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Adolescent Friendly Health Services, Uganda

Project Name and Location:

Basic Education, Child Care and Adolescent Development (BECCAD), with a particular focus on Adolescent Friendly Health Services (AFHS) in 5 districts of Uganda: Nebbi; Rukungiri; Kabale; Mbale; and Kiboga.

Background/Rationale for Project:

The 1991 Population census showed that one-quarter of Uganda's total population is between the ages of 10 and 19 years. The effect of the AIDS epidemic in Uganda has been severe. As of 1998, UNAIDS estimates that 930,000 Ugandans are living with HIV infection or AIDS. In adults, the infection rate is estimated to be 9.5%.

It is estimated that 1.8 million Ugandans have already died of AIDS and there may be as many as 1.7 million children who have lost their mothers or both parents to AIDS. USAID estimates considerable increases over time and that 2.7 million children will be orphans by the year 2000. It is notable that at least one child out of four families in Uganda is taken care of by adults who are not the child's biological parents (DHS 95). It is estimated that 7.3% of reported AIDS cases are children less than 12 years (ACP Surveillance report March 1999).

It is also reported that AIDS is responsible for 12% of annual deaths in Uganda and has surpassed malaria and other diseases as the leading cause of deaths among individuals 15-49 years of age. Approximately 26% or 43,000 babies are infected through mother to child transmission of HIV every year and two thirds of those do not live to see their second birthdays.

However, there is reason for hope. Recent data indicate a significant declining trend in HIV seroprevalence (the proportion of the population infected) and incidence (the number of new infections during a certain time period expressed as a proportion of the population at risk). In sentinel site surveillance through antenatal clinics (ANCs), all urban sites showed evidence of significant decline during the first half of the 1990s- as much as 10 to 15 % in some sites. There appears to be a great deal of regional variability in the spread of HIV infections in Uganda. While two major urban areas remained at a median of 14.7 % at the end of 1997, areas outside of urban centres varied from 1.6 % to 14.5 %, with a median of 8.75%. There is evidence that the decline in prevalence is not because of a 'saturation effect', the stage in an epidemic where most of those who might be infected are infected. There are districts in Uganda where HIV prevalence among the sexually active population has remained relatively low and the prevalence in this population has decreased further over time.

It was also reported that Uganda has the third largest teenage pregnancy rate in Africa. The Uganda Demographic and Health Survey (UDHS) 1995 indicates that by 17 years of age, 43.3% of adolescent girls have begun child bearing and by 19 years over 70.8% of adolescent girls have given birth or are pregnant with their first child. Reports from Mulago Hospital show that 20-30% of maternal deaths were due to complications resulting from teenage abortions.

Street children are also a growing phenomenon in Uganda. Currently 10,000 children are estimated to live and work on the streets during the day in urban areas. Child labour is also emerging as a major problem. About 23% of children between 10 and 14 years old are presently working. In Uganda, services for vulnerable children are mainly provided by extended families, communities, CBOs and NGOs. However, the capacities of extended families to cope with the demand are generally acknowledged to have peaked, while district and local councils are yet to fully respond to the need for increased services.

Project Description

Timeframe: 1998-2000

Implementer(s): Reproductive Health Division in the Ministry of Health (MOH) and District Health Management Teams in collaboration with other district staff.

Lead Partner: Reproductive Health Division, MOH

Partner(s)/alliances: Ministry of Gender, Labour and Social Development, WHO, UNFPA, NGOs and private associations

Funding Source(s) and Overall Budget: General resources and supplementary funding from SIDA/Austria. 1999 budget 200,000 USD.

Objectives: Promote the full cognitive and psycho-social development of children and adolescents within a supportive family and community environment which is conducive to education for all, prevention of HIV/AIDS/STIs, adequate care and protection of children and adolescents from birth to adulthood. Programme interventions include:

Support to complementary forms of primary education for children 8-14 years of age from vulnerable groups
Advocacy and social mobilisation for girls' education
Technical support for the review and reform of legislation and its enforcement, as a means of ensuring the legal protection of children
Special protection measures for categories of children and adolescents in need (primarily through support to NGOs)
Sensitisation of local communities, families and local governments on child care, protection and adolescent health and development (ADH) issues
Use of mass media as well as traditional media for reaching out to adolescents with information
Promoting life skills education for in and out of school adolescents
Promoting the provision of adolescent friendly services (AFS) in collaboration with NGOs and local governments

Beneficiaries/participants: Young people between 10 and 24. No figures available on number and gender reached

Description of Activities:

Adolescent Friendly Health Services:

Develop sensitisation package for adolescent friendly services
Conduct sensitisation on adolescent friendly services in project districts � Develop pilot sites for adolescent friendly services
Develop communication manual for health workers
Orientation and training of health workers
Develop capacity of district staff to develop result-oriented plans for AFHS.
Brief field visit to Mubende and Rukungiri to obtain a "snapshot" picture of existing programmes for ADH, what is being measured and existing gaps. MOH, UNICEF and a consultant presented the findings at a meeting in Geneva. Eight countries participated in the programme and attended the five day peer exchange.
Nine indicators for Adolescent Sexual and Reproductive Health/Life skills developed and pre-tested in Kampala with young people and NGO/government partners.
Developed life skills materials for in and out-of school and trained national teacher trainers.
Support to the development of a national adolescent health and youth policy. Other initiatives for young people in crisis:
Psychosocial support initiatives for young people in two districts in conflict i.e. Kitgum and Kasese have been given priority attention. Supported initiatives include training of counsellors, training in psychosocial support for teachers and Community Development Assistants, recreational activities for young people, STD diagnosis and treatment, and HIV/AIDS prevention strategies.

