairs Office (WAO/PMO),
  • The Womens Affairs Departments (WAD) or units of
    sectoral ministries and organizations, and
  • Gender focal points
  • At Regional Level
  • Womens Affairs Offices
  • At Woreda and Kebele levels
  • Womens Affairs Offices /focal points

26
Women in Parliament Gender Equality/Equity
(Feb. 2004, Inter-Parliamentary Union/IPU)
27
Implementation Gaps and Challenges for Gender
  • A/RH and HIV/AIDS not covered in the national
    women policy,
  • Ethiopia has women policy, but not a
    comprehensive gender policy,
  • Gender not properly understood and not
    mainstreamed,
  • No strategic framework and national action plans
    programs to take policy to implementation,
  • Inadequate capacity at all levels,
  • WADs and gender focal persons not given
    visibility,
  • WAO like its counterparts (MoH, MoYSC) does not
    have ministerial portfolio/cabinet seat, and
  • Women representation in decision making and
    parliament low at all levels.

28
Proposed Recommendations and Actions
  • Accelerate the Education Sector Development
    Program (ESDP) for Girl Education,
  • Engender the national frameworks and instruments
    (Sustainable Development and Poverty Reduction
    Strategy (SDPRP), MDGs, national action plans,
  • Introduce gender budgeting system at all levels,
    federal, regional and woredas.

29
Proposed Recommendations and Actions
  • Strengthen institutional and human capacity of
    women and gender institutional frameworks and
    programs,
  • Increase commitment to gender equality and equity
    (political, economic, social, technological),
  • Review the current women policy to incorporate
    gender and youth issues, with focus to ARH,
  • Apply affirmative actions to increase womens
    participation in policy and decision making
    positions, increase access to resources and
    services,

30
Youth in Ethiopia
  • High unemployment, higher for girls,
  • Of the adolescents between 15 and 19 years of
    age, only 26 percent are in school.
  • Migration to urban areas is high, increasing
    vulnerability of youth, particularly women,
  • Commercial sex work is common, with 73 HIV/AIDS
    prevalence (UNAIDS 2002),
  • Youth have been excluded from social and
    programmatic issues,
  • Existence of deep-rooted age and gender based
    discrimination

31
Policy Framework for Young People
  • National Youth Policy (2003), Ministry of Youth,
    Sports and Culture, mandate to lead, monitor and
    coordinate youth affairs A national council that
    includes federal government implementing
    organizations as members and directed by the
    MoYSC shall be established in order to coordinate
    youth oriented activities and make them
    fruitful.,
  • The Constitution of Ethiopia (1995)
  • Draft Youth Policy (2003),
  • Youth Charter (2003), and
  • Culture Policy, Ministry of Information and
    Culture of FDRE (1995).

32
Institutional Arrangements to Implement Youth
policy and Issues
  • At MoYSC
  • Federal level
  • the Ministry of Youth, Sport and Culture,
  • the Womens Affairs Departments (WAD),
  • The Culture Department,
  • At Regional Level
  • Bureau of Youth, Sport and Culture
  • At Woreda and kebele levels
  • Youth Affairs/focal points

33
Institutional Arrangements to Implement Youth
policy and Issues
  • Ministry of Education (MoE) for in-school youth
  • Education Sector Development Program, program for
    Girls Education,
  • Technical and Vocation Education and Training
    (TVET),
  • Ministry of Health coordinating and providing
    health services to all
  • MoLSA Coordinating and facilitating issues of
    out of school and vulnerable youth,
  • Developmental Social Welfare Policy of Ethiopia
    (1996),
  • Programs for HIV/AIDS work place issues
  • Ministry of Finance and Economic Development
    (MoFED)
  • National Office of Population,
  • SDPRP and MDG coordination Unit
  • Ministry of Agriculture (MoA)
  • TVET for Kebele and Rural Communities,
  • Agriculture Extension Package,
  • Guideline for Mainstreaming Gender in
    Agricultural Sector.

34
Implementation Gaps and Challenges to Youth
Related Policy
  • Weak coordination of ARH and youth initiatives,
  • Youth policy in draft form,
  • No strategic framework and national action
    plan/programs,
  • MoYSC relatively new, with inadequate capacity,
  • Inadequate budget line item for youth programs,
  • Youth not effectively included as partners in
    development
  • Minimal attention given to youth services for
    out-of-school, rural and vulnerable adolescent.
    The few youth initiatives are urban and
    semi-urban focused and 85 are in rural, and
  • Youth service packaging not based on client
    needs, and segmentation of youth groups.

