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

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 (M&E, 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. Government (Key): Ministry of Youth, Sport and Culture (MoYSC), Women’s 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 Who are the Stakeholders of ARH, Gender and HIV/AIDS?

8. Others: NGOs, both indigenous and international, Youth and women’s 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.) Who are the Stakeholders of ARH, Gender and HIV/AIDS?

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, Women’s 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 People’s 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 Office’s (HAPCO/NAC 2002) mandate: serving as the secretariat under the Prime Minister’s 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 M&E 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 ofwomen.

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), Women’s Affairs Sector accountable to/in the Prime Minister Office, mandate : coordination, facilitation and monitoring of women’s 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 Girl’s education/ESDP • Women’s 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 Women’s Affairs Office (WAO/PMO), • The Women’s Affairs Departments (WAD) or units of sectoral ministries and organizations, and • Gender focal points • At Regional Level: • Women’s Affairs Offices • At Woreda and Kebele levels: • Women’s 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 women’s 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 Women’s 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 Girl’s 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, • Women’s 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 M&E 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 Women’s 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