National ARH Strategy, Bangladesh (2006)
BANGLADESH ADOLESCENT REPRODUCTIVE HEALTH STRATEGY
LIST OF CONTENTS
1. THE CONTEXT: GOALS AND REALITIES
1.1 Adolescents’ Reproductive Health in Bangladesh: A Socio-cultural Perspective
1.1.1 Defining Adolescence
1.1.2 Adolescents and the Bangladeshi Population
1.1.3 Adolescents and Socio-cultural Background
1.1.4 Marriage, Pregnancy and Contraception
1.1.6 Education and Employment
1.1.7 Violence, Exploitation and Abuse
1.1.8 Sexual and Other Behaviour of Adolescents
1.2 Bangladesh’s Response to Adolescent Reproductive Health Issues
1.2.1 Legal and Policy Framework
1.2.2 Interventions in Government Sector
1.2.3 Role of NGO and Private Sector
1.2.4 ARH and the Development Partners
1.2.5 International Commitments to ARH
1.3 Opportunities for the Future
1.4 Strategy Development Process
2. THE FRAMEWORK OF THE STRATEGY
2.1 Guiding Principles
2.2 The Time Frame
2.3 The Vision
2.4 The Goal
2.5 The Objectives
3. STRATEGIES AND ACTIVITIES
3.1 Strategies for Improving Adolescents’ Reproductive Health Knowledge
3.1.1 Effective Dissemination of ARH Knowledge and Information Through Curricula
3.1.2 Organizing Effective Community Based Dissemination of ARH Information
3.2 Strategies for Creating Positive Change in the Behavior and Attitude of
3.2.1 Advocacy at Community Level for the Gatekeepers of Adolescents
3.2.2 Develop and Implement Mass Media Campaign
3.3 Strategies to Reduce Incidence of Early Marriage and Pregnancy
.3.1 Community Mobilization Against Early Marriage and Pregnancy
3.3.2 Strengthening Implementation of Existing Laws
3.3.3 Increasing Access of Married Adolescents to Family Planning Services
3.4 Strategies for Reducing the Incidence and Prevalence of STI, Including HIV/AIDS
3.4.1 Scaling up of and Improving Coordination Between Existing Interventions
3.4.2 Dissemination of STI Preventing Messages in all Available and Appropriate
3.4.3 Mulisectoral Advocacy for Creation of Supportive Environment for
Adolescents to Practice Safe Behaviours
3.5 Strategies for Provision of Easy Access of All Adolescents to ARH and Other Related
3.5.1 Introducing and Expanding Adolescent Friendly Health Services
3.5.2 Ensuring Good Quality of Care in Adolescent Friendly Outlets
3.5.3 Promotion of Adolescent Friendly Services
3.6 Strategies for Creating Favorable Conditions which
Discourage Risk Taking Behaviours
3.6.1 Mobilisation of Adolescents and Their Gatekeepers Against Risk Taking
3.6.2 Supportive Policies for Reducing Risk Taking
4. IMPLEMENTATION OF THE ARH STRATEGY
4.1 Leadership and Coordination
4.2 Resource Mobilization
THE CONTEXT: GOALS AND REALITIES
1.1 Adolescents’ Reproductive Health in Bangladesh: A Socio-cultural Perspective
1.1.1 Defining adolescence:
Adolescence is generally accepted as a period of rapid and important change- the transition between childhood and adulthood. Although it is generally accepted that the onset of adolescence is marked by the appearance of secondary sexual characteristics (which again vary from individual to individual), the termination of adolescence- i.e. the beginning of adulthood is less well marked. It is also a period of rapid development when young people acquire new capacities and are faced with new situations that create not only opportunities for progress but also risks to health and well-being. It is a time when growth is accelerated, major physical changes take place and differences between boys and girls are accentuated.