35
Proposed Recommendations and Actions
  • Strengthen the institutional and human capacity
    of MoYSC,
  • Develop strategic framework and action plan to
    implement the youth policy in a participatory
    process,
  • Increase coordination with multi-sectoral
    partners and stakeholders,
  • Provide focus to youth with special needs, e.g.
    disability,
  • Adapt a gender and segmented programming to
    respond to client needs.

36
Proposed Recommendations and Actions
  • Strengthen the institutional and human capacity
    of MoYSC and related department,
  • Develop strategic framework and action plan to
    the youth policy in a participatory process,
  • Increase coordination with multi-sectoral
    partners and stakeholders,
  • Provide focus to youth with special needs, e.g.
    disability,
  • Adapt a gender and segmented programming to
    respond to client needs.

37
ARH Issues in Ethiopia
  • Pre-marital and casual sex is high, particularly
    for boys, with 1/3 of girls aged 15 to 19 years
    had sexual activity and 1/5 become sexually
    active (DHS2000),
  • Teenage pregnancies, fertility and abortions are
    high,
  • A household survey of adolescents in Addis Ababa
    in 1998 reported that of the 957 respondents, 50
    percent were pregnant and 74 percent of these
    pregnancies resulted in abortion,
  • Every day 8 girls are abducted for a forced
    marriage (Wuleta 2003),  
  • Maternal mortality is high among teenage women,
    1,193 out of 100,000 (UNFPA 2003)

38
RH Service Coverage for Pregnant Women aged
15-25 years in Ethiopia, (DHS 2000)

39
Country Comparative CPR (Contraceptive
Prevalence Rate) Coverage in , (UNFPA 2003)


40
Adolescent Reproductive Health (ARH) and Health
Policies
  • Adolescent Reproductive Health (ARH) within MOH
    mandate to strengthen inter-sectoral activities
    address the special needs of women, adolescent
    and children within the health system and develop
    appropriate policies.
  • Ministry of Health (MoH)
  • Health Policy/Health Sector Development Program
    (1996/2015)
  • Adolescent Reproductive Health National Plan of
    Action/Family Health Department (2003),
  • Guideline for Mainstreaming Gender in the Health
    Sector (2002), and
  • Health Extension Package.

41
ARH Related Institutional Arrangements
  • Ministry of Health (MoH)
  • Family Health Department (FHD), Adolescent
    Reproductive Health team,
  • Womens Affairs Department (WAD/MoH),
  • Disease Prevention and Control Department
    (DPCD/MoH), HIV/AIDS team, and
  • Health Education Center,
  • Intersectoral task forces for ARH.

42
Implementation Gaps and Challenges
  • A/RH and gender not adequately addressed in the
    health system,
  • Weak inter-department/program linkages and
    coordination,
  • The FHD, with component of A/RH issues recognized
    as department at federal level and not prominent
    at regional and lower levels,
  • Lack of youth friendly services programs with
    gender perspective in the public sector,
  • Health sector has not developed comprehensive
    HIV/AIDS national strategy, and

43
General gaps and Challenges to Mainstreaming ARH,
Gender and HIV/AIDS
  • Many policies, but many implementation
    impediments and gaps,
  • Vertical initiatives, linkages between gender,
    A/RH (health outcomes), HIV/AIDS and poverty not
    given emphasis,
  • Inadequate ME and disaggregated data collection
    at all levels

44
General gaps and challenges continued
  • Governance Issues inadequate commitment to
    gender, youth and A/RH issues (political, social,
    resources, economic, accountability),
  • Existing social capital (community structures not
    tapped,
  • Disparities between Legal framework Vs Customary
    practices,

45
Proposed Recommendations/Actions and Way Forward
  • Wider dissemination of policies and advocacy for
    their effective implementation,
  • Strengthening the legal and judiciary frameworks,
  • Revise Women Policy for a broader gender
    perspective
  • Develop an Adolescent Reproductive Health (ARH)
    policy with a strong gender perspective,
  • Facilitate and strengthen the implementation of
    the existing Adolescent Reproductive Health (ARH)
    national action plan of MoH,
  • Conduct institutional assessments to develop
    capacity building plans of (ARH, gender and
    HIV/AIDS)

46
Proposed Recommendations.
  • Improve partners coordination and harmonization,
  • Scale up male involvement,
  • Undertake mapping exercise of who is doing what
    in mainstreaming, gender and ARH issues
  • Strengthen and scale up successful multi-sectoral
    initiatives, and
  • Strengthen public-private partnerships.