How have adolescent boys and girls been involved in the project? In what stages have they been involved - situation assessment, situation analysis, planning, implementation, monitoring, and/or evaluation?

Adolescent boys and girls were involved as researchers and as informants/participants in focus group discussions (FGDs), mapping exercises and interviews in a needs assessment for AFHS in 5 districts. One 24-year-old young person was part of the national team analysing the data, writing the reports and presenting the findings to stakeholders at national level.
Adolescents participated in a planning meeting for AFHS.
For AFHS the pilot districts have planned for training peer educators and involving adolescents in monitoring the activities.
Adolescents were involved in developing adolescent sexual and reproductive health/life skills indicators during an FGD. What influence has their involvement had on the project? The recommendations for implementing AFHS in the needs assessment reports were primarily based on suggestions from adolescents, although the opinion of other key stakeholders (teachers, parents, community leaders) were also included. How have the adolescent girls and boys involved in the project been affected personally? Information not available. What have been the achievements of this project to date?
Draft sensitisation package for adolescent friendly services in place. The package includes definitions of key concepts, an overview of adolescent health and services, institutional framework, roles and responsibilities and monitoring and evaluation.
Commitment obtained from key district staff to pilot AFS in the five pilot districts of Nebbi, Rukungiri, Kabale, Mbale and Kiboga during initial consultation.
Sensitisation on adolescent friendly health services has taken place in all the selected pilot districts. The district participants also went through a planning exercise for draft Adolescent Health and Development (ADH) manual for health workers on communication and counselling skills developed and currently being pre-tested.
Fourty-eight health workers in four districts trained in communication and counselling skills for Adolescent Health and Development.
Increased coverage and quality of AFHS in two districts observed.
District capacity to plan, implement and monitor AFHS strengthened. For example, four districts have developed logical frameworks for the programme, and all districts have developed workplans for funding the implementation of AFHS. In one district AFHS has been integrated into the next 3-year District Development Plan with funds committed from all pilot sub-counties.
Needs Assessment for AFHS completed in five districts with data on the coverage and quality of services in the district. The study involved district staff thus building the capacity to conduct research and analyse data.
Draft adolescent health and youth policy developed.
Steering committee established to oversee the 2-year programme to strengthen integrated programming for adolescent health and development. The members are from UNICEF, UNFPA, WHO, Population Secretariat and Ministry of Gender. The programme supported by WHO and UNFPA is piloted in two districts of Mubende and Rukungiri. The objective is to develop systems for co-ordinating implementation and monitoring of programmes for ADH.
Draft national position paper on child labour in Uganda discussed at a one-day national workshop conducted in January 1998. The finalised position paper was tabled at the OAU/ILO/UNICEF African conference on child labour held in February 1998. Inter-ministerial national steering committee in place and charged with responsibility for developing national programme of action and overseeing its implementation. US Government has announced support to ILO to initiate IPEC in Uganda.
A national study on sexual exploitation and abuse completed, conducted by ULRC. A draft report is available. The report makes a series of legal and "non-legal", programmatic recommendations. The former will serve as a basis for revision of existing laws.
An assessment of existing psycho-social support programmes for children and families affected by conflict in Northern Uganda has been completed. A draft report is available. The assessment recommends future psychosocial interventions to meet the gaps as well as to enhance present psychosocial services. A workshop on psycho-social programmes in Northern Uganda was organised in July 1998 and various stakeholders presented work they were currently involved in

Has a formal evaluation been performed? Please elaborate. Not as yet

What were the main constraints in meeting the project objectives?

The local governments elections that took place during 1999 slowed down the pace of implementation of planned activities
The ongoing restructuring of national ministries and massive downsizing of civil service at national level is contributing to the loss of some our key counterparts who were playing a critical role in the implementation of activities
The success of AFHS is highly dependent on the existing functionality of the district health systems. Thus in districts where the system is weak (e.g. few trained staff servicing health units, few monitoring visits to health units) the AFHS did not take root.
Despite training and follow-up of health workers, negative/authoritarian attitudes and lack of dialogue with adolescents continue.

Lessons Learned/Recommendations/What would you do differently if you could do it over?

Develop a detailed strategy for implementing AFHS at an early stage in the programme.
Develop materials (IEC and monitoring tools) at an earlier stage in the programme.

What programme support tools/resources were developed that can be used/adapted by other country offices?

A booklet on "Talking with our children about sex and growing up"
Straight Talk and Young Talk newspapers
AFHS needs assessment report

Youth Perspective: Not available

Source of information:

Tim Rwambuhemba UNICEF-Kampala