A universally accepted definition categorizes those belonging to 10-19 years of age as adolescents. This period is further staged into early adolescence (10-14 years) and late adolescence (15-19 years). The WHO definition of adolescents has been extensively used worldwide to identify adolescents and to plan and operationalize programmes for them. This Strategy is built upon this universally accepted definition of adolescents. The definition however masks the huge heterogeneity found in this group, in terms of the physical, mental and social characteristics of the adolescents, their dynamics with the society, and their behaviour and responses. The reproductive health needs vary greatly within this broad age range, 1 which encompasses individuals who may be married or unmarried, sexually active or have not yet entered into that kind of relationship, girls who have already experienced childbirth, etc. Marriage is a particularly critical landmark event. Once married, the girls or boys are socially considered as adults, while those of similar age but unmarried and/or in school are considered as children/less mature.
In Bangladesh, adolescents represent more than one fourth of the total population.
Although adolescents are the healthiest members of the communities having survived infancy and early childhood diseases, they face a number of important health risks arising out of early pregnancies, violence, inadequate nutrition etc. Their sheer number also makes them an important determinant of the overall health status of the country.
1.1.3 Adolescents and socio-cultural background
Although at the prime of their life, an estimated 1.7.million adolescents die every year mainly from accidents, violence, pregnancy related problems or illnesses that are either preventable or treatable. Many more develop chronic illnesses that damage their chances of personal fulfillment. Among adolescents, the experience of girls and boys differ widely. Gender discrimination in the form of discrimination against girls has been identified as one of the prime adolescent reproductive health (ARH) issues in Bangladesh. The discrimination exists in most spheres of life including employment, marriage, social mobility, food allocation etc. However, recent government initiatives to encourage girls’ education, including universal free primary education and stipends for girl students, have initiated groundbreaking positive trend in girl’s enrollment in schools where, at secondary level, they outstrip boys in number (51 percent for girls and 49 percent for boys).
There is a wide disparity in opportunities available to rural versus urban adolescents. Higher frequency of early marriage among girls, early dropping out from schools and, for boys, early joining of work to supplement family income are some of the hallmarks of rural adolescents. While urban adolescents belonging to middle and higher income families enjoy better lifestyle, their counterparts from lower socio-economic situations have to struggle for survival and grow in impoverished, disadvantaged environment
where malnutrition, poor health, exposure to antisocial activities and drugs etc. continuously plague them.
Families remain the cornerstone of Bangladeshi lives. In rural areas, most families are extended. In urban areas, there is a growing trend of nuclear families. Whether in rural or urban areas, parents and elders in the family exert a profound influence and control on
the lives of adolescents. Their accesses to information, freedom of movement, marriage, practice of certain behaviours are closely regulated by parents or by the influencing members of the family. Outside the immediate family, teachers, close relatives and
community leaders also influence their lives, more often acting as barriers than as facilitators to adolescents exercising their simple rights.
1.1.4 Marriage, pregnancy and contraception
In spite of set minimum legal age for marriage (18 years for girls and 21 years for boys),
early marriage, especially among female adolescents, is prevalent in Bangladesh with about 11 percent of those in the 10-14 years and 46 percent of those in 15-19 years being married.
Marriage at an even earlier age is common in rural areas where about 85 percent of the girls are married before they reach the age of 16. Increasing trend of dowry, lack of safety and security of young girls and less economic value attached to girls are some of the reasons for continuing early marriage. Once married, the girls are under pressure to prove their fertility, and as a result pregnancy closely follows. One third of adolescents aged 15-19 have begun child bearing, 28 percent have given birth and another 5 percent are pregnant with first child. Childbearing begins earlier among adolescents in the poorest 40 percent of the households. Fertility rate among the 15-19 years old is about
135 per 1000 women, one of the highest in the world for this age group. Contraceptive use is low- 42 percent as opposed to the national average of 58 percent. Due to inherent risks of early pregnancy, maternal mortality rate is higher in this group-about 4 times higher than the national average. Low birth-weight is more common among babies born of this group of women than among older women. Young girls facing unwanted pregnancies are known to resort to unsafe abortion, in spite of the existence of a wide network of menstrual regulation (MR) providers. This often results in morbidities which girls have to suffer from for the rest of their lives.
