START The Girls Count Series S T A The Girls Count series uses adolescent girl–specifi c data and analysis to drive R T meaningful action. Each work explores an uncharted dimension of adolescent girls’ WITH A GIRL W lives and sets out concrete tasks for the global community. Together, these actions I T can put 600 million adolescent girls in the developing world on a path of health, H education, and economic power—for their own wellbeing and the prosperity of their A A NEW AGENDA families, communities, and nations. G I R L The Girls Count series is an initiative of the Coalition for Adolescent Girls. : FOR GLOBAL A www.coalitionforadolescentgirls.org N E W HEALTH A Start With A Girl: G E A New Agenda for Global Health N D A GIRLS COUNT REPORT ON A In Start with a Girl: A New Agenda for Global Health, Miriam Temin and Ruth Levine ADOLESCENT GIRLS F describe the positive multiplier effect of including adolescent girls in global health O R programs and policies—and the risks if they continue to be left out. G L O B “Protecting the health of adolescent girls is a human- “Everyone has a role to play in fulfi lling the promise A L rights priority. Whether by combating child marriage, of girls’ futures. Much of what needs to be done H facilitating access to quality health care, or eliminating challenges us: we need to work across sectors, in E A harmful traditional practices, gains in adolescent girls’ a sustained way over many years, tackling some of L health permit the full realization of human potential.” the most controversial topics. But to do less is to fail T H girls—and ourselves.” Mary Robinson President of Realizing Rights: The Ethical Helene Gayle Globalization Initiative and former President and CEO of CARE USA President of Ireland “Prioritizing the health and prosperity of adolescent “There are 600 million adolescent girls in developing girls is fundamental to ensuring the health of future countries and their health and wellbeing should be generations and to accelerating economic progress. a top priority. If educated, healthy and empowered, To get there, we need to transform the health-care they can build a better life for themselves, their sector to reach girls specifi cally with services and families and nations. UNFPA is proud to be an active to engage them as the next-generation health-care member of the UN Interagency Task Force on Adoles- workforce.” cent Girls. I hope this report contributes to action to Muhammad Yunus improve their health and unleash their full potential.” Founder and Managing Director of Thoraya Ahmed Obaid Grameen Bank Executive Director of the United Nations Population Fund MIRIAM TEMIN RUTH LEVINE CENTER FOR GLOBAL DEVELOPMENT Cert no. SW-COC-000850 START WITH A GIRL A NeW AGeNDA foR GLoBAL HeALTH TAKe ACTIoN foR GIRLS’ HeALTH 1 3 Implement a Place adolescent girls at comprehensive health the center of international agenda for adolescent girls and national action and in at least three countries. investment on maternal Working with countries that demonstrate national health. leadership on adolescent girls, bilateral donors, the New advocacy and programmatic investments give World Bank, the WHO, UNFPA, and UNICEF can renewed hope for maternal health. Within advocacy comprehensively support girl-focused interventions and program efforts, specific attention to girls will (including girl-friendly reproductive health services), pay off. Donors should support research on the broad health sector changes, transformations in risk factors for pregnant adolescents and evalua- social norms, community resources for girls, and tions of programming for girls facing high hurdles girls’ schooling. Accompanied by operational and to health care. They should translate evidence into evaluation research and funded by domestic and programming to reduce adolescent maternal mortal- international resources, the aim is to achieve full pro- ity beyond labor and delivery to also include family gram coverage among the poorest segments of the planning, nutrition, and abortion-related care. Fund- population by 2016. ing should be earmarked for adolescents within any new resource package for maternal health. 2 4 Eliminate marriage for Focus HIV prevention girls younger than 18. on adolescent girls. Child marriage is a manifestation of girls’ powerless- ness and a driver of health risks. International To turn off the tap of new infections and break the agencies should identify the practice, affecting back of the epidemic, HIV prevention efforts must at least half of all girls in about a dozen countries, focus more on girls and young women. As the as a human rights violation. Girls need national laws Global Fund to Fight AIDS, TB and Malaria, the to prevent child marriage, along with donor sup- U.S. President’s Emergency Plan for AIDS Relief, port for national responses—for example, marriage and other major international HIV/AIDS initiatives registration systems and incentive schemes to keep step up HIV prevention efforts, adolescent girls must daughters in school—and programs to mobilize com- be at the forefront. This means supporting efforts munities and create viable alternatives to marriage. to transform harmful social norms, ensuring that essential services and commodities are in place for girls, educating girls about avoiding HIV/AIDS as part of comprehensive sexuality education, and working with boys and men to change their behavior—for themselves and their partners. ii 5 7 Make health–system Create an innovation strengthening and fund for girls’ health. monitoring work for girls. The evidence base on girls’ health, and effective strategies to improve it, is weak. Girls urgently need If the health system is failing girls, it’s failing. Strate- investments in data collection (e.g. through the gies to strengthen health systems are unfolding, Demographic and Health Surveys and longitudinal funded by vertical and health sector sources and new studies) and multi-country evaluations of promising resources. Those designing health system reforms programs, including the 12-year-old check-in and should pay particular attention to community-based programs to change boys’ and men’s attitudes and service delivery for girls, girl-friendly reproductive behaviors. Philanthropic funders could create an health services, health worker training to increase innovation fund to stimulate knowledge generation competency on adolescent girls’ and boys’ health, and dissemination, leveraging resources from govern- and financing and payment strategies that prioritize ments and official donors’ agencies along the way. girls’ health. 