Republic of Zambia
MINISTRY OF HEALTH
DRAFT REPORT
SITUATION ANALYSIS
ADOLESCENT HEALTH IN ZAMBIA
Reproductive Health Unit
Directorate of Public Health and Research
Ministry of Health
Ndeke House
Lusaka, Zambia
October 2009
Republic of Zambia
Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
CONTENTS
CONTENTS ................................................................................................................................................... I
FOREWORD ............................................................................................................................................... III
ACKNOWLEDGEMENTS .............................................................................................................................. IV
ABBREVIATIONS AND ACRONYMS .............................................................................................................. V
1
EXECUTIVE SUMMARY ....................................................................................................................... 1
1.1
1.2
1.3
1.4
INTRODUCTION ........................................................................................................................................ 1
PURPOSE AND METHOD ............................................................................................................................ 1
MAIN FINDINGS ....................................................................................................................................... 1
RECOMMENDATIONS ................................................................................................................................ 2
2
INTRODUCTION ................................................................................................................................. 4
3
BACKGROUND ................................................................................................................................... 4
3.1
3.2
3.3
4
PURPOSE AND METHODOLOGY ....................................................................................................... 11
4.1
4.2
4.3
5
COUNTRY PROFILE.................................................................................................................................... 4
THE HEALTH SECTOR ................................................................................................................................ 6
JUSTIFICATION OF THE ASSIGNMENT ............................................................................................................ 9
PURPOSE .............................................................................................................................................. 11
METHODOLOGY ..................................................................................................................................... 11
LIMITATIONS AND CHALLENGES ................................................................................................................. 11
MAIN FINDINGS ............................................................................................................................... 12
5.1
5.2
5.3
5.4
5.5
5.6
HEALTH PROBLEMS FACING ADOLESCENTS .................................................................................................. 12
DETERMINANTS AND OUTCOMES OF ADOLESCENT HEALTH ............................................................................ 18
ADOLESCENTS’ NEEDS FOR HEALTH SERVICES .............................................................................................. 21
GOVERNMENT EFFORTS IN IMPROVING ADOLESCENT HEALTH ......................................................................... 22
CURRENT HEALTH SERVICE PROVISION TO ADOLESCENTS ............................................................................... 27
EXTENT OF COVERAGE BY OTHER SECTORS AND PARTNERS ............................................................................. 40
6
STRENGTHS, WEAKNESSES, OPPORTUNITIES AND THREATS (SWOT) ............................................... 41
7
RECOMMENDATIONS ...................................................................................................................... 44
7.1
7.2
7.3
7.4
8
POLICY AND LEGAL FRAMEWORK ............................................................................................................... 44
PLANNING AND DEVELOPMENT ................................................................................................................. 44
IMPLEMENTATION FRAMEWORK ............................................................................................................... 44
MONITORING AND EVALUATION ............................................................................................................... 46
APPENDICES .................................................................................................................................... 46
APPENDIX I:
ZAMBIA: POPULATION AND SOCIO-ECONOMIC TRENDS ....................... ERROR! BOOKMARK NOT DEFINED.
APPENDIX II:
ZAMBIA: NATIONAL HEALTH PRIORITIES ........................................... ERROR! BOOKMARK NOT DEFINED.
APPENDIX III: ZAMBIA: THE 10 MAJOR CAUSES OF VISITATION TO HEALTH FACILITIES (ALL AGES), 2006-2008 .... ERROR!
BOOKMARK NOT DEFINED.
APPENDIX V:
LIST OF INSTITUTIONS VISITED AND PERSONS INTERVIEWED .................. ERROR! BOOKMARK NOT DEFINED.
APPENDIX VI: FIELD GUIDELINES AND AGENDA FOR FIELD VISITS ............................... ERROR! BOOKMARK NOT DEFINED.
APPENDIX VII: TERMS OF REFERENCE OF THE ADH TWG ......................................... ERROR! BOOKMARK NOT DEFINED.
APPENDIX VIII: OTHER SECTORS INVOLVED IN THE MULTI-SECTOR RESPONSE TO ADOLESCENT HEALTH. ERROR! BOOKMARK
NOT DEFINED.
APPENDIX IX: CHARACTERISTICS OF ADOLESCENT FRIENDLY HEALTH SERVICES ............. ERROR! BOOKMARK NOT DEFINED.
APPENDIX X:
LIST OF PUBLIC HEALTH FACILITIES WITH YFCS ................................... ERROR! BOOKMARK NOT DEFINED.
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Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
APPENDIX XI: YFC-DHMT QUARTERLY ASSESSMENT FORM .................................... ERROR! BOOKMARK NOT DEFINED.
APPENDIX XII: PACKAGES OF HEALTH SERVICES BY DISEASE AND LEVEL ....................... ERROR! BOOKMARK NOT DEFINED.
APPENDIX XIII: OTHER GOVERNMENT DEPARTMENTS PROVIDING SERVICES RELEVANT TO ADOLESCENT HEALTH .... ERROR!
BOOKMARK NOT DEFINED.
APPENDIX XIV: OTHER PARTNERS PROVIDING SERVICES RELEVANT TO ADOLESCENT HEALTH ....... ERROR! BOOKMARK NOT
DEFINED.
APPENDIX XV: LIST OF RELEVANT DOCUMENTS/LITERATURE ................................... ERROR! BOOKMARK NOT DEFINED.
APPENDIX XVII: TERMS OF REFERENCE – ADOLESCENT HEALTH SITUATION ANALYSIS ...... ERROR! BOOKMARK NOT DEFINED.
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Republic of Zambia
Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
FOREWORD
As you may be aware, since 1992, we have been implementing wide-ranging health sector
reforms, aimed at achieving “equity of access to assured cost-effective quality health care,
as close to the family as possible”.
Since the commencement of these reforms, we have made significant progress, as
witnessed by the major improvements in selected key health performance indicators, which
include malaria incidence, HIV prevalence, immunization levels and, maternal and child
mortality levels, which have all shown trends towards improvement. These trends were
reported and confirmed in the annual Health Management Information System (HMIS)
reports for the period 2006 to 2008, the Zambia Demographic and Health Survey of 2007
(ZDHS 2007), the Health Sector Mid-term Review of 2008 (MTR 2008) and the health
sector Joint Annual Reviews (JAR) the period from 2005 to 2008. We have also been
successful in establishing strong partnerships with the major stakeholders, including the
communities, other line ministries and government departments, the civil society and
cooperating partners.
However, one of the areas, which appear to have not received adequate attention, is
adolescent health and development. Even though adolescent health has been mentioned in
various national and sector policies and strategies, it has not been adequately addressed. It
is our view that, considering the demographic significance of the adolescents in Zambia
(currently estimated at 27% of the total population) and the high vulnerability of the
adolescents to various health risks, particularly HIV&AIDS, maternal mortality, sexual
abuse, and drug and alcohol abuse, it is of critical importance that we prioritise adolescent
health in our sector strategic plan, annual action plans and in the allocation of resources.
It is therefore our hope that this report will help explain the adolescent health situation and
provide a basis for prioritization and development of an appropriate national strategy on
adolescent health.
Honourable Kapembwa Simbao, MP
MINISTER OF HEALTH
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DRAFT REPORT
Adolescent Health Situation Analysis
ACKNOWLEDGEMENTS
It is indeed gratifying to note that we have successfully completed the situation analysis on
adolescent health in Zambia. As you may be aware, addressing adolescent health is a
critical factor towards the achievement of the national health objectives and the
Millennium Development Goals (MDGs), particularly those related to combating
HIV&AIDS and Sexually Transmitted Infections (STIs), reduction of child and maternal
mortalities, education and literacy, and improving nutrition. This is due to the fact that
adolescents represent a significant proportion of the national population and are among the
most vulnerable to various health risks, including HIV&AIDS.
On behalf of the Ministry of Health (MOH), and indeed on my own behalf, I wish to
commend all the institutions and individuals that have contributed to the successful
completion of this important assignment. I wish to particularly thank the World Health
Organisation (WHO) for the financial and technical support rendered to this process,
through Dr. Mary Katepa-Bwalya – National Professional Officer for Child & Adolescent
Health. Special thanks to all the members of the Adolescent Health Technical Working
Group (ADH-TWG), particularly Mrs. Ruth Bweupe – Chief Family Planning and
Adolescent Health Officer at MOH, Dr. Sitali Maswenyeho – UNICEF, Dr. M. Masuka –
Health Services and Systems Program (HSSP), Mrs. H. M. Wina – Planned Parenthood
Association of Zambia (PPAZ) and Mrs. Mwansa Mabuku – Care International, for
supervising and coordinating this assignment. I also wish to thank the consultancy team,
comprising of Alex N. Chikwese - project consultant, and his assistant, Peter Chilambwe,
for their technical support to this important assignment.
Finally, I wish to call upon all the MOH departments, cooperating partners, private sector
and civil society organizations with interests in adolescent health, to take this opportunity
to study this report and provide appropriate feedback that would help strengthen our
national response to adolescent health needs.
Dr. Velepi Mtonga
PERMANENT SECRETARY
MINISTRY OF HEALTH
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DRAFT REPORT