The nutritional status of adolescents in Bangladesh is deplorable. Sub-optimal nutrition during adolescence is mainly the consequence of interaction of socio-economic and environmental factors. Lack of proper knowledge, incorrect food habits, inability to
fulfill additional dietary needs during pregnancy are some of the major causes which lead to this state. In a study conducted among students up to class X, girls were found to have better nutritional indices than boys; thereafter, the scenario completely reversed, possibly due to prevailing norms, which adversely affected food distribution in the family. In rural areas, early and repeated childbearing further compromise the nutritional status of girls
which contribute to higher maternal mortality rate and greater incidence of low birth weight babies in the rural areas.
1.1.6 Education and employment
Education and employment are both known to positively impact on reproductive health by creating enabling environment for acquiring knowledge and information, accessing services and practising positive behaviours. Bangladesh has made important strides in the education sector in the recent past. Large scale government intervention, through scholarships/stipends and other incentives, as well as provision for free education for all upto primary level and for girls up to class XII, has increased enrollment at both primary and secondary educational levels and the gender gap has been largely narrowed. About
88 percent of girls aged 15-19 years are now enrolled in schools. In spite of these recent achievements, dropout rates continue to be high, especially among girls, many of whom discontinue in order to get married. Outside formal education, the extensive network of non-formal education, primarily operated by NGOs, has been successful in providing older girls with basic reading and learning skills. Educational attainment is higher in urban than rural areas with 28 percent girls in urban and 36 percent of girls in rural areas having no education. The corresponding figure for boys was 20 percent for urban and 29 percent for rural areas.
About 18 percent of the 10-14 year old and 57 percent of the 15-19 year old adolescents are employed. The employment rate is higher in urban than in rural areas among both age groups except 15-19 year old boys, among whom a larger proportion was employed in the rural than in the urban areas10. This statistic however clouds the fact that most of the girls, especially in rural areas, are heavily involved in household chores, often disproportionate with what their bodies can cope with. The pattern of employment also varies between the rural and urban areas. While in rural areas, most employment is in the
agriculture sector, a large proportion of urban girls and boys, especially the earlier group, work in the rapidly expanding industrial sector, including the garments factories. Long working hours, adverse work environment and lack of adequate access to basic amenities put adolescents working in this sector at higher health risks and risks of sexual abuse. This situation also makes their access to the usual network of health services difficult. A large number of adolescents also work as domestic helps, although their number is unknown. Physical abuse including sexual abuse is not uncommon among those employed as domestic helps, as evidenced by a number of newspaper reports in the recent past.
1.1.7 Violence, exploitation and abuse
Violence against adolescents takes many forms-physical, sexual and psychological. They are exposed to all prevalent forms of violence against women- e.g. dowry related violence, marital rape, sexual harassment and intimidation at work, trafficking, forced prostitution, acid throwing, rape etc. It is difficult to get accurate data on such violence. However a review by UNICEF indicated that the mean age for sexual abuse was 11.6 years, and most rape cases took place among very young girls, including children. About a quarter of child domestic workers were sexually abused, and most acid survivors were under 18. In spite of existence of tough laws, acid violence continues unabated, with an average of 250 cases being reported annually. Trafficking women, most of whom are in their teens, across the border to neighboring countries has become a regular affair. The fact that an estimated 300,000 young Bangladeshi girls work in the brothels of India while 200,000 women have been trafficked to Pakistan over the last 10 years, demonstrate the magnitude of the problem. While sexual abuse of boys is much less talked about, there are anecdotal experiences on record of prevalence of such violence at household as well as institutional levels.