8 6 Increase donor support Make secondary school for adolescent girls’ completion a priority for health. adolescent girls. Obtaining better health for girls requires signifi- Getting girls through secondary school is one of cant—yet feasible—investment by governments, the most important actions governments can take donors, and the private sector. There is no valid to improve girls’ chances for good health. Gov- estimate of current spending on girls’ health. In the ernments should extend the definition of basic absence of a baseline, but knowing that girls’ health education, to which all are entitled, to lower sec- programs constitute a small share of current effort, ondary or to age 16. Governments and the private OECD donors should increase official development sector, with donor support, must increase formal assistance in areas that benefit girls by at least $1 and non-formal school places by extending primary billion per year. This constitutes approximately 6% of school facilities, offering targeted scholarships or current spending on global health. In addition, non- household cash transfer schemes to disadvantaged traditional donors, including emerging donors in the girls, and offering open-learning programs so girls Middle East, should identify girls’ health as a focus can study at their own pace. area and commit $1 billion per year. iii START WITH A GIRL A NeW AGeNDA foR GLoBAL HeALTH A GIRLS CoUNT RePoRT oN ADoLeSCeNT GIRLS MIRIAM TeMIN RUTH LeVINe Center for Global Development, Washington 20036 Support for this project was generously provided by the Nike Foundation © 2009 Center for Global Development and the Bill and Melinda Gates Foundation. The views expressed are those ISBN: 978-1-933286-42-6 of the authors and should not be attributed to the directors or funders of Miriam Temin and Ruth Levine. 2009. the Center for Global Development. Start with a Girl: A New Agenda for Global Health. Washington, D.C.: Center for Global Development. Cover Photo Credit: Brent Stirton / Getty Images 10 9 8 7 6 5 4 3 2 v START WITH A GIRL CoNTeNTS ii Take Action for Girls’ Health 57 Creating family and community resources to protect girls’ health xi foreword 60 Increasing the health benefits of schooling xii Acknowledgements and investments in other sectors xiii Preface 65 Livelihoods and microcredit approaches to improving girls’ health 1 executive Summary 66 Reaching girls and young women in the 6 Chapter 1: Why Adolescence, and workplace Why Now 67 The research agenda 8 The numbers are large 68 Chapter 5: The Way to Adolescent Girls’ 11 Why girls’ health matters Health: An Action Agenda 16 Chapter 2: Today, Adolescence Is Bad 70 Succeeding for girls in the health sector for Her Health 73 Accelerating success through other 18 Social determinants of adolescent sectors girls’ health 75 The bottom line: costs and benefits 22 Causes of death and burden of disease 79 Who can take the next step? 23 Girls’ health and reproduction 80 Start here: priority actions for change, now 31 Girls’ health and unequal sexual relationships 82 References 33 The legacy of unhealthy childhoods 93 Advisors 36 New risks in a changing world 97 About the Authors 39 The barriers to good health care 42 Chapter 3: Keeping Girls Healthy: Working through the Health System 44 Making the health sector work for girls 49 Making health-system strengthening and demand-side financing responsive to girls 52 Chapter 4: for Higher Pay-off: Working outside the Health System 54 Changing social norms to promote healthy behavior vii START WITH A GIRL BoxeS, fIGUReS & MAPS — Boxes 61 4.7 A combined approach has an impact, but a limited one: school, community, and 11 1.1 Governments have already committed health services in Tanzania to girls: international treaties that protect girls’ health 62 4.8 Aahung: surmounting cultural and political barriers to improve sexual and 23 2.1 Dangerous preparation for woman- reproductive health in Pakistan hood: female genital cutting 64 4.9 The IMAGE project in South Africa 27 2.2 One of early childbearing’s most devastating consequences 66 4.10 Keeping young domestic workers healthy and safe in the Philippines 31 2.3 Especially vulnerable adolescents 74 5.1 Tracking global spending on adolescent 36 2.4 Poor access to water takes a toll girls’ health on girls’ health 45 3.1 Using hospitals to support young rape victims in Zimbabwe — figures 45 3.2 WHO framework for youth-friendly 12 1.1 Mother’s age is a risk factor for children’s health services health problems 46 3.3 A modest proposal: the 12-year-old 22 2.1 The effect of mother’s household check-in wealth on child mortality by age of mother 48 3.4 Pharmacist training to improve 24 2.2 Adolescent girls’ burden of disease adolescents’ access to essential goods by cause, 2002 and information 28 2.3 Unmet need for contraception among 56 4.1 Using partnerships and technology married women by age and region to broaden access to comprehensive sexuality education in Nigeria and Brazil 34 2.4 Physical and/or sexual intimate- partner violence and non-partner sexual 57 4.2 Stepping Stones: addressing gender- violence among adolescents 15-19 based violence in South Africa 38 2.5 Percentage of students 13-15 years 58 4.3 Changing young men’s gender norms who are overweight through the Promundo Program improves girls’ and women’s health in Brazil 41 2.6 Illustrative factors impeding adoles- cent girls’ use of health services 59 4.4 Involving young adolescents, their mothers, and the media in Nicaragua 76 5.1 Estimated average annual financial requirements (millions US$2009) of 60 4.5 A safe space for out-of-school girls a comprehensive priority intervention in Egypt package for adolescent girls (2010-2015) 60 4.6 Safe spaces for adolescent mothers: the 77 5.2 Estimated annual costs of priority Women’s Centre of Jamaica Foundation interventions by region viii