The Sexual Reproductive Health and Rights Status of Young People in Uganda: The Rationale for Continued Youth Focused Investment

Dlamini BR^1*, Tagoola FM², Mutalya KC², Odaga J³, Christiansen M², Najjemba M², Mukasa P¹, Nalikka I² and Ogolla R^1
*Correspondence: Dlamini BR, Sexual Reproductive Health and HIV Unit, United Nations Population Fund-Swaziland Country Office, Mbabane, Swaziland, Tel: +268 2 409 6600/6620, Email:

Keywords

Sexual reproductive health and rights (SRHR); Adolescents; Youth; Young people

Introduction

There has never been an opportunity and rationale for a global youth focused development than this time, considering that the world has a massive youth population (over 1.8 billion) of young people between the ages of 10 and 24 years. The developing countries are home to more than 90% of this young population. The 10-24-year olds are over 344 million in Africa out of a total population of 1.2 billion [1]. Moreover, sub-Saharan Africa is the only region in the world in which the number of young people continues to grow substantially [2]. More than 436 million of young people is projected to be living in sub- Saharan Africa in 2025 and 605 million by 2050 [1,2]. In light of the Sustainable Development Goals (SDGs), young people, especially the 10-24-year old are the core population. They will be the determining population group of whether the SDGs agenda is achieved or not.

For example, attainment of the targets for the UN Global Strategy for Women’s, Children’s and Adolescents’ Health 2016-2030 is dependent on how far access to SRHR services is made to these young people. Positive policies have been developed from the highest level such as the recently launched UN Youth Strategy (2016-2030) which strives to create a world in which the human rights of every young person are realized; that ensures every young person is empowered to achieve their full potential; and that recognizes young people’s agency, resilience and their positive contributions as agents of change. However, the translation of the policies into practical programs for young people will determine achievements of targets.

The Republic of Uganda is home to more than 12 million young people aged 10-14 years [3]. Provided with the essential skills and chances needed to reach their potential, these young people can be a driving force for supporting development and contributing to peace and security. Therefore, Youth Serving Organizations and Youth-led organizations need to be fully resourced, not only in terms of policies, guidelines and standard operating procedures.

They need adequate resources (including funding to ensure that young people are empowered to participate in translating the 2030 Agenda into local (meaning at their communities’ level), national and district policy. With a positive and supportive policy environment, young people have the potential to make the most effective transformation of the world into a better place for all. All they need is an opportunity to reveal their potential.

For young people, their sexual and reproductive health and rights (SRHR) are a crucial part of their lives. An improvement in the status of young people’s SRHR could mean a country is on its way towards harnessing the so-called demographic dividend. A lucrative opportunity for most developing countries, especially in Africa. For the past 25 years, countries including Uganda, committed in delivering SRHR for all people, especially for women and girls. The aim of this retrospective analysis is to provide a comprehensive and cross-sectoral picture of the SRHR Status of Young People in Uganda.

Research Methodology

The SRHR status of Young People in the Republic of Uganda was prepared in stages. Desk review and analysis involved collecting, analyzing, and synthesizing background documents. Specific attention was focused on key policies affecting the various thematic areas and the programmatic interventions in place to support SRHR among young people. Consultations/interview meetings with key stakeholders were undertaken in order to fully understand key policy framework issues and policy and programmatic gaps. A standard interview guide was used during the interviews.

Data analysis and compilation of the report was accomplished by triangulating the information collected during the desk review, FGDs, and stakeholder consultations.

In addition, demographic and statistical analyses were conducted, mainly using secondary data sources such as the National Population and Housing Census 2014, the Demographic and Health Survey (DHS) of 2016, and various sector-specific regular surveillance and evaluation publications.

Results

SRHR policy environment for young people in Uganda

Some of the global commitments have been translated into the country’s policies and strategic plans to give effect to their realization. The government of Uganda is a co-signer of the Eastern and Southern Africa (ESA) Ministerial Commitments on sexuality education, since 2013. The government of Uganda represented by the Ministers of Health and Education endorsed the ESA Commitment to scale up access to quality Sexuality Education (SE) as well as Sexual and Reproductive Health Services for young people.