1.1.8 Sexual and other high risk behaviour among adolescents
Sexual activity among adolescents is not restricted only to the married ones. Although
social customs and values discourage premarital or extramarital sexual relationship, increasingly there are reports of prevalence of such behaviour. Five percent respondents in a survey on adolescents reported premarital sex.In yet another study, less than 1 percent of unmarried girls and 8 percent of unmarried boys reported having sex Young men, including adolescents boys, are known to visit sex workers and about a third of them are reported to have used the services of sex workers. This group is especially vulnerable to unwanted pregnancy and disease, including sexually transmitted infections (STIs), HIV infection and the stigma and discrimination associated with either condition.
Male to male sex is not uncommon, and often adolescent boys are forced to participate in such sexual acts. Due to lack of awareness and information, most of these sex acts are unprotected and result in the spread of sexually transmitted infections. This is evidenced by high proportions of male adolescents reporting that they knew of people who suffered from such diseases (88 percent). Drug use, including use of injecting drug among them is on the increase. Injecting drug users share needles routinely, greatly increasing their
chances of contracting HIV/hepatitis and other blood borne infections. Older adolescents, especially in urban areas, are getting more and more involved in violence and crime. Use of adolescent boys for perpetrating hartal violence is common. Many of the small time drug peddlers are young teenagers.
Thus a huge range of risky behaviours is seen among today’s adolescents, all of which directly or indirectly also impact on their reproductive health.
1.2 Bangladesh’s Response to Adolescent Reproductive Health Issues
1.2.1 Legal and Policy Framework
The Bangladesh Government (GoB) has shown exemplary farsightedness in creating an overall supportive policy and legal environment to promote adolescent reproductive health. The Constitution of Bangladesh guarantees equal rights for men and women irrespective of caste, creed, and colour. All citizens are entitled to equal protection under the law. A number of laws are in places which directly or indirectly dissuade adverse practices. These include the Dowry Prohibition Act, 1980 which provides taking and giving of dowry an offence and punishable by fine and imprisonment; Cruelty to Women (Deterrent Punishment) Act, 1983 which makes punishment by death or life imprisonment for the kidnapping or abduction of women for unlawful purposes, trafficking women or causing death or attempting to cause death or grievous injuries to wives for dowry; the Immoral Traffic Act and the Women and Children Repression (Amendment) Act, 2000 enacted to regulate offences (like sexual harassment, rape, trafficking, kidnapping, dowry) against women; the Child Marriage Restraint Act, 1929 (Amended in 1983) enacted to restrain child marriage and ascertain the legal age of marriage, which is 21 years for boys and 18 years for girls, and the Children Act, 1974 which provides provisions relating to protection and treatment of children and trial and punishment of youth offenders.
The Government of Bangladesh has recognized the importance of ensuring ARH and has incorporated this issue in important national policies. The Population Policy of 2005 has provision of information, counseling and services for adolescents as one of its objectives and outlines a number of strategies for achieving this goal. The Policy addresses the
ARH issue not just from the population but also from a development perspective, which is a major breakthrough. The Policy puts special emphasis on providing vocational and non-formal education to both in-school and out-school adolescent boys and girls.
The National Health Policy of 2000, on the other hand, does not contain any explicit mention of the adolescents or address the ARH issue, though the objectives and strategies are comprehensive enough to encompass the issue. The newly adopted Youth Policy has, as one of its objectives, involvement of youth in issues of national importance such as preventing the spread of HIV/AIDS and drug abuse, and specially mentions the importance of involving members of the society in imparting youth with knowledge
about reproductive health.
The Reproductive Health Strategy developed under the leadership of the Ministry of Health and Family Welfare (MOHFW) outlines improving services for married adolescent girls as a priority area for action. The health of adolescent girls is identified to be a critical issue and the role of education, employment and empowerment is acknowledged as a necessary condition for improving their reproductive health. The National Maternal Health Strategy considers improving the access of adolescents to emergency obstetric care and sexual and reproductive health services as a priority.
Objectives set under this Strategy are broadly supportive of ARH; specifically, objectives related to reducing low birth weight, improving maternal nutrition, making health
services more sensitive to women’s needs, building zero tolerance against violence in health facilities would directly contribute to improving the ARH status. Providing easy access of adolescents to information about sexual health and safer sex practices and relevant services has been emphasized in the National HIV/AIDS Policy.
In reality, there has been limited impact of these favourable laws and policies.
‘Reported’ acid and dowry violence is decreasing slightly, age at marriage is showing gradual increase and there is increasing sensitivity to sexual abuse and violence against the adolescents. However, law enforcing mechanisms in Bangladesh are weak and, given a cumbersome legal system, very few people have recourse to law. Similarly, lack of focus on operationalising policies and strategies and inadequate monitoring of progress have detracted from the benefits, which could have been achieved by implementing these policies and strategies. Moreover, such policies and strategies are often drafted in isolation, and as a result the synergy which could be derived from operational sing different policies is missing. Formation of an Interministerial Committee on the issue of
ARH and better coordination or synergy could be achieved in the future on this particular strategy. Several socio-cultural factors, including improved access of adolescents to education, the rapidly developing media access, increasing recognition of importance of protecting the health of adolescents, and a slowly developing effective local government structure, offer excellent opportunities for accelerating progress in this regard.
1.2.2 Interventions in the Government Sector
ARH has so far been mainly a concern of the Ministry of Health and Family Welfare, though other ministries have of recent integrated ARH issues in some of their projects/programmes. Important programme initiatives undertaken by MOHFW on this issue include steps to train providers on adolescent friendly health services and introduce ARH services in Maternal and Child Welfare Centres (MCWCs) and countrywide project under Global Fund to Fight AIDS Tuberculosis and Malaria (GFATM) to prevent the spread of HIV/AIDS among young people. Nutritional supplementation of pregnant mother with iron /folic acid, introducing skilled birth attendants and expansion of Emergency Obstetric Care (EOC) services, initiatives to improve quality of care in government centers are other initiatives which will directly contribute to improving ARH especially of adolescent mothers.
A number of other ministries have also come forward on this issue. The Ministry of Local Government, Rural Development and Cooperatives, under the Urban Primary Health Care Project (UPHCP) has embarked upon an ambitious programme to introduce health services to a large number of municipalities and all City Corporation areas in phases. Under an ongoing project covering 4 of the 6 City Corporations, Adolescent Spaces have been set up in all health facilities under the project. The Ministry of Education’s inclusion of ARH issues in the formal curricula of schools and religious institutions is a major step in breaking the silence around ARH issues. The Ministry of Social Welfare, through its centres for street children and juvenile delinquents, is providing valuable support to extremely marginalized groups of adolescents, though the number of such centres is grossly inadequate and important opportunities are missed for promoting ARH through them. Legal support and skills training provided to women, including adolescent girls, by the Ministry of Women and Children’s Affairs, and the Ministry of Youth and Sports’ youth advocacy, along with provision of livelihood training and peer education through the Youth Clubs, are other important initiatives which deserve special mention.
Although the ARH issue has received the attention of a range of ministries, most of the programmes are being implemented vertically, resulting in a lack of sustainability of the initiatives. The MOHFW interventions are anchored in existing programmes and therefore could continue in the long term. ARH is already included in various curricula, although the fact that teachers avoid taking classroom sessions on the topic due to shyness is a huge drawback. Most of the initiatives of other ministries are through externally funded projects and could cease after the funding is withdrawn. Their scale is also modest in relation to the need, except in the case of the Ministry of Youth and Sports, which works through (information to be added by Dr. Noor Mohammad, UNFPA).
1.2.3 Role of NGOs and other private sector enterprises
The NGOs have played a pioneering role in this area by catalyzing the inclusion of this important topic in the national agenda on the one hand and establishing programmes for adolescents on the other. NGO interventions have mainly been on provision of health education and awareness building, delivery of health services for adolescents, and peer education and life skills approach for enabling them to establish their rights. A large number of NGOs- local, national and international have been involved in designing and implementing interventions. Many of these interventions have used innovative approaches and have been truly responsive to the needs of adolescents. Some of the programmes have been particularly successful in addressing highly marginalized groups such as those living on the street and employed in risky jobs and work in hazardous environment. A number of well researched and effective tools and materials have been produced.
In spite of a long engagement of the NGOs in this sector, there has been limited impact of the intervention by NGOs. Reasons for this are manifold, the most important being the fact that these interventions have been mostly implemented through donor financed projects carried out in localized areas, and at a scale not large enough to generate a
critical national response. Rural areas have been largely neglected, and due to dependence on external funds and limited opportunity to make these interventions financially viable, the interventions have been short-lived. Due to lack of coordination and collaboration, the synergy which could have evolved, was lost. An NGO networking forum, NEARS, has been launched and an existing one, DAWN, has been revived. These forums could play a critical role in promoting the issue of collaboration and coordination among the NGOs.
The for-profit sector had so far played a rather limited role in this area. Most of the involvement has been in carrying out research, although under GFATM a public-private partnership is evolving where the private sector expertise and experience is being used to develop messages and materials.
1.2.4 ARH and the Development Partners
The Development Partners, including the UN agencies and bilateral and multilateral donors, also have a long history of involvement in the area of ARH, which is reflected as a priority of most UN agencies working in the health sector including WHO, UNICEF, UNAIDS, IOM, ILO, UNFPA etc. The focus of these different agencies differs, but together they encompass all the facets of the issue, including education, health, nutrition, establishment of rights, empowerment and systemic issues such as monitoring progress and promoting youth participation. The role of bilateral donors has mainly been to support, through technical as well as financial inputs, projects and programmes of NGOs. Along with the UN agencies, these bilateral agencies have played a valuable role in highlighting the importance of ARH.
1.2.5 International commitments to ARH
Bangladesh has made important commitments on ARH to the international community. Bangladesh is a signatory to International Conference on Population and Development (ICPD), ICPD+5, Child Rights Convention, Beijing Platform of Action, and the Millennium Development Goals (MDGs). Given the huge number of adolescents in the country and their potential role as change agents, any small improvement in the ARH status of adolescents can actually trigger an accelerated achievement of the other goals and targets. Already there have been important gains that have helped to push up Bangladesh’s ranking in the Human Development Index list, and Bangladesh is well poised to meet some of the MDGs, including the one on education.
1.3 Opportunities for the future
The importance of improving adolescent reproductive health has been realised by the Government of Bangladesh since long. Successive national level policies/programmes in the health sector (the Population Policy, the HIV/AIDS Policy, HPSP and HNPSP) have paid importance to the issues, programmes have been launched in both the government and NGO sectors, and the topic has also been successfully taken up by the media. The legal framework of the country provides a supportive environment and Development
Partners have been actively supporting the issue. Against this backdrop, the Government of Bangladesh felt that it was of paramount interest to the country to have a National Strategy in place to develop the issue further in a concerted and coordinated way, and work towards a consensual goal.
The development and introduction of the Strategy at this point of time would also present important synergies for implementation of the Strategy. The local government institutes, with appropriate orientation and sensitization, were poised to play an effective role as change agents. Local government leaders, including Union Parishad members, Ward Commisssioners, etc. working in coordination with other parts of the civil society, could, through the Parliamentarians and the Parliamentary Standing Committees, take the issue up to the national Parliament for debate, discussion and passing of appropriate laws. Several well spread out infrastructures within the society are well positioned to take this development further. This includes the formal infrastructure of health and education, both government and private, the National Nutrition Programme of the government, other
parts of the civil society, e.g. the network of Scouts and Girl Guides, BDRCS volunteers in the coastal areas, and members of the Youth Clubs, who are already aware of the issue and whose energy can be built upon to transform the ARH issue into a movement.
The role of media would be critical in promoting the ARH issue. Through involvement in various adolescent related interventions, a large section of the media has already been primed on the issue, and its influence can be harnessed to further accelerate change. As a result of expanding media influence, communities are more ready to embrace change now than ever before. The corporate sector of the country has so far played little role. However, with the introduction of open market economy and rising trade and consumerism, the corporate sector, as part of social responsibility, is getting involved in issues such as prevention of smoking among young people, building awareness against HIV/AIDS, etc. There is a huge opportunity for more systematic and greater involvement of this sector in ARH issues, given the large client/customer base that adolescents provide to some of the big corporate entities.
There also exists a critical mass of experience, skills and technical resources in the country to rapidly expand ARH programmes. Effective tools and training programmes have been developed, innovative peer approach strategies have been tested out, links have been forged between adolescents and their gatekeepers and collaboration between
the government and NGOs has been established. It is therefore a prime opportunity for all
sectors of the Bangladeshi society to come together to develop adolescent reproductive health.
1.4 Strategy Development Process
In 2002, a two days’ sensitization workshop on Adolescent Health and Development Strategy in Bangladesh was organized by Obstetric and Gynaecological Society of Bangladesh (OGSB) and Institute of Child and Mother Health (ICMH), with funding from World health Organisation (WHO). The workshop discussed the issue of adolescent reproductive health within the broader framework of adolescent health and development. The next important step in developing the ARH strategy was taken in 2003 when an
Inter-ministerial Committee was established under the Joint Secretary (Development- Family Welfare) of MOHFW to lead the process. The Committee included representation from 6 relevant ministries, UN agencies, NGOs and bilateral donors. During this time, preparatory steps were taken for development of the strategy through the commissioning, by WHO of a paper to review the situation of adolescents in the country. Several intermediary steps were taken by MOHFW for development of the Strategy, and ultimately a Strategy Drafting Committee was formed by the Inter-ministerial Committee in May 2005. The Strategy Drafting Committee included representatives from MOHFW, including the Directorates of Health and of Family Planning, Ministry of Youth and Sports, Development Partners (WHO, UNICEF, CIDA) and individual experts. A National Programme Officer (NPO) from UNFPA served as General Secretary of the Committee. The work of the Committee was facilitated by a Consultant appointed by UNFPA. The Strategy Drafting Committee was assigned the challenging task of developing the Strategy within a short time span of three months. The Drafting Committee, immediately after its formation, started intensive work and, after several meetings, developed a plan for the process of strategy development, which was approved by the Inter-ministerial Committee. Accordingly, the Drafting Committee organized a
3day workshop for development of the Strategy. A wide range of government, NGO, private sector, civil society and media representatives, including representatives of the adolescents, participated in the workshop. Through this workshop, the outline of a strategy emerged. Individual and group consultations at the national level, divisional
level feedback from a cross section of stakeholders, and inputs and reviews from eminent experts were included and the Strategy was thus finalized.
The following Strategy represents the outcome of the Workshop and the combined
thoughts of policy makers, programme planners, implementing agencies in the government and NGO sectors, researchers and experts in the field, religious leaders, community leaders, media experts, philanthropists and representatives of other parts of the civil society. Most importantly, the Strategy also reflects the inputs of the adolescents themselves who were closely involved with the process of its development.
The Framework of the Strategy
2.1 Guiding Principles
Bangladesh’s ARH strategy rests on global consensus declarations on human rights including the right of all persons to the highest attainable standard of health; and on Bangladesh government’s constitutional obligation to guarantee fundamental human rights and dignity to all its citizens. To ensure that the ARH Strategy fulfills these fundamental rights, development of the Strategy has been guided by the following eight principles:
1 ARH should be viewed as an overall development issue: Attainment of the highest standard of reproductive health by adolescents requires adolescents to be empowered to make decisions and act upon them, with support from all the gatekeepers. Education, access to information, affordability of relevant services, access to communication facilities, etc. therefore need to exist for development of ARH to the highest standards.
2 ARH should be embedded in all national planning frameworks related to human development: Since ARH is an overall developmental issue, it should be integrated in the development planning of the country at the national and sectoral levels. While important international and national commitments of the Bangladesh Government (MDGs, the ICPD, the PRSP, the Bangladesh Population Policy, which has placed a lot of importance on the issue) have ARH explicitly integrated within them, other policy frameworks should integrate this issue, either explicitly or implicitly through programmes.
3 The ARH Strategy should have special focus on marginalized and highrisk adolescent groups: The ARH Strategy should include all segments of the adolescents with special emphasis on adolescents living in rural areas, the poor, especially the hard-core poor, the marginalized, the disabled and adolescents with special needs. Girls as well as boys have unmet needs, and the Strategy should address the needs of both the sexes.
4 The Strategy should be gender sensitive: Being part of a traditional, conservative society, girls suffer from a number of gender based discriminatory practices
which adversely affect their reproductive health. The Strategy should address these discriminatory practices in order to provide adolescent girls an enabling environment to grow and thrive in.
5 Wide scale community support should be generated: Communities and families are the ultimate facilitators and barriers to achieving the desired status of ARH For this, communities need to be involved in programmes. Bangladesh has strong traditions and cultures built around religious and family values. Programmes
should build upon these positive traditions and cultures, and should be sensitive to the community’s and society’s points of view.
6 Sustainability of interventions should be aimed for: In designing interventions, long term sustainability should be kept in mind. To the extent possible, interventions should be anchored in existing programmes, and skill and capacity building of adolescents and institutions should be seen as elements of sustainability.
7 Adolescents should participate at all levels of planning and implementation: For the Strategy to be effectively designed and implemented, adolescents need to be made an integral part of the entire process. Participation of all segments of adolescents, especially the poor, marginalized, disabled and those with special needs, has to be ensured.
2.2. The Time Frame
The ARH Strategy spans over a period of 10 years, i.e. up to 2015. In the interest of more pragmatic planning, given the rapidly changing dynamics of the Bangladeshi society, changes in external situations, which impact on the country’s economy and society, the impending hazard of a concentrated HIV epidemic, the changing funding situation etc., detailed planning is confined to the coming five years- i.e. up to 2010. Thus, a ‘Vision’ of this Strategy encapsulates a long term (10 years) objective, while the ‘Goal’ articulates
the more immediate (5 years) objective. Achieving the Goal would contribute to the Vision. However, as we near 2010, this Strategy would be revisited to adapt it to the changing scenario.
2.2 The Vision
By 2015, all adolescent girls and boys, including the disadvantaged, will be able to enjoy safe and complete reproductive life through access to appropriate knowledge, skills and services in a socially and legally supportive environment
2.3 The Goal
By 2010, all adolescents will have easy access to information, education and services required to achieve a fulfilling reproductive life in a socially secure and enabling environment.
2.4 The Objectives
The objectives of the ARH Strategy are
1. To improve the knowledge of adolescents on reproductive health issues.
2. To create a positive change in the behaviour and attitude of the gatekeepers of adolescents (parents/guardians, teachers, religious leaders etc.) towards reproductive health
3. To reduce the incidence of early marriage and pregnancy among adolescents
4. To reduce the incidence and prevalence of STIs, including HIV/AIDS, among adolescents
To provide easy access of all adolescents to adolescent friendly health services (ARSH)
and other related services
To create a socio-political condition, where adolescents are not subjected to violence or abuse, and which discourages substance abuse and other risk taking behaviours among adolescents
Strategies and Activities
In order to achieve the 6 objectives mentioned in the last chapter, a wide range of strategies would have to be undertaken, involving a variety of stakeholders and a number of sectors. Given the ambitious time frame and a limited resource envelope, the strategies have been defined in a way that would maximize impact and address the priority needs.The following sect