Nicola As we speak, decision makers from around the world are at the Nairobi Summit to commemorate the 25th anniversary of the International Conference on Population Development. What is exciting about the Nairobi Summit this year is that it’s exploring universal access to sexual and reproductive health rights, particularly for adolescents. There is also a focus on gender-based violence and tackling harmful gender norms. So within that context, it would be great to hear your thoughts as to what the key priorities are for adolescents and youth in Ethiopia. Could you begin by telling me about any positive changes you noticed during the baseline research that have happened in Ethiopia over the last decade?
Workneh From the baseline, we observed that access to health services has generally expanded both in rural and urban areas. Even in some remote rural areas, women and adolescent girls have started to use family planning – but it’s still not a widespread practice. I think this is the most significant achievement we have observed in the last ten years, because previously access to reproductive health services was a huge challenge particularly in rural areas. In addition, there has been an increase in adolescent girls’ enrollment in primary schools, which is helping increase awareness about health risks and family planning issues. Adolescent girls, typically in secondary schools, have the chance to engage in girls’ clubs where they discuss issues related to violence, child marriage, family planning, contraception and other health risks.
Nicola The rapid increase in girls’ enrollment and the health extension system has brought about a lot of change, but can you tell us about the gaps that some adolescent girls face in terms of equal access.
Abreham There have been efforts by the state government to improve services like family planning, girls clubs and educations or awareness training by health extension workers. But service provision is not even, especially in rural remote areas – such efforts are almost not even there.
Nardos I think there is a difference between married and unmarried girls. Traditionally, there are many social norms that hinder married girls from accessing and using contraceptives. They think that if you are married, you don’t need to use them. But even if you are allowed to access them, it is only the married girls, because if unmarried girls try then they think that she is not a ‘good girl’.
Abreham I think the biggest challenge is still traditional norms in religious areas, especially in our research sites in Oromia region and Afar region. Communities in Harare and Afar resist the implementation of services that aim to improve sexual and reproductive health. For instance in Afar, a remote pastoralist area, I remember when I interviewed a health worker there, he said to me that they will not intervene when traditional leaders decide on situations of marriage and issues like sexual and reproductive health. They don’t intervene in community traditions, which they think are above the justice system. They also link it to their religious doctrine.
Nicola Given these differences, do you think the government is adequately adapting its approach to local specificities? Are they changing the message depending on the local context?
Workneh Yes, I think the regional differences are very clear. In Amhara, the data clearly shows that health extension workers cover almost every base and that heath posts are much better in terms of service provision as compared with other areas, for example Hararghe and Afar. For married girls, the situation is more or less similar across the regions. In Afar, one of the immediate challenges is access to health services in general. It’s so poor because the absence of primary schools means that health information is extremely limited. Also, adolescents in Afar can have sexual relationships even at an early age – often with partners met during the cultural dance ‘Sadah’ and sometimes this leads to unwanted pregnancies, which creates conflict within communities. In order to avoid conflict, some adolescent boys and girls start to use contraceptives. They go to remote market areas to buy them from private companies. The other issue is that the education system starts giving lessons on SRH too late. By the time adolescents reach the second cycle of primary school, they have already reached mid-adolescence and the information can vary even after changes have happened to their bodies, for example girls have already gone through their first menstruation.
Nardos In Amhara, adolescent girls are knowledgeable, even unmarried girls use family planning measures and their parents support that. By contrast in Hararghe and Afar, health extension workers are unavailable and the facilities are not conducive to adolescents’ needs.
Nicola In Amhara, are parents supportive because of the belief in their rights to bodily integrity and to have a sex life, or is it due to other reasons?
Roza From interviews with mothers, I learned that when girls go on to secondary school, they often travel alone to a nearby town. The mother allows her to have contraceptives in order to prevent pregnancy and continue her education.
Workneh Some fathers in Amhara also reported that they advised their adolescent girls, even the unmarried ones, to go to health centres to use contraceptives for fear that they may be raped or start a sexual relationship with somebody, and then face an unwanted pregnancy.
Workneh The other point which needs consideration is the little attention given to the health conditions of adolescents with disabilities. The data clearly shows that adolescents with disabilities have less access to health and SRH services.
Nicola I think I also remember them saying that because there are no health professionals who have sign language abilities, even if adolescents who are deaf do get there, then it’s difficult to actually explain what they want.
Workneh Yes and in general, adolescents in rural areas are more at risk of sexual violence including rape, because of the long distances that they travel to market and to school. Because of the stigma, most of them do not report what happened to them, which is why they either decide by themselves to use contraceptives, or why parents make a decision that their girls should use contraceptives to avoid negatively impacting their future life.
Workneh The other challenge that adolescents in the families reported was the spread of HIV/AIDS. In Amhara, it happens because of two reasons. One, most of the time condoms may not be available in remote rural health centres or health posts. Second, there has been a huge migration of divorced women from rural areas into smaller towns who become concubines. In Afar, sex with multiple partners is normal. But access to condoms is limited and the cultural norm is also against their use. Because of that, one small town has reported an increase in HIV/AIDS, even in remote pastoralist areas.
Nicola In the communities where these kinds of partnerships are more prevalent, did you see efforts by the state government to try and tackle these issues or to raise awareness, to improve testing?
Fitsum Testing is mainly available in urban areas.