47
Promising Approaches and Tools
  • Multi-sectoral Task Forces
  • The National Reproductive Health Task Force of
    the Ministry of Health under the Family Health
    Department, with members from key government
    sectors, NGOs, professional associations,
    development partners and community initiatives.
    It is chaired by the Consortium of Reproductive
    Health Associations (CoRHA) and the has four
    specialized task team
  • The Youth National Council at the Ministry of
    Youth, Sport and Culture composed of
    representatives from key government sectors, NGOs
    and civil society, youth groups, and others
    working on youth issues

48
Promising Approaches and Tools
  • Multi-sectoral Task Forces
  • The National Advisory Board of HIV/AIDS
    Prevention and Control Office (NAB/HAPCO) that
    has sub-committees on key issues such as health
    and education working on youth issues,
  • The joint parliamentary social and women standing
    committee that overlooks common issues such as
    population, reproductive health, youth, gender
    violence and related issues

49
Promising Approaches and Tools
  • HIV/AIDS Interventions
  • Several PLWHA groups working as registered NGOs
    or groups, among them
  • TILLA PLWHA Womens group based in Awassa, SNNP
    Region, support women including young girls/women
    with HIV/AIDS It supports/cares for women PLWHA,
    provides IEC on gender and HIV/AIDS and mobilizes
    women to get involved on HIV/AIDS initiatives.
  • Don of Hope (Biruh Tesfa), a national PLWHA NGO
    which is the pioneer working on HIV/AIDS
    interventions prevention, support and care.

50
Promising Approaches and Tools
  • Integrated ARH and HIV/AIDS Projects
  • Integrated Services for HIV/AIDS Prevention and
    Support Organization (ISAPSO), working with
    vulnerable and high risk groups and with youth
    focused projects have projects with truck
    drivers, commercial sex workers, higher learning
    institutions and works with communities and with
    government partners MoH, schools, kebele
    councils, etc.
  • Mary Joyce, an NGO working with community and do
    have comprehensive interventions to HIV/AIDS
    preventions, treatment and care and support.
    Women and youth groups work as volunteers in
    home-based care.
  • Pathfinders International supporting several
    A/RH initiatives and programs in the country and
    works with multi-sectoral partners government,
    NGOs, community initiatives, private sector and
    learning/research institutions

51
Promising Approaches and Tools
  • Youth Focused Initiatives
  • Family Guidance Association of Ethiopia (FGAE),
    pioneer NGO working on RH issues since 1972 and
    with youth friendly services since early 1990s ,
    particularly for adolescent. It covers eight
    Regions of the country, working closely with
    government sectors, communities, and youth
    groups. It had now a gender focal person to
    mainstream gender to its on-going projects. It
    is member of several national task forces to
    advocate for A/RH and youth friendly services.
  • DSW (German Foundation for Population), working
    closely with youth groups and clubs, building
    their capacity and helping them mobilize and
    organize their clubs/groups. It is on the
    process of establishing a youth training center.

52
Promising Approaches and Tools
  • Youth Focused Initiatives
  • The World Bank Summer Camp A school based youth
    group supported by the World Bank Ethiopia
    Office. Currently, it is involved in information
    dissemination, experience sharing forum and
    providing ITC/computer access to youth. There is
    a plan to increase their involvement in HIV/AIDS
    and related initiatives and programs.
  • Addis Ababa Youth Association (AAYA) with over
    73,000 membership, covers all the kebeles in the
    Addis Ababa City Administration. 53 of members
    are female. It works on A/RH issues and is keen
    to expand gender in its operations.
  • Ethiopia Youth Network (EYN) with several youth
    club members all over the country trying to
    develop database of youth clubs/groups. It is
    supported by FHI.
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