A number of national frameworks and guidelines have been developed to meet the targets. This includes the National Sexuality Education Framework. Other important frameworks committing the country to prioritize adolescent health are the African Union Continental Policy Framework on Sexual and Reproductive Health and Rights (SRHR) and the Maputo Plan of Action, which provides for delivery of quality and affordable health services to promote maternal, newborn and child health.

Considering that Uganda is a young population with over 75% of the 40 million people aged less than 35 years, young people are more vulnerable to most SRHR challenges. The Addis Ababa Declaration 2013: emphasis on demographic dividend, ending child marriage and adopting inclusive development policies and strategies is very relevant to the country.

As such the country has produced the State of the Uganda Population Report, a report that highlights the key demographic investment areas to harness the demographic dividend, of which health is one of them. A coordinated investment in adolescent and youth sexual and reproductive health and rights (AYSRHR) is required if the country is to achieve its vision 2040 goal, of attaining a middle-income country status.

The Republic of Uganda provides a legal framework which promotes and protects the rights of adolescents and young people in the development process. Uganda is a signatory to both domestic laws and international legal documents that address adolescent health and development. The supreme law is the Constitution of Republic of Uganda, 1995 (as amended 2018).

The Penal Code Act, 1950 (as amended 2007) outlines various offences/crimes and sentences; The HIV and AIDS Prevention and Control Act, 2014; The Tobacco Control Act, 2015; The Prohibition of Female Genital Mutilation Act, 2010; The Domestic Violence Act, 2010; The Education (Pre-Primary, Primary and Post-Primary) Act, 2008 which gives full effect to Universal Primary and Post Primary Education Policy of Government; The Children Act, 2003 (as amended 2016), and The Employment Act, 2006.

Uganda is no different from most African countries n having several policies and legislations that support AYSRHR. The policies include:

• Second National Health Policy 2010, which provides overall direction for the health sector for universal access to a minimum health care package as well as equitable and sustainable financing mechanisms.

• National Adolescent Health Policy for Uganda, 2004. The process of a new policy or policy review should be guided by the new cabinet policy approval process.

• National Policy Guidelines and Service Standards for Sexual and Reproductive Health and Rights (3rd Edition, 2012) and Standards and Guidelines for Reducing Maternal Morbidity and Mortality from Unsafe Abortion in Uganda (April 2015).

• National Strategy on Youth Friendly Health Services.

Interrelated sectoral policies include: National Population Policy which is currently under review; National Sexuality Education Framework of 2018 by Ministry of Education and Sports; Guidelines on Policy, Planning, Roles and Responsibilities of Stakeholders in the Implementation of Universal Primary Education (UPE) for Districts and Urban Councils of 2008; National Physical Education and Sports Policy; Uganda National Youth Policy 2016; Uganda Gender Policy 2007 and The Orphans and Vulnerable Children Policy 2004 (Table 1).

In addition, several strategic plans have been developed by the Ministry of Health and its interrelated sectors targeting the health of young people. These integrate or specifically target health and welfare needs of adolescents and young people. The existing strategic plans include:

The impact of these comprehensive legal frameworks, policies, guidelines and strategies has not been documented across sectors. The SRHR status of young people in Uganda might provide a glimpse.

The status of adolescent and youth sexual reproductive health and rights in Uganda

Fertility rate: Investment towards AYSRHR has gained momentum both at global and at the country level, since the wellbeing of young people has the potential to ensure the achievements of the 169 targets of the SDGs by 2030. Research is envisaging that ASRHR investment it can result in a 10-fold economic benefit. The scientific rationale is the fact that young people constitutes a larger proportion of the population and face unprecedented social, economic, and health challenges. Uganda has a very high total adolescent birth rate, by 2016; it was at 132 per 1000 live births. Early childbirth increases the risk of pregnancy complications, low birth weight (LBW), and maternal and infant mortality. Figure 1 presents the fertility rate in Uganda, with a marked focus on the young people. A significant proportion of adolescent females between ages 15-19 are already mothers or carrying their first pregnancy [3].

Teenage pregnancy: Uganda has made significant progress in reducing teenage pregnancy. Early motherhood has childbearing and motherhood has progressively declined from 43% in 1995, 31% in 2001, 25% in 2006 and 24.5% in 2011. However, Uganda still has one of the highest rates in Sub-Sahara Africa. The current teenage pregnancy rate in Uganda is at 25%, despite the policies and strategies put in place by government and other stakeholders.

The Health Sector Development Plan targets to reduce teenage pregnancy to 14 percent by 2020. The lifetime opportunity cost of adolescent pregnancy in Uganda amounts to an estimated 30% of the country’s annual GDP [4].

This percent could increase in the poorest households. The disparity between educated and uneducated girls is more pronounced with teenage pregnancy being higher among uneducated girls at 35 percent compared to 17 percent of girls with secondary education (Figure 2). Early sexual debut, high adolescent fertility rate, unmet need for family planning, and on-going problems with sexual and gender-based violence (GBV) are some of the key issues faced by young people in terms of reproductive health.

There are many indicators that highlight a need for national sexuality education and evidence-based interventions. A one size fit al program might not achieve the desired impact, considering the complexities and the different contexts of the young people. Most young people are rural based, some urban and some from special areas, not to forget the youth from refugee settlements. Policy makers, programmers and technocrats should think outside the box when programming for these young people. The deadline for the agenda is just 11 years ahead.

Rural and less educated Ugandans continue to bear the burden of early motherhood. More than 40% of rural teenagers compared to 33% of urban teenagers in Uganda had begun childbearing.

A very unfortunate statistic as a majority of young people in Uganda resides in the rural part of the country. This evidence emphasizes that a one size fit all programming might not yield the expected results. Figure 3 shows the teenage pregnancy by residence.

Family planning: The Republic has made significant progress in improving access to modern family planning (FP) methods. The contraceptive prevalence rate has increased from xxxx to xxxx in 2016 However; it is not the same for young Ugandans. Young people have the highest unmet need for family planning (more than 29%) compared to general population. Figure 4 presents the FP demand and unmet need among young people in Uganda.

Education plays a crucial role in addressing the access to FP services and well-being of young people and can serve as a buffer against teenage pregnancy and sexually transmitted infections. Young people with no education have limited demand for FP (57%) as compared to 71% for those with post-secondary education. The latter have low unmet need for FP as compared to those with no and or primary education. Figure 5 shows FP demand and unmet need by education status for young people in Uganda.

Child marriage: Child marriage is the most significant driver of teenage pregnancy in rural communities in Uganda and girls who marry before 18 years tend to have little or no say on decisions about their sexual and reproduction health. Teenage pregnancy increases the risk of unsafe abortions and is estimated to account for 28% maternal deaths annually in Uganda [3]. This has led to lifetime opportunity cost resulting from adolescent pregnancy to an estimated 30% of the country’s annual GDP.

Antenatal care: The Republic of Uganda seems to be having the highest antenatal care attendance by young people in the Eastern Southern Africa region. Considering that more than 97% of young people less than 20 years receives antenatal care from a skilled provider (SP) and more than 78% are delivered by skilled birth attendants. Compared to most African this is a unique data, requiring further inquiry to document best practices that can be replicated in other parts of the continent. Figure 6 presents the antenatal care attendance by young people in Uganda.

Youth, HIV/AIDS, and other STIs: HIV/AIDS - remains a key issue in the current response with prevalence of HIV among adolescent girls four times that of male adolescents. UDHS 2016 notes that even when most adolescents in Uganda know of a place where they can be tested for HIV, only 45% of girls and 25% of boys have had an HIV test.

The recent results of the 2016 UPHIA survey puts prevalence of HIV among children aged 0-14 at 0.5% (approximately 95,000 children living with HIV). Those aged 15-19 years was 1.1%, 3.3% among those aged 20-24 years and 6.3% among those aged 25-29 years. This means that new infections remain an urgent public health issue among young people [5].

Discussion

The world has never had a young population like it has today. The total world population is estimated to be above 7.2 billion and over 3 billion are younger than 25 years. As such, the young people account for 42% of the world population making it the determining population group for all health and development programming, including the ambitious 169 targets of the SDGs. However, much focused and deliberate investment is to be urgently implemented for young people if the SDGs are to be achieved, considering that more than 11% of all births worldwide still happen among girls aged 15–19 years [6].

The Republic of Uganda has an asset to drive the demographic dividend agenda. This asset is the untapped resource of its young people. With continued youth-focused and deliberate investments, Uganda can harness the population bonus. Developing and implementing youth inclusive programs for the more than 12 million Ugandans at scale could ensure that the country attains middle income country status by 2040 as envisioned [7]. Uganda has a very supportive policy environment for protection and good health of young people across sectors including the President’s Office, with increased focus on adolescent development and wellbeing.

Uganda has signed and ratified several international legal instruments that promote and protect Human Rights of adolescents. However, several legislations are not implemented to the latter, while; most policies have not yet been updated to match the emerging adolescent and youth health issues. Some policy review processes specific to adolescent and youth sexual reproductive health and rights have either been stalled and or recalled due to contentions saying it contradicts the legal framework.

Teenage pregnancy has progressively declined in Uganda, from 43% in 1995, 31% in 2001, 25% in 2006 and 24.5% in 2011 [3]. It remains a huge challenge of the government of Uganda to reduce to 14% as targeted in the Health Sector Development Plan of 2016-2020 2020. The disparity between educated and uneducated girls is more reflected with teenage pregnancy. It is higher among uneducated and rural girls at 35% compared to 17% of girls with secondary education [3]. This means a one size fit all program might not address some contextual issues across the communities in Uganda. Policy makers, programmers, experts need to innovate for comprehensive and inclusive policies and programs that will impact the lives of young Ugandans. Teenage pregnancy or early motherhood remains a major health and social concern because of its association with higher morbidity and mortality to both the mother and child.

Conclusions and Recommendations

Significant progress has been made in reducing HIV/AIDS mortality rates, however, adolescents, especially girls, are the only population group for which AIDS related deaths are not falling worldwide. In Uganda, HIV/AIDS remains a public health concern, especially for adolescents (15-19) years with an HIV prevalence of 2.4%, whilst the HIV prevalence is almost doubled (3%) as compared to that of boys of the same age group (1.7%). A total of 87,236 adolescents (10-19) years are living with HIV and more than 11,026 new infections occur among adolescents.

Key recommendations for Sexual and Reproductive Health and Rights (SRHR) are below.

• Establish an Inter-ministerial accountability task team, in partnership with donors and civil societies including youth networks, to monitor and account for the implementation of AYSRH related policies and guidelines. This task team should provide timely updates on the successes, opportunities, challenges and lessons learnt in the implementation of the policies and strategies.

• Meaningfully and deliberately engage young people in policy and programming development not as beneficiaries but as equal stakeholders.

• Implement community-informed and owned programs, including structured and men and boys’ friendly health services and parents to child communication initiatives, using evidence proven theories like the Ecological Model.

• Scale up innovative information communication technology initiatives to reach young people at the comfort of the place.

• Interventions targeted at gatekeepers such as religious and cultural leaders to ensure buy-in, community ownership and leadership in enforcing the laws and policies

References

1. Das Gupta M, Engelman R, Levy J, Gretchen L, Merrick T, et al. (2014) The power of the 1.8 billion, adolescents, youth and the transformation of the future, State of World Population. UNFPA Report MHIN: A Global Community of Mental Health Innovators.
2. United Nations Population Division (2013) World Population Prospects: The 2012 Revision United Nations, Department of Economic and Social Affairs, Population Division, New York.
3. Statistics UB (2016) The national population and housing census 2014-main report. Kampala: Uganda Bureau of Statistics.
4. Chaaban J, Cunningham W (2011) Measuring the economic gain of investing in girls: the girl effect dividend. The World Bank, Washington D.C. USA.
5. Uganda AIDS Commission (2017) The Uganda Population-Based HIV Impact Assessment. The Uganda Population-Based HIV Impact Assessment (UPHIA).
6. World Health Organization (2018) Monitoring health for the SDGs: Sustainable development goals. World Health Organization, Switzerland, Geneva.
7. Minister of State for Finance, Planning and Economic Development (2018) State of Uganda Population Report 2018.