Abreham Yes, in urban areas the health centres, heath extension workers and the health bureaus are better at creating awareness, and at the same the time the role of private health providers is also significant. We found, for example, in Dire Dawa or in Debre Tabor, many private clinics and pharmacies who make services such as contraception available. In addition, there are messages sent through formal and social media, so adolescents in urban areas have better access to information than those living in rural areas.
Abreham When I interviewed a religious leader in one of our research sites in Amhara, they mentioned that they have attended about three or four trainings on the use of contraceptives, but they didn’t mention anything about HIV. Programme implementers like NGOs and also the state government are forgetting about HIV/AIDS. I don’t think that people are aware about HIV/AIDS, its severity and how it’s transmitted, especially in rural areas.
Nicola Is there are culture here that if you use condoms, you expect to get them from the health post, rather than purchasing them? Is that part of the challenge? And then if there is no health extension worker, then people think ‘oh well, I won’t bother’?
Abreham Yes, what we need is awareness which will inspire a change in attitude. I think that what we need to do is provide awareness of these issues, so that people know the severity and consequences.
Workneh In Amhara, the attitude is there but sometimes there are supply shortages. In one of our remote rural research communities, there were no condoms at baseline but when we went back , condoms were available at the health posts. In Oromia, because of traditions and people’s attitude towards condoms, there are no condoms in health extension centres, and even the health extension workers do not believe they’re necessary. In Afar, the total absence of health centres and health posts means these services aren’t available anywhere in rural areas. In urban areas, one of the main challenges is the cost of buying condoms. Many of them do not have the money, but in private pharmacies a packet of 3 is between 10 and 15 birr.
Nardos In theory, youth centres provide adolescent-friendly services, but our research participants say that they don’t use them to access SRH services but rather recreational, sports, or drama services. Even then, girls usually do not go to youth centres because they are not girl-friendly.
Nicola So, how can out of school adolescents be reached?
Workneh I think the advantage in urban areas is that the state government is strict about sending every child to school. So, in urban areas, HIV and other school clubs are strong and can be an opportunity for awareness-raising and training.
Workneh In Oromia, and in rural areas, even the role of girls clubs is highly limited. Only very few girls are part of these clubs and they’re not well coordinated. But in urban areas, for example in Batu, many girls are part of girls clubs and they have a separate room where they can change their sanitary pads and where they can rest during menstruation. In addition, in urban areas, adolescent girls who are engaged in commercial sex work have better access to counseling and SRH services. For example, in one of our sites in Dire Dawa, the health centre is located in an area where there is lots of commercial sex work happening and it’s open 24 hours. When we interviewed the head of that centre, she said that every day a large number of young adolescent girls who are engaging in sex work visit them for counselling and to check for HIV.
Nicola The research findings that you have been discussing reflect a very complex picture. What stands out is the unevenness of SRH services for adolescents. There are some good practices but also very significant gaps. So, what do the research findings suggest by way of achieving more even coverage and universal access?
Fitsum I think we should use community leaders to train and teach sexual and reproductive health. The major challenging is the culture and attitudes of the community. When the community’s attitude changes, service provision follows.
Nicola What do you think brings about change for the religious leaders?
Abreham One of the priests in the dissemination workshop in Batu told us that early marriage is not supported in the bible, and he quoted a certain statement that early marriage is not promoted or supported by the bible itself. So when they undergo the training, they should try to link their religious doctrine with their acceptance of the need to avoid early marriage. I think the pickup is there because the state government is not doing this by itself, rather it supported by other NGOs. Changing social norms is quite important, but training for influential individuals or religious and clan leaders needs to consider the specific cultures and traditions.
Workneh As part of this suggestion, I think it is really important to expand health services to remote rural areas where they’re currently very limited. In addition, I think it is important to improve the capabilities of adolescent girls and boys to negotiate these issues. GAGE research also shows that it is important to work with adolescent boys and adult men in order to increase their awareness of services available for their sisters and daughters.
Workneh From what we understand, there are changes in the minds of fathers towards contraception. Previously, one of the major challenges was that people were against it, but now at least they’re behind it which is positive.
Fitsum I also want to say one point related to service provision. As we know, the health extension workers are meant to reach the grassroots level, but in most cases, when I go to different rural areas, I don’t see any health extension workers providing services. In fact, they are often not physically available because they have to travel from the district town, which means that they are only available two or three times in a week in an area. If the state government is able to construct houses in and around the health posts, then the health extension workers can be available at all times.
Abreham Yes, that is a point I also wanted to raise. In Ethiopia, the health extension programme is declining and risks failing altogether. The major reason is that health extension workers have provided this service for more than a decade, most of whom haven’t had a promotion in 15 years and their salary increase is so small. So, I think the state government should improve services, or they need to find another way to provide them.
Nicola That’s an interesting point. Health extension service providers are certainly tasked with a lot of responsibilities and are often seen as the entrypoint for many issues. So, you’re saying that the system could be at risk if there is not greater investment in its sustainability.
Abreham Health extension workers are also members of cabinets in kebele, which means that they have a lot of extra responsibilities, and obviously they are expected to spend more time on political issues.
Nicola Thank you very much for sharing your reflections. Clearly there are lots of complexities to be taken into account in designing and equitably implementing adolescent-friendly SRH services for all. Let us hope that there will be renewed and bold commitments in Nairobi this week.