Adolescent Health Situation Analysis
ABBREVIATIONS AND ACRONYMS
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Ministry of Health
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1.1
DRAFT REPORT
Adolescent Health Situation Analysis
EXECUTIVE SUMMARY
Introduction
The Ministry of Health (MOH) and its partners have identified the need to conduct a
situation analysis on adolescent health in Zambia to support policy, planning and
development of an appropriate national response. This report presents the findings of the
situation analysis on adolescent health in Zambia, which was conducted between August
and October 2009. It highlights the background, method, findings and recommendations
of this study.
1.2
Purpose and Method
The purpose of this assignment was to establish the current situation in respect of
adolescent health in Zambia, which should form the basis for the development of an
appropriate national strategy on adolescent health. The method used included a desk
review of relevant documents, structured interviews with key players and field visits to
Lusaka and Solwezi districts. A copy of the field visits guide is provided at Appendix VI,
while the list of places visited and people interviewed is at Appendix VII.
1.3
Main Findings
The following were the main findings:
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Globally and at country level, adolescents represent a major demographic force. In
Zambia, adolescents constitute 27% of the total population, while globally they are
estimated at 20% of the world’s population1;
The main health problems facing the adolescents include: general health problems
(see Appendix III); Sexually Transmitted Infections (STIs), including HIV&AIDS
and syphilis; early and unprotected sex; early marriages and unwanted pregnancies;
sexual, drug and alcohol abuse; violence; unsafe cultural practices; and mental health
problems;
The main determinants of adolescent health in Zambia include: the disease burden
dynamics; the socio-economic environment, including literacy and education, poverty,
employment status, cultural and religious beliefs; and the family and community
environments within which the adolescents exist;
The health services needed by adolescents are in form of a package of “Adolescent
Friendly Health Services (AFHS)”, aimed at addressing special health needs of the
adolescents and barriers to health services (See Appendix IX for details);
Broadening the Horizon: Balancing Protection and Risk for Adolescents, WHO, Department of adolescent Health and Development,
2002
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1.4
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DRAFT REPORT
Adolescent Health Situation Analysis
The Government’s efforts towards strengthening adolescent health and development
include: Zambia is signatory to various protocols on child and adolescent health and
development, including the United Nations Convention on Children’s Rights (UNCRC); has incorporated the rights of children and adolescents in the Bill of Rights and
the National Constitution; developed the National Youth Policy, National Child
Health Policy and National Reproductive Health Policy; introduced specific
legislations aimed at addressing sexual, drug and alcohol abuse, home and gender
based violence and other forms of abuse; established the Ministry of Youth, Sport and
Child Development; introduced Youth Friendly Health Services (YFHS) through the
establishment of Youth Friendly Corners (YFCs) in pilot districts; and has recently
strengthened the adolescent health institutional framework within the MOH
organizational structure. However, there are still significant weaknesses that need to
be addressed;
The status of adolescent health services in Zambia is weak. Even though YFCs have
been established in selected health facilities, these are inadequate and not
appropriately supported;
The packages of health services available to the adolescents include: specific AFHS
services offered through YFCs, where such facilities exist; and services offered to the
general public, which do not necessary provide for specific AFHS;
Services offered by health facilities that have introduced YFCs include: general
healthcare services; peer counseling and education; Voluntary Counseling and Testing
(VCT); Family Planning (FP) services; life-long skills programmes, Edu-sport and
drama activities within the communities and schools; and health promotion and
information;
Currently, the resources available to support adolescent health are inadequate:
funding to adolescent health/YFCs is poor and not clearly defined; involvement of
health workers in YFC activities is inadequate; there is lack of training of health
workers in AFHS; only a limited number of health facilities are offering AFHS; and
the services are affected by the erratic supply of essential drugs and medical supplies;
The existing health information systems, particularly the Health Management
Information System (HMIS), do not adequately address adolescent health reporting
needs. Disaggregation of data to isolate data on adolescents is still a major weakness;
and
Adolescent health is broad and there are several players involved, including
government ministries, private sector, civil society and CPs. However, coordination
is weak.
Recommendations
Strengthen the policy framework for multi-sector coordination of adolescent health:
Revise the National Child Health Policy to incorporate adolescent health needs, and
rename it into “National Child and Adolescent Health Policy”;
Strengthen Planning. Develop appropriate strategy for adolescent health, providing
for a unified multi-sectoral response. Prioritise adolescent health in sector strategies
and plans;
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DRAFT REPORT
Adolescent Health Situation Analysis
Strengthen coordination: Operationalise the Adolescent Health Technical Working
Group (ADH-TWG). Review the composition, Terms of Reference (TORs) and
leadership of the ADH-TWG and strengthen participation of all the key stakeholders;
Strengthen institutional framework for adolescent health:
 Implement the approved MOH structures for adolescent health at all the levels;
 Expand the network of YFCs/AFHS to cover all districts;
 Provide for appropriate facilities for YFCs/AFHS. Revise construction guidelines
for health facilities to include minimum requirements for AFHS;
 Introduce and Adolescent Health Week or integrate adolescent health activities
within the existing Child Health Week programmes; and
 Introduce AFHS component in all health training programmes;
Prioritise adolescent health in resource allocation. Provide for specific and adequate
resources, particularly financing, health workers and essential medical inputs. Solicit
for financial and technical support from CPs. Ensure high standards of transparency
and accountability;
Provide for appropriate incentives for Youth Volunteers, in similar lines with other
community health partners. Enhance incentives for youths accessing YFCs/AFHS;
and
Strengthen M&E for adolescent health: Ensure that all major health information
systems and performance reviews cover adolescent health.
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Adolescent Health Situation Analysis
INTRODUCTION
Adolescents are a major demographic force. Globally, they are estimated at 20% of the
world’s population, while in Zambia they represent approximately 27% of the total
population. Adolescents also constitute a significant proportion of the sexually and
economically active population, representing a major factor in the social, economic and
human development agenda of the country. Largely due to the difficult socio-economic
situation and the high disease burden, particularly the HIV&AIDS epidemic, adolescents
in Zambia are significantly exposed to various social, economic and health problems.
MOH has observed that, even though adolescents have been mentioned in various
national policies and strategies, issues of adolescent health and development in Zambia
have not been adequately articulated and addressed. Further, there is little information on
adolescent health. In view of the foregoing, MOH and its partners have identified the
need to conduct a situation analysis on adolescent health, so as to gather relevant
information, which could form the basis for developing an appropriate national response.
This report presents the background, methodology, findings and recommendations of the
adolescent health situation analysis, conducted between August and October 2009.
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3.1
BACKGROUND
Country Profile
3.1.1 Demographic Overview
Zambia is a landlocked country located in the southern part of Sub-Saharan Africa. It
covers an area of approximately 752,612 Km2 and shares boundaries with eight other
countries, namely: Tanzania and the Democratic Republic of Congo (DRC) in the North,
Malawi and Mozambique in the East, Zimbabwe, Botswana and Namibia in the South and
Angola in the West. Presented on the left hand side is the map of Zambia, while Table 1
below, presents the status of selected demographic indicators on Zambia.
Table 1: Zambia – Selected Demographic Data, 2008
Indicator
Source
Population
UNAIDS 2006
Average Annual Population Growth Rate
CSO, 2000 Census
Life Expectancy at Birth
CSO Projections Report
Population Under the Age of 15 Years (%) CSO, 2000 Census
Urban Population
CSO, 2000 Census
Poverty Level
ZDHS 20072
Status
12.5 million
2.5%
51.3 Years
47%
34.7%
67% (overall)
Presented in Figure 1 is the projection of population distribution by age and sex for the
year 2010.
2
Zambia Demographic and Health Survey 2007 (ZDHS 2007)
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Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
Projected Age and Sex Distribution for the Year 2010
Zambia is a politically stable country, which has continued to enjoy uninterrupted peace
since its attainment of independence from the Great Britain on 24th October 1964.
Following a major political change in 1991, the country has reintroduced a multi-party
democracy political system, backed by a market oriented economic system.
3.1.2 Socio-Economic Overview
Since 1992, Zambia has
been implementing major
socio-economic
reforms,
with the objective of
achieving
sustainable
social-economic
development.
Currently,
the country is focusing at
attaining
the
“Vision
2030”, which aims at
transforming Zambia into a
“prosperous middle-income
nation by 2030”.
Over the period of five years ended December 2007, the country’s economy had shown
major improvements, as demonstrated by the consistent economic growth rate of above
5% per year, and the decline in inflation and lending interest rates. However, the
performance in 2008 showed some deterioration, which was largely attributed to the
impact of the global economic crisis and major unplanned local events, particularly the
presidential by-election. Figure 2 presents the trends in selected macroeconomic
indicators for the period from 2004 to 2008.
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Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
The difficult economic situation has continued to significantly impact on the provision of
social services, such as health and education, to the population. The most affected are the
vulnerable population groups such as the adolescents, children, women, physically
challenged persons and the rural populations.
3.2
The Health Sector
3.2.1 Overview
As part of the socio-economic reforms, which commenced in 1992, Zambia has been
implementing major health sector reforms. The vision of these reforms is to attain
“equity of access to assured cost-effective, quality health care, as close to the family as
possible”. Even though over the past decade significant achievements have been made,
the health sector has continued to face major challenges, with significant implications on
its performance. These challenges include: the high burden of disease, exacerbated by the
high impact of malaria and HIV&AIDS; critical shortages of qualified health workers;
erratic supply of essential pharmaceuticals and other medical supplies; inadequate
infrastructure and maintenance; and inadequate funding to the sector.
3.2.2 Disease Burden
Zambia is a high disease burdened country. Despite the major improvements reported in
the HMIS reports and the recent health surveys3, the country has continued to face a huge
disease burden. Malaria has continued to be the leading cause of morbidity and mortality
in the country, accounting for 3.2 million cases and 3,781 deaths in 20084. Malaria is
endemic in all parts of the country, with minor seasonal and geographic variations.
HIV&AIDS is also a major epidemic in Zambia and cuts across age, gender, geographical
and socio-economic status of the population. It is currently estimated that 7% of young
women and 4% of young men between the ages of 15 and 19 years are HIV positive5. An
analysis of the trends for the top 10 diseases in Zambia is presented in Appendix III.
3.2.3 Health Sector Structure
The health sector in Zambia is liberalized and comprises of three main categories of
health service providers, namely the public, faith-based (mission) and private/civil society
owned health facilities. Figure 3 presents the health sector structure, by type of
ownership.
3
the Zambia Demographic and Health Survey 2007 (ZDHS 2007), the Malaria Indicator Survey 2008 (MIS 2008), Zambia Sexual
Behaviour Survey 2006 (ZSBS 2006)
4 Health Management Information System (HMIS) 2008, Ministry of Health, Zambia
5 Zambia Demographic and Health Survey 2007 (ZDHS 2007)
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Ministry of Health
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Adolescent Health Situation Analysis
Figure 3: Zambia: Health Sector Players
Public Health Sector
(Owned by MOH and
other Government
Departments)
ZAMBIAN HEALTH
SECTOR
Faith-Based Health
Sector under CHAZ
(Mission facilities)
Private Health Sector
(for-profit and notfor-profit)
Table 2 presents an analysis of the existing health facilities by type, size and ownership as
at 2008, while the description of these facilities is presented at Appendix IV.
Table 2: Zambia: Health Facilities by Type, Size and Ownership, 2008
Type of Facility
3rd Level Hospitals
2nd Level Hospitals
1st Level Hospitals
Health Centres: Urban
Rural
Health Posts
TOTAL
Number of
Beds
Cots
2,532
4,204
6,016
1,814
9,224
198
23,988
417
827
859
300
559
11
2,973
Number of Health Facilities by
Ownership
Government/ Faith-based Private
State Owned
(CHAZ)
6
0
0
13
3
5
39
29
4
206
6
53
930
77
22
161
2
8
1,355
117
92
Total Facilities
Number
%
6
21
72
265
1,029
171
1,564
0.3%
1.0%
5.0%
17.0%
66.0%
11.0%
100.0%
Note: 3rd Level Hospitals include the Cancer Diseases Hospital located at the UTH (Opened in 2007)
Source: Heath Institutions in Zambia, Ministry of Health, 2008
3.2.4 Health Sector Strategy and Priorities
The current health sector strategy is articulated in the NHSP 2006-10, which also forms
an integral part of the Fifth National Development Plan (FNDP). It is based on the
following strategic framework:
Vision:
To ensure equity of access to assured quality, cost-effective and
affordable health care services, as close to the family as possible, so
as to significantly contribute to the human and socio-economic
development of the nation.
Overall Goal:
To establish a society in which Zambians create environments
conducive to health, learn the art of being well and provide basic
level healthcare to all.
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Key Principles:
Equity, affordability, cost-effectiveness, transparency and
accountability, partnerships, decentralisation and leadership.
Theme:
Towards attainment of the health related MDGs and national health
priorities.
National Health Identified a set of national health priorities, which take into account
Priorities:
national health needs, as well as the regional and international health
commitments, particularly the MDGs, the Abuja and Maputo
declarations, the Paris declaration and the Roll Back Malaria (RBM)
initiative. Table 4 presents an analysis of the national health
priorities identified by the NHSP 2006/10.
3.2.5 Selected Health Performance Indicators
Table 3 below, presents trends in selected health performance indicators.
Table 3: Zambia: Selected Socio-economic and Health Indicators, 2005 - 2008
Selected Health Indicators
Malaria Incidence
Unit
Per 1,000 Population
First Antenatal Visits
Times
First Antenatal Coverage
Percentage
Institutional Deliveries
Supervised Deliveries
Trained traditional birth attendants (tTBAs)
Percentage
Percentage
Percentage
Fully Immunised Children Under Age of 1
Year
Underweight Prevalence
Percentage
Percentage
Selected ZDHS Indicators
2005
373
2006
412
2007
358
2008
252
3.0
2.9
2.8
2.6
93%
43%
62%
92%
43%
61%
92%
45%
62%
98%
45.2%
60%
19%
18%
17%
15%
82%
87%
86%
90%
16%
14%
10%
6%
ZDHS
1992
ZDHS
1996
ZDHS
2002
ZDHS
2007
HIV Prevalence
Percentage
Under 5 Mortality Rate (U5MR)
Per 1,000 Live Births
191
197
16.1
168
14.3
119
Infant Mortality Rate
Maternal Mortality Rate
Per 1,000 Live Births
Per 100,000 Live Births
107
109
649
95
729
70
591
Adult Mortality Rate
Per 1,000 Population
10.9
14.1
12.5
Sources: Ministry of Health, Zambia Economic Reports, Bank of Zambia, ZDHS 2007
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Adolescent Health Situation Analysis
Justification of the Assignment
3.3.1 Overview
Internationally, adolescents are broadly defined as young people between the ages of 10
and 24 years. However, this definition is not universal and differs from one school of
thought to another. The Zambia National Population Policy of 2007 defines adolescents
as young people between the ages of 15 and 19 years. Adolescence represents the period
when young people attain puberty and experience the process of transformation into
adulthood. At this stage, young people acquire new capacities, including sexuality and
capacity to contribute to socio-economic development. However, at the same time, they
face new and peculiar challenges, which require appropriate support for them to survive
and grow into healthy and responsible adults. These challenges are largely related to
vulnerability to risks associated with behaviour change, which could have life-long
implications on health, social and economic life of the adolescents. In this respect, it is
generally recognised that appropriate planning and management of adolescent health has
significant potential to contribute to overall socio-economic development at both country
and global levels.
Adolescent health could be defined as the optimal state of well being of the adolescents in
all areas of human development, including physical, psychological, emotional, social and
spiritual6.
Reasons for Focusing on Adolescents Health
Over the past two decades, there has been significant global concern for the health and
development of the adolescents, led by the World Health Organisation (WHO). This has
largely been due to the realization of the important role that the adolescents play in the
general socio-economic and human development of any country. Adolescents are also an
important factor in the quest to achieve the Millennium Development Goals (MDGs),
particularly those related to: the fight against malaria, HIV&AIDS, STIs and TB;
reduction in child and maternal mortalities; improving nutrition; and education.
There are several justifications for the need to focus on adolescent health. These include,
the fact that adolescents are:
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A major demographic force: Globally, adolescents are a major demographic force,
estimated at one fifth (20%) of the world’s population7. In Zambia, adolescents
account for approximately 27% of the total population;
A major socio-economic force: Adolescents form a major proportion of the socially
and economically active populations and contribute significantly to the socioeconomic well-being of their families, communities and countries, through paid and
unpaid labour, sports and entertainment;
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Guiding Principles for Promoting Adolescent Health
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Broadening the Horizon: Balancing Protection and Risk for Adolescents, WHO, Department of adolescent Health and Development,
2002
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Have significant potential to influence the future: Adolescents have significant
potential to influence the future population and socio-economic trends of their
respective countries;
Are entitled to human rights: Adolescents have the right to health and protection, as
provided for in the United Nations Convention on the Rights of Children (UN-CRC).
In Zambia, just like all the citizens, adolescents are entitled to the basic human rights
and to participate in national development, as enshrined in the Bill of Rights of the
National Constitution;
Are highly vulnerable to various social vices and health risks: Adolescents are
vulnerable to risky behaviours, which could lead to long term health and social
problems. In Zambia, by the age of 18 years, about 60% of girls and 51% of boys are
reported to have had sex, and only about one quarter of adolescents aged between 15
and 19 years use condoms at first sex8;
Adolescents constitute a large proportion of pregnant women: Globally, about 16
million women aged between 15 and 19 years give birth each year, representing
approximately 11% of all births worldwide. The proportion of births that take place
during adolescence is about 2% in China, 18% in Latin America and the Caribbean
and more than 50% in Sub-Saharan Africa9. In Zambia, 3 in 10 young women aged
15 to 19 years have either given birth or carrying a pregnancy. Between 2004 and
2007, about 36,000 girls dropped out of school due to pregnancies; and
Adolescent pregnancy is dangerous for both the mother and the child, contributing to
high maternal and neonatal mortalities.
Zambia Demographic and Health Survey 2007 (ZDHS 2007)
Fact sheet: Why is giving attention to adolescents important for achieving MDG 5?, WHO, 2008
10
Republic of Zambia
Ministry of Health
4
4.1
DRAFT REPORT
Adolescent Health Situation Analysis
PURPOSE AND METHODOLOGY
Purpose
The main purpose of this study was to carry out a situation analysis of adolescent health
and development in Zambia, in order to:



4.2
Provide for appropriate information and understanding of the status, challenges and
opportunities for adolescent health;
Provide a basis for the development of the national adolescent health strategy; and
Feed into the process of developing a section on adolescent health, which would be
incorporated into the relevant sector strategic plans, the Sixth National Development
Plan (SNDP) and other national policies, for purposes of prioritizing adolescent health
at sector and national levels.
Methodology
The methodology adopted included a desk review, interviews with key players/
informants, field visits and consultations with stakeholders.
The desk review included collection and analysis of documents/data relevant to
adolescent health and development. The literature collected included relevant policies
and legislative frameworks, plans and progress reports. The list of documents consulted
is provided at Appendix IX.
Two districts were selected for field visits, namely Lusaka and Solwezi districts. The field
visits involved visiting and interviewing a range of key stakeholders on the status,
achievements, problems and opportunities of adolescent health. The discussions took the
form of semi-structured interviews. Data collected included qualitative and quantitative
data. The list of institutions visited and persons interviewed is provided as Appendix V
and a copy of the field visits guide is provided at Appendix VI.
4.3
Limitations and Challenges
Limiting factors and challenges included: the limited scope of coverage for the field
visits, i.e. only 2 districts out of 72; non-coverage of typical rural sites to contrast with the
urban areas; limited data on adolescent health, particularly quantitative data, making it
difficult for some stakeholders to provide all the requested data; limited scope of the
Health Information Systems (HIS), particularly the HMIS, which does not adequately
disaggregate data to allow for ease isolation and analysis of data on the adolescents; and
difficulties in securing and sustaining appointments for interviews with some targeted
institutions, leading to delays and, in some cases, failure to meet with some stakeholders.
11
Republic of Zambia
Ministry of Health
5
DRAFT REPORT
Adolescent Health Situation Analysis
MAIN FINDINGS
This section highlights the main findings of this study. The main areas highlighted
include: health problems facing the adolescents; determinants and outcomes of
adolescent health; adolescents’ needs for health services; the government’s efforts in
improving adolescent health; current health service provision to adolescents; and the
extent of coverage by other sectors and partners.
5.1
Health Problems Facing Adolescents
The study revealed that the main problems facing the adolescents in Zambia, include:








General health problems;
Early and unprotected sex;
Sexual abuse;
Early marriages and pregnancies;
Drugs and alcohol abuse;
Accidents and violence;
Unsafe cultural practices; and
Mental health problems.
Whilst members of the general public are also susceptible to these health problems, the
adolescents are more vulnerable. This could be attributed to a number of factors,
including:
1) the behaviour change associated with adolescence; 2) the fact that
adolescents are not fully grown-up adults and therefore may have difficulties in making
responsible decisions; 3) a large proportion of adolescents are not socially and
economically independent, and are exposed to various forms of manipulation and abuse;
and 4) the existing health services do not adequately address the specific health needs of
the adolescents.
5.1.1 General Health Problems
Zambia is a high disease burdened country, with high prevalence of both communicable
and non-communicable diseases. According to the HMIS 2008 bulletin, the main causes
of morbidity and mortality in Zambia include: malaria; respiratory infections (nonpneumonia), particularly tuberculosis and acute respiratory infections; diarrhea (nonbloody); trauma (accidents, injuries, wound and burns) and others. The HIV&AIDS
epidemic is also a major cause of morbidity and mortality across the country. Appendix
II presents the top 10 causes of visitations to health facilities among the general
population in Zambia. Also refer to Section 3.2.2.
12
Republic of Zambia
Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
5.1.1.1 Malaria
Malaria is the leading cause of morbidity and mortality in Zambia Adolescents are also
affected by the malaria burden. The impact of malaria is higher among the adolescents
forming part of vulnerable groups, such as pregnant, rural populations and orphaned
adolescents, with little or no financial means to access basic protection and treatment. In
2008, about 3.2 million cases of malaria and 3,781 deaths were reported across the
country. However, over the past 3 years, malaria incidence per 1,000 population is
reported to have reduced from 412 cases in 2006 to 358 cases in 2007 and 252 cases in
2008 (MOH, HMIS 2008).
Malaria in pregnancy is a major cause of morbidity and mortality in pregnant women
(accounting for approximately 20% of maternal mortality). According to the ZDHS
2007, 3 in 10 young women aged 15 to 19 years have either given birth or carrying a
pregnancy.
5.1.1.2 Respiratory Infections (Non-Pneumonia)
Adolescents are also susceptible to Respiratory Infection (non pneumonia), particularly
Tuberculosis (TB), which remains a major problem in Zambia, accounting for significant
proportions of morbidity and mortality. The high vulnerability of the adolescents to HIV
also contributes to the numbers of adolescents affected by TB, through the TB/HIV coreinfection factor. It is estimated that approximately 70% of confirmed TB patients in the
country are also HIV positive. In some cases, even where adolescents are not infected by
TB, they are also affected due to the economic impact that this disease may have on their
parents or guardians. Respiratory infection (non pneumonia)10 is currently the second
leading cause of morbidity in Zambia. In 2007, WHO’s estimated incidence for all forms
of TB cases in Zambia was 553/100,000, while that for sputum smear positive was
228/100,000, corresponding to around 67,800 and 28,000 cases, respectively. The
situation has been complicated by the emergence of drug resistant TB and the high
prevalence of TB/HIV core infections.
5.1.1.3 HIV&AIDS and Sexually Transmitted Infections
HIV&AIDS and STIs present a major
health problem for the adolescents in
Zambia. According to the ZDHS 2007,
approximately 7% percent of young women
and 4% of young men aged 15-19 years are
HIV positive. Figure 3 presents analysis of
HIV prevalence among the youths 15-24
years of age.
Figure 3: Zambia: HIV Prevalence in Youths
Aged Betwwen 15 and 24 Years, 2007
20
15
% 10
5
0
10
8
4 4
15-17
4
18-19
20-22
Zambia: HMIS Report 2008
13
Men
Women
2
Age (Years)
10
15
10
23-24
Republic of Zambia
Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
Further, current estimates indicate that in Zambia, about 700,000 children, including
adolescents, have been orphaned as a result of AIDS. In Lusaka and North-Western
Provinces, HIV prevalence in adults between the ages of 15 and 49 years is currently at
21% and 7% respectively.
According to the recent surveys and reviews11, over the past 5 to 10 years, Zambia has
recorded major improvements in the fight against HIV&AIDS. In particular, HIV
prevalence among the adults between the ages of 15 and 49 years, has dropped from
16.1% in 2002 to 14.3% in 2007.
5.1.1.4 Nutrition Problems
In Zambia, lack of proper nutrition is
a major problem among the
adolescents, particularly those who
are orphaned or live in rural areas,
where poverty levels are highest.
Due
to
high
poverty
and
unemployment levels among the
population, a large proportion of the
population can not afford decent and
adequate nutritional needs for their
families.
Figure 4.
Zambia: Trends in Under Nutrition-Children
Stunting
Under weight
50
45
40
Wasting
47
45.4
42
40
35
30
25
28
25
24
20
14.6
15
10
5
5
5
4
5
0
1992
1996
2001/2
2007
Poverty levels in the countries are
estimated at 67% (overall poverty)
and 72% (extreme poverty). Current estimates indicate that 14.6% of women aged
between 15 and 19 years are thin, with a Body Mass Index (BMI) of below 18.5. Normal
BMI is 21.2. Figure 4 presents the trends in under nutrition in children. Under-nutrition
in childhood could lead to serious health consequences in adolescence, including delayed
attainment of puberty and susceptibility to various diseases.
Nutrition is also an important factor in adolescent health and development. During
adolescence, children experience rapid physical and mental growth, which demands for
extra nutrition. Poor nutrition would significantly impact on the health and development
of the adolescents, including poor physical-stunting and mental growth, delayed
attainment of puberty and susceptibility to infections. In adolescent women, poor
nutrition could lead to high mortalities during pregnancies and higher likelihood of giving
birth to under-weight and unhealthy babies, with reduced chances of survival.
5.1.2 Sexual Abuse
In Zambia, sexual abuse involving adolescents is a major problem. Prevalence of sexual
abuse was confirmed in both Lusaka and Solwezi, particularly by the Zambia Police
Victim Support Units.
11
Zambia Demographic and Health Survey 2007 (ZDHS 2007); Zambia Sexual Behaviour Survey 2005; Mid-Term Review 2008
14
Republic of Zambia
Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
The most common types of sexual abuse among adolescents include voluntary sexual
abuse and forced sexual abuse, such as defilement and rape cases and forced marriages.
According to available statistics, in 2003, 16.9% of girls aged 15-19 years reported that
they had been forced to have sex (CSO et al, 2003).
In North-Western Province, for example, a survey conducted in 2005 confirmed that
relationships between teachers and pupils (usually a male teacher and a female pupil)
were reported to be common, and in most cases welcomed by the girl’s family12. Sexual
abuse was reported to be more prevalent with girls aged 11-16 years, even though boys
are also vulnerable.
Other forms of adolescent abuse include child labour, particularly for the 11-15 years,
child trafficking and exposure to unprogressive traditional procedures, such as sexual
cleansing. The consequences of child sexual abuse are severe and wide-ranging,
including the risks of contracting STIs, particularly HIV, early pregnancies, abortions and
other problems, which are discussed separately.
5.1.3 Early and Unprotected Sex
The study confirmed
that
early
and
unprotected
sex
involving
adolescents is a
major problem in
Zambia.
Table 4: Sexual Behaviour Among Young People 15-24 Years, by Sex and
Residence, 1998-2005
Sex
and Young People 15-24 Years Condom Use at Last Higher
Residence
with More than One Sexual Risk Sex Among Young People
Partner in Last Year
15-24 who are Sexually Active
Males
%
%
%
%
%
%
%
%
Urban
0
7.8
8.2
4.3
13.6
12.3
17.1
12.8
Rural
0
15.4
8.6
7.4
22.3
13.3
9.6
10.6
0
Total
12.4
8.5
6.2
26.4
12.9
12.5
11.4
Males
Urban
0
1.8
4.0
2.1
26.9
7.5
7.8
7.0
Rural
0
2.3
1.8
3.1
17.3
5.2
4.4
1.8
0
Total
2.1
2.7
2.8
21.1
6.1
5.8
3.6
TOTAL
Urban
0
3.8
5.9
3.1
30.6
9.2
11.9
9.6
Rural
0
7.4
4.9
5.0
20.2
8.3
6.8
5.6
0
All
6.0
5.3
4.3
24.1
8.7
8.8
7.1
Respondents
In Zambia, majority
of young people
begin
sexual
relations
during
adolescence.
The
ZDHS 2007 reported
that 56% of women
aged between 15 and Source: Zambia Demographic and Health Survey 2005
24 years had sex
before the age of 18 years, while only 24% of women between 15-24 years of age used a
condom at first sex. Similarly, 51% of men between 15-24 years had sex before age of 18
years, and only 22% of them used a condom at first sex. Table 4 presents the trends for
selected indicators of sexual behaviour among adolescents between the ages of 15 and 24
years. This practice significantly exposes adolescents to HIV and other STIs, teenage
pregnancies, unsafe abortions and dropping out of school.
12
Rapid Socio-Cultural Research as a Methodology for Informing Sexual and Reproductive Health/HIV/AIDS Programming in NorthWestern Province, Zambia, Government of the Republic of Zambia, UNFPA Zambia, 2005
15
Republic of Zambia
Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
5.1.4 Unsafe Cultural Practices
In Zambia the main unsafe cultural practices affecting the adolescents include Female
Genital Mutilation (FGM), sexual cleansing and unsafe traditional male circumcision
practices. However, even though FGM is practiced among some tribal groupings, it is not
widely practiced and does not represent a major problem.
5.1.4.1 Sexual Cleansing
Even though sexual cleansing is being
discouraged and has significantly
reduced in Zambia, it still exists,
particularly in remote rural areas.
Adolescents, especially females, are the
most vulnerable to this practice.
His Royal Highness Acting Senior Chief
Kapijimpang’a of North Western Province
This matter was extensively discussed
with the Acting Chief Kapijimpang’a of
North Western Province, who indicated
that his royal establishment was
vigorously discouraging sexual cleansing
practices. The photograph above shows
the Acting Senior Chief at his palace.
Sexual cleansing is a traditional practice
whereby, when a married person dies, the surviving spouse is traditionally either given a
new spouse or is required by tradition to have unprotected sex with a selected member of
the family of the diseased person. Such a practice leads to significant exposure to the
risks of contracting HIV and other STIs. It also presents a violation of human rights, as
some people are forced into these practices.
5.1.4.2 Unsafe Traditional Male Circumcision
The study confirmed that traditional male circumcision is mainly practiced by the Lunda
and Luvale people of the North-Western province. This is conducted when adolescents
attain teenage during initiation ceremonies. It is currently estimated that about 70% of the
male population in the North-Western Province have been circumcised, while the
proportions in the other provinces are negligible.
His Royal Highness Acting Chief Kapijimpang’a also confirmed that the practice of
traditional male circumcision is widespread in North-Western province and that currently,
MOH is collaborating with traditional rulers in making traditional male circumcision
safer, through training of traditional surgeons in safer circumcision procedures and the
use of safe instruments.
16
Republic of Zambia
Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
The Chief also confirmed that MOH is currently promoting clinical male circumcision
throughout the province. In Lusaka, discussions with health facilities and YFCs
confirmed that clinical circumcision is being scaled up with the participation of the
adolescents.
WHO currently estimates that safe clinical circumcision has potential to reduce the
chances of infection of HIV by about 60% to 70%. However, traditional male
circumcision has inherent risks of transmitting STIs, including HIV, as well as avoidable
physical injury and death, if not conducted properly and in a safe environment.
5.1.5 Drugs and Alcohol Abuse – Substance Abuse
Abuse of alcohol, drugs and other psychotropic substances is another major problem
affecting the adolescents in Zambia. This was also acknowledged by most of the persons
interviewed. The most common mode is smoking of cigarattes and drugs, mainly
cannabis. According to a study conducted in the town of Kafue, in Zambia in 1999,
overall 8.2% of the adolescents were current cigarette smokers, while 10.4% males and
6.2% females were current smokers13.
5.1.6 Accidents and Violence
Accidents and various forms of violence are also prevalent among the adolescents in
Zambia. These include road traffic accidents, industrial accidents, home-based violence,
sexual violence, robberies, murder and other forms of violence. This was confirmed by
the Police Victim Support Units and Health Facilities visited. According to the HMIS
2008 report, in Zambia, trauma, which includes accidents, injuries, wounds and burns, has
for the past three years been consistently ranked as number four among the top ten causes
of morbidity in the country. It is also confirmed that trauma is a problem among the
adolescents, and is more prevalent in urban areas than rural areas. During the field visits,
most of the institutions interviewed expressed concern at the increasing rates of violence
and accidents among the adolescents.
As a result of such problems, a large number of adolescents are reported to have suffered
injuries, which sometimes lead to morbidity, permanent disabilities and/or death. The
main concern is that in Zambia and many other countries, particularly in Sub-Saharan
Africa, home-based violence is not receiving serious attention from the Police and other
law enforcement agencies.
13
Malawi Medical Journal; 19(2):75 - 78, June 2007
17
Republic of Zambia
Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
5.1.7 Mental Health Problems
Adolescents in Zambia are also vulnerable to various forms of mental health problems. In
Zambia, hospital based figures show a prevalence rate of 3.61 and 1.8 per 10,000
population for acute psychotic states and schizophremia, respectively. It is also estimated
that 10% of admissions for acute psychotic states are alcohol and drug misuse related,
where more males are reported to abuse alcohol and drugs than women14. Both males and
females admitted for abuse of alcohol and drugs are usually within the sexually active age
group, including adolescents.
Globally, it is estimated that over 12.5% of the burden of disease is due to mental and
neurological disorders. About 90,000 adolescents between the ages of 10 and 24 years
commit suicide each year across the world.
5.2
Determinants and Outcomes of Adolescent Health
The main determinants of adolescent health in Zambia include the disease burden, socioeconomic factors, and the family and community environment.
5.2.1 Disease Burden
The disease burden for Zambia is discussed in more detail in Section 3.2.2. The levels
and complexity of disease burden, including epidemics, is a major risk to health for the
adolescents. In this respect, the types of diseases, prevalence levels and distribution
patterns determine the levels of risks and exposure to diseases and ill-health. In the case
of Zambia, the main risks include HIV/STIs, malaria and TB, which are highly prevalent
in the country.
5.2.2 Socio-economic Environment
The socio-economic environment has a major determining impact on whether a child or
adolescent would live a healthy life. As discussed in Section 3.1.2, Zambia’s socioeconomic situation is weak. In Zambia, the main socio-economic factors affecting the
health and development of the adolescents include: inadequate educational/literacy
opportunities, high poverty levels, high levels of unemployment and low access to safe
water.
14
Mental Health Policy, Ministry of Health, 2005
18
Republic of Zambia
Ministry of Health
5.2.2.1 Education and Literacy
In Zambia, it is estimated that
more than 6 in 10 women (64%)
and 8 in 10 men (82%) are
literate. Urban areas have higher
literacy levels than rural areas.
Table 5 presents the trends in
enrollments and Gender Parity
Index (GPI) at basic schools by
gender for the period from 2006
to 2008.
DRAFT REPORT
Adolescent Health Situation Analysis
Table 5: Enrollments and GPI at Basic Schools (Grade 1-9) by
Gender, 2006-2008
Gender
2006
2007
2008*
% Change
2008/07
Female
1,464,137 1,547,715
1,631,009
5.4
Male
1,522,644 1,618,595
1,704,018
5.3
Total
2,986,781 3,166,310
3,336,009
5.4
% Increase
0
6%
12%
(from 2006)
GPI
0.962
0.956
0.957
*Preliminary
Zambia: Economic Report 2008
Literacy rates among men are fairly high across all provinces, ranging from 71% in
Eastern to 90% in Copperbelt provinces. Whilst there are no clear patterns of literacy by
age, however, for women, literacy is highest among young women aged 15-19 years
(73%), while for men it is highest among the 15-19 years and 40-44 years (84% each)15.
According to the 2008 Economic Report, pupil enrolment at basic education level (grade
1-9) increased by 5.4% to 3,336,009 from 3,166,310 in 2007. The GPI stood at 0.957.
As with literacy, education rates are higher among males than females.
15
Zambia Demographic and Health Survey
19
Republic of Zambia
Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
Education and literacy levels have significant impact on adolescent health and
development. Literacy is an important asset for promoting adolescent health, as it
presents individuals with the capacity to read and write materials relevant to the
promotion of adolescent health and development, including relevant Information,
Education and Communication (IEC) materials.
Education is also a critical factor for understanding various issues on adolescent health
and development, and is an important tool for accessing better jobs and household wealth
status, which all have direct impact on the socio-economic well-being of individuals.
5.2.2.2 Poverty
As discussed in Section 5.1.1.4, poverty prevalence in Zambia is high. Poverty is one of
the major determinants of health and development for children and adolescents. Poverty
leads to failure to meet the basic needs and nutrition, with significant implications on
health, growth, morale and self esteem. It also has potential to expose the adolescents to
bad practices, such as prostitution, early pregnancies and other life-threatening
behaviours. Poverty also impacts on the ability of the families to support the educational
needs of their children/adolescents, and contributes to creating environments for drug
abuse, violence, commercial sex and sexual abuse, particularly among the adolescents.
5.2.2.3 Other Socio-Economic Factors
The other socio-economic factors, with significant influence on adolescent health and
development in Zambia include employment status, access to safe water and sanitation,
conflicts and natural disasters. Unemployment among the adolescents and their
parents/guardians is high a major cause of poverty and poor access to basic needs.
5.2.3 Family and Community
Zambia is a multi-cultural society, characterized by different racial and ethnic groups,
religious and traditional beliefs, urbanization and broader access to the internet and other
sources of sharing information with the global community. This has an impact on
adolescent health.
20
Republic of Zambia
Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
Adolescent health is significantly influenced by the family and community environments
under which they are raised. Parental care and guidance, society values and practices,
religious teachings and practices, cultural and traditional practices, and peer pressure all
have significant influence on the behaviour, character formation, health and development
of the young people.
5.3
Adolescents’ Needs for Health Services
The study revealed that adolescents have special requirements for health services, which
need to be addressed with appropriate approaches that encourage and promote access to
such services. The type of health services and support that the adolescents need are those
which effectively address their various barriers to accessing health services. In the case
of Zambia, the main barriers include physical, psychological and socio-economic barriers.

Physical barriers: These include inadequate and inequitable distribution of health
facilities; long distances to the nearest health facility; shortages and inequitable
distribution of health workers; lack of appropriate facilities and services for
adolescents; perceived lack of efficiency and effectiveness of the services; poor
conditions of transport and communication infrastructure; geographical challenges
and conflicts;

Psychological barriers: These include the inner fear and lack of confidence to open
up and freely discuss health problems with parents, peers and medical personnel; and
misdirected health seeking behaviours, leading to prioritization of non-medical
options, such as traditional medicine;

Social and economic barriers: These include the lack of financial capacity to meet
the costs of health services; certain religious and cultural beliefs and misconceptions,
in some cases discourage youths from discussing their bodies, sexuality and health
problems, which hinders adolescents from accessing certain health services; gender
barriers e.g. some girls and boys do not feel comfortable to be examined or attended
to by a medical person of opposite sex; and stigmatization of some diseases.
In this respect, the package of health services needed for the adolescents should
adequately address these and other barriers. Such services should also be “adolescent
friendly”, consider the determinants of adolescent health and take into account the
following key adolescent needs:
 Assured privacy and confidentiality of services, with no or minimal requirement of
parental consent;
 Easily accessible facilities and services, with minimal physical barriers;
 Services should be convenient, appropriate, comprehensive and integrated, providing
for continuity of care; and
 Cost effectiveness, with either free or highly subsidized health services.
21
Republic of Zambia
Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
The health services provided should not just be restricted to treatment of diseases, but
should be comprehensive enough to include: prevention interventions; treatment of
diseases/health conditions, according to recommended medical practices; care for
adolescents who are ill, particularly those with chronic health conditions; and psychosocial counseling of the adolescents, in order to deal with depressions and other emotions.
Whilst the health service providers are expected to develop and offer such adolescent
health services, the families, peers and communities also have significant roles to play.
5.4
Government Efforts in Improving Adolescent Health
The Zambian governments has the overall responsibility of establishing appropriate
environments for smooth flourishing of interventions aimed at promoting adolescent
health and development in Zambia. To this effect, the government has continued with its
efforts towards establishment of appropriate policies, legal and regulatory frameworks,
institutional and implementation frameworks, and monitoring and evaluation frameworks,
that take into account the needs of the adolescents. However, there are still a number of
weaknesses that need to be addressed so as to strengthen adolescent health throughout the
country.
5.4.1 Policy and Legal Frameworks
Zambia is an active partner in the Text Box 1: All children and adolescents should have
promotion of child and adolescent rights. the means and the opportunity to develop to their full
To this effect, it has signed and ratified the potential.
1990 United Nations Convention on the Life, survival, maximum development, access to health and
Rights of the Child (UN-CRC), the access to health services are not just basic needs of children
and adolescents, but fundamental human rights.
Organisation of African Unity (OAU)
African Charter on the Rights and Welfare of the Child (UN-ACRWC), the Reproductive
Health Strategy for the African Region, as well as the optional protocols on the minimum
standards of employment and on the worst forms of child labour.
Zambia’s commitment to adolescent health
and development is justified by a number
of policies and legislation that have been
developed to domesticate the CRC and
other relevant protocols, taking into
account the country’s situation.
The
national policy and legal framework
guiding child and adolescent health and
development includes the policies and
pieces of legislation highlighted in Text
Box 2.
Text Box 2: Key Policies and Legislation Relating to
Children and adolescents

The Constitution of Zambia (the Constitution);

The National Population Policy;

The National Child Policy;

The National Youth Policy;

The National Child Health Policy;

The National Reproductive Health Policy; and

The Mental Health policy;

The National Policy on Education;

The Human Rights Act;

The Juvenile’s Ac; and

The Termination of Pregnancy Act of 1972.
22
Republic of Zambia
Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
The
Zambian
Constitution
(the Text Box 3: The Constitution of Zambia – Political and
Constitution): Through the Bill of Civil Rights and Freedoms
Rights, the Constitution guarantees  The right to liberty;
specified political and civil rights and  The right to protection from slavery and forced labour;
right to protection from torture, inhuman and
freedoms of the citizenry, including  The
degrading punishment;
children and the adolescents. It is worth  The right to property; the right to privacy of home and other
property;
noting that these rights specifically
 The right to free trial;
include “the right of young persons to  The right to freedom of conscience;
protection from physical or mental ill-  The right to freedom of expression;
right to freedom of assembly and association;
treatment, all forms of neglect, cruelty  The
The right to freedom of movement;
or exploitation, or trafficking in any  The right to protection from discrimination on the grounds
of race, sex, tribe, place of origin, marital status, political
form”. Further, all the other rights and
option, colour or creed; and
freedoms apply to all citizens, which  The right of young persons to protection from physical or
mental ill-treatment, all forms of neglect, cruelty or
also include children and adolescents.
exploitation, or trafficking in any form.
These rights and freedoms are
highlighted in Text Box 3. All these
fundamental rights and freedoms are guaranteed and justiciable.
In addition to the fundamental rights and freedoms contained in the Bill of Rights, the
Constitution also provides for economic, social and cultural rights, which are however
non-justiciable and therefore not legally enforceable.
Other policies and legislation relevant to child Text Box 4: Policies and Legislation Relevant to
and adolescent health:
Apart from the Adolescent Health
National Constitution, there are a number of  Policies:
 National Population Policy
policies and legislation which have relevance
 National Youth Policy
 National Child Health Policy
to the promotion of child and adolescent health
 National Reproductive Health Policy
and development. These are highlighted in  Legislation:
 The National Constitution, Bill of Rights - The right
Text Box 4 and aim at providing appropriate
of young persons to protection from physical or
frameworks for implementation of the specific
mental ill-treatment, all forms of neglect, cruelty or
exploitation, or trafficking in any form.
rights, freedoms and commitments enshrined in
 The Human Rights Act
the National Constitution, as well as to
 Termination of Pregnancy Act 1975
domesticate and provide for country level
implementation of the various international and regional conventions and protocols,
which have been signed and ratified by Zambia.
5.4.2 Gaps and Weaknesses
Whilst the fundamental political and civil rights
related to children and adolescents are
guaranteed by the National Constitution and
other relevant legislation, there are still some
gaps/weaknesses that need to be addressed in
order to strengthen the policy and legal
framework for protection of children and
adolescents. Some of the apparent gaps are
presented in Text Box 5.
23
Text Box 5: Child Rights in Zambia: Indentified
Ambiguities and Gaps
An assessment of the National Constitution and Laws,
against the provisions of the CRC, reviews the
following ambiguities and gaps:
 Discrimination on the basis of birth – The Con
 The right to express their of
 xxx
Source: Children and the Budget, idasa, Save the Children
Sweden, 2004
Republic of Zambia
Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
The critical issue, though, is the fact that the economic, social and cultural rights are nonjusticiable, and are more of directives to inform policy, without placing significant burden
on the government to ensure the timely development and implementation of such
directives. This issue is of major concern, considering that the socio-economic situation
is one of the major determinants of child and adolescent health and development in the
country, and has continued to be weak. This is because the major problems affecting the
youths are the high levels of poverty, inadequate access to clean and safe water and
sanitation, inadequate access to education, high unemployment levels, high disease
burden/HIV impact and access to appropriate health services. These are the areas which
would have the desirable impact on the promotion of the health and development of the
young people.
5.4.3 Institutional and implementation Frameworks
MOH considers adolescent health and development as a cross-cutting issue, which
requires an appropriately designed multi-sectoral response, providing for efficient and
effective coordination of the various sectors and partners involved in the implementation
of the various programmes and interventions, aimed at addressing the different needs for
the adolescents.
The existing institutional and coordination arrangements for adolescent health programme
within the Zambian health sector is summarized in Figure 5.
Figure 5: Institutional Structure – Adolescent Health
MOH (Leadership, Policy,
Coordination,
Implementation)
Cooperating Partners
(Financial and
Technical Support)
ADOLESCENT
HEALTH in
ZAMBIA
Other Sectors
(Implementation of
some components)
24
Private sector and
civil society
(Implementation
and support)
Republic of Zambia
Ministry of Health
DRAFT REPORT
Adolescent Health Situation Analysis
This structure includes the following key players.
5.4.4 Ministry of Health
MOH is responsible for the overall coordination of the adolescent health programmes
across the sectors. To facilitate this role, the following structures are in place:
Adolescent Health Technical Working Group (ADH_TWG), Sector Advisory Group
(SAG), MOH Headquarters, Provincial Health Offices (PHOs), District Health Offices
(DHOs), health facilities and YFCs. Within these MOH structures, there are specific
units and staff assigned to coordinate adolescent health.
5.4.5 Other Government Ministries and Departments
Some aspects of adolescent health are implemented by other sectors, such as the School
Health and Nutrition (SHN) Programme, under the MOE. Other sectors that are actively
involved in adolescent health programmes include: the Ministry of Youth, Sport and
Child Development; Ministry of Agriculture, Food and Fisheries; Ministry of Commerce,
Trade and Industry; Ministry of Finance and National Planning; the National Food and
Nutrition Commission (NFNC) and National AIDS Council (NAC). Policy guidance and
technical supervision for such programmes is provided by MOH, through the
Reproductive Health Unit. Appendix VI presents the roles and responsibilities of the
various sectors involved in promoting adolescent health.
5.4.6 Cooperating Partners, Private Sector and Civil Society
Several cooperating partners and civil society organizations are also involved in the
implementation and promotion of adolescent health related programmes. At national
level, the ADH-TWG on adolescent health has been established, which is coordinated by
the Reproductive Health Unit of MOH.
This TWG draws members from MOH, other relevant line ministries and government
departments, civil society organizations and cooperating partners, which currently include
the WHO, UNICEF, Planned Parenthood Association of Zambia (PPAZ) and CARE
International. At national level, coordination of stakeholders is provided through the
ADH-TWG and SAG coordination mechanists, at provincial level by the provincial
health office, while at community level it is coordinated by the District Health Office. At
implementation levels, various civil society organizations are directly involved in the
promotion and implementation of adolescent health related programmes.
5.4.7 Adolescent Health Technical Working Group (ADH-TWG)
In order to provide for effective coordination of the multi-sector response to adolescent
health, MOH and its partners have established the ADH-TWG, which has broad
representation. This working group is led by MOH and is chaired by the Director of
Public Health and Research. Appropriate terms of reference (TORs) have been developed
to guide the organisation and performance of the TWG (See Appendix V).
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Ministry of Health
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Adolescent Health Situation Analysis
The ADH-TWG is responsible to the Inter-Agency Technical Committee on Population
(ITCP) at the Ministry of Finance and National Planning (MOFNP). The current
members of this TWG are presented in Table 6.
Table 6: Composition of the ADH-TWG
Leadership/Chair
MOH – Director of
Public Health and
Research
Government Departments
MOH - Reproductive Health
(Secretariat)
CPs and other Partners
UN Agencies: WHO, UNFPA,
UNICEF
MOH - Lusaka District Health
Office (LDHO) – MCH Section
Ministry of Youth, Sport and
Child Development (MYSCD)
Ministry of Education (MOE)
Swedish International Development
Agency (SIDA)
Health Services and Systems
Program (HSSP)
Planned Parenthood Association of
Zambia (PPAZ)
Ministry of Finance and National CARE International
Planning (MOFNP)
Ministry of Finance and National Non-Governmental Organisations
planning (MOFNP)
Coordinating Committee (NGOCC)
YMCA
YWCA
Several other NGOs
However, it should be mentioned that, even though the ADH-TWG has been established,
it is currently not active and requires reactivation. Equally, the ITCP has not been active.
5.4.8 Implementation Framework – Adolescent Health
The implementation framework for health programmes, including the adolescent health
programme, includes a system of policies and legislation, strategies, institutional
arrangements, and monitoring and evaluation system. The main strategic documents
guiding the implementation of the adolescent health programme are as outlined in Table
7.
Table 7: Strategic Frameworks Guiding Adolescent Health
Implementation Level
National Level
Sector Level
MOH Departmental Level
MOH Facility Level
Strategic Direction/Document
 Vision 2030
 Fifth National Development Plan 2006-10
 National Health Strategic Plan 2006-10
 Other relevant sector strategies: e.g. Ministry of
Education/School Health and Nutrition; and Ministry of Youth,
sport and Child Development
 Sector Medium-Term Expenditure Frameworks (MTEF) and
Annual Action Plans/Budgets
 Maternal Health Strategy and Roadmap
 Child Health Strategy and Roadmap
 Strategic plans 2006-10
 MTEF/Annual Action Plans
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DRAFT REPORT
Adolescent Health Situation Analysis
The main weakness of the existing health strategic framework is that it does not
adequately cover adolescent health. The NHSP 2006/10 only referred to adolescent
health in the chapters dealing with child health and reproductive health and did not
articulate this matter in greater detail.
5.5
Current Health Service Provision to Adolescents
Currently, in Zambia, there are two categories of health services available to the
adolescents, namely: those offering specialized AFHS services, through the introduction
of YFCs; and health facilities offering healthcare services to the general public.
The concept of AFHS was introduced by the WHO to help define packages of health
services targeted at providing the adolescents with appropriate and convenient health
services, which take into account their special needs. AFHS seek to provide adolescents
with access to essential health services in an adolescent friendly environment, providing
for appropriate location of health facilities, appropriate standards of care, privacy and
confidentiality, cost effectiveness and affordability of services, flexibility, availability of
appropriate IEC materials, effective partnerships and involvement of the adolescents in
policy formulation, planning and implementation of adolescent health programmes.
Based on the WHO Global Consultation in 2001 and the WHO Expert Advisory Group
Meeting held in Geneva in 2002, a set of key characteristics of AFHS was developed (see
Appendix IX). However, this listing of key characteristics of AFHS is only intended to
guide various countries and health providers in structuring their adolescent health
programmes. It does not purport to impose a standard package of AFHS on any country
or health services provider, as specific packages of AFHS depend on each country’s
circumstances.
5.5.1 Services Offered in Health Facilities with AFHS in Zambia
Zambia recognizes the importance of providing appropriate support to the health and
development of children and adolescents. This has been demonstrated by the fact that the
country has signed and ratified the UN-CRC, developed a number of national policies and
legislation aimed at advancing the rights of children and adolescents, and established the
Ministry of Youth, Sport and Child Development to provide for holistic coordination of
youth development in the country. The country has also developed the National Child
Health Policy and the National Reproductive Health Policy, to provide for policy
direction and guidance in the implementation of child health and reproductive health
programmes, which are cardinal to adolescent health.
However, notwithstanding these positive developments, the status of adolescent health
services in the country is weak. Though YFCs, which are currently the only vehicle for
delivery of AFHS services, were introduced during the late 1990s, the past 5 years have
witnessed significant deteriorations in the organisation, management and performance of
these centres. Further, since their introduction, YFC services have not been scaled out to
cover all the other districts, and have largely remained within the initial pilot districts.
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Adolescent Health Situation Analysis
5.5.1.1 Establishment of AFHS and Extent of Coverage
AFHS could be initiated in different ways. This could be through government policy,
initiatives of individual health facilities or through groups of individuals or civil society
organizