Adolescent health as a priority for RMNCAH

In 2014, the World Health Organization reported that gains made in maternal and child health were at risk of being lost if investments in adolescent health were not increased. The United Nations Global Strategy for Women’s, Children’s and Adolescents Health 2016 to 2030 (The Global Strategy), building on the 2010 Strategy of Women’s and Children’s Health, includes focus on adolescent health in recognition of the pivotal role of this area in achieving the 2030 global development agenda. Countries have correspondingly elevated adolescent health within their policies, strategies and programming.

Adolescent health in sub-Saharan Africa is of particular public health importance. In 2015, an estimated 1.2 million adolescents died in the WHO Africa region, mostly from preventable causes. Some of the most pressing health issues in this age group include:

• early pregnancies (average 19% in sub-Saharan Africa in 2016) which are the leading cause of death in girls aged 15 to 19 years
• HIV infection (2 million adolescents infected with most in the WHO Africa region)
• violence
• mental health, particularly depression which is a leading cause of illness, disability and suicide in this age group

The scorecard as a mechanism to track adolescent health

Since 2013, ALMA has supported 29 African countries to develop and implement country-led RMNCAH scorecard management tools. The scorecards support national ministries of health to strengthen action and accountability for RMNCAH. They track high-priority indicators using real-time data and thus provide a mechanism for continuous monitoring of programme performance. Scorecard reviews are integrated into country mechanisms, such as quarterly performance review meetings, leading to timely identification of performance shortfalls, and triggering corrective action.

Indicators selected for tracking through the scorecard tool meet three basic criteria:

1. they are a priority – essential to meeting national RMNCAH programme goals
2. they are routinely measured using country systems, predominantly the HMIS/DHIS
3. they are actionable.

When high priority actionable indicators are identified but lack a data-source or when indicators are identified as future priorities they are categorised as “future wave indicators,” and put on hold until all criteria are met. Country’s periodically review and update their scorecard indicators (approximately every 18 months) in order to continuously reflect programme priorities. Updating of indicators includes:

• dropping indicators when high performance has been achieved and sustained, which leads to their de-prioritisation for continuous scorecard tracking,
• adding new or emerging priorities, and
• activating future-wave indicators, usually when data sources become available

Over time, adolescent health-specific indicators have been increasingly prioritised for tracking through the scorecard. Among the 18 countries implementing scorecards in 2014, seven (Botswana, Ghana, Madagascar, Rwanda, Senegal, Uganda and Zimbabwe) included at least one adolescent health indicator in their scorecards. Malawi, Sierra Leone and Zambia prioritised adolescent health indicators but did not have data available for their routine monitoring. In the period 2018 to 2020, 13 of 21 (62%) countries (Botswana, Ghana, Madagascar, Rwanda, Senegal, Uganda, Zimbabwe, Burundi, Malawi, Swaziland, Tanzania, The Gambia and Zambia) included at least one adolescent health indicator. It is notable that in 2014, all countries tracking had only one adolescent health indicator, compared to subsequent years where the number of adolescent health indicators per country-scorecard range from one to four. Four countries with current adolescent health indicators also have future wave indicators, which currently lack routinely available and accessible data sources.

Six countries have not tracked any adolescent health indicators over the period of scorecard implementation, however two of these (Cote d’Ivoire and Nigeria) have prioritised indicators categorised as future wave due to lack of routinely available data.

The adolescent health indicators most tracked relate to prevalence of adolescent pregnancies, availability to adolescent-friendly services and access to family planning. Additionally, HIV testing, antiretroviral therapy (ART) initiation among adolescents with HIV (Zambia), access to services for victims of domestic violence (Malawi) and coverage of HPV vaccination among adolescent girls (Uganda) are also tracked.

Future wave indicators include among others:

• percentage of youth accessing services
• adolescents receiving family planning
• maternal deaths among adolescents
• adolescents receiving counselling for mental health

Analysis of the RMNCAH scorecard in Rwanda revealed that the western province performance and particularly Rusizi district was lagging behind for Family Planning (FP) indicators. This was presented in a quarterly meeting that gathers the senior health sector decision makers including the Director General of district, provincial and referral hospitals, and chaired by the Honourable Minister of Health, who decide to implement actions in Rusizi district, including door to door family planning by community health workers aimed at sensitising parents and adolescent girls and boys to modern contraceptive methods. This led to a significant uptake of family planning coverage in the district.

In Uganda, a drop in human papillomavirus (HPV) vaccination coverage in one district led to the district’s health team conducting an in-depth review of the gaps of the vaccination programme, followed by efforts to increase vaccinations drives through schools and health facilities. This led to a 10% increase in performance within two quarters.

In Kenya’s Siaya County, the scorecard review showed persistently low antenatal care (ANC) rates correlated with high rate of teenage pregnancy. This led the County to prioritising services for pregnant teens by establishing a Teenage Pregnancy Task Force chaired by the County Commissioner and setting up of a Teen Moms Club. Since July 2017, free pregnancy testing is also done at the community level in Siaya County to improve accessibility and affordability of client- and youth-friendly services with ANC4 rates improving by 35% between 2016 and 2018, from 43% to 58% respectively.

Conclusion

The increasing prominence of adolescent health indicators tracked by the scorecard across multiple countries, corresponds to the expansion of country maternal and child health programmes to integrate and prioritise this health area. Additionally, the trend towards an increasing number of indicators tracked per country, illustrates growing availability of routine data on adolescents. While this progress in data availability is laudable, countries still lack the breadth of information required to comprehensively monitor progress towards desired adolescent health outcomes. The Global Strategy estimates demographic dividends of US$ 500 billion a year in sub-Saharan Africa, if countries make adequate investment in early childhood and adolescent health and development. To measure both the level and impact of investment, it is essential that countries with support from partners continue to prioritise investments in data to enable accountability.

There is both anecdotal and objective evidence of the adverse impact of the COVID-19 pandemic on adolescent health in numerous countries. Increases early pregnancies, domestic violence and sexual abuse are some of the noted adverse effects, which are compounded by reduced access to services. The full impact of the pandemic is still unfolding and likely to have far-reaching and long-term consequences. The scorecard tool provides an effective mechanism to support stakeholders from communities to the highest levels of government to maintain focus on adolescent health and collectively monitor and respond to successes and challenges. The COVID-19 pandemic and its potential impacts heightens the need for robust accountability and action for adolescent health.

Additional resources and information

Partnership for Maternal, Newborn and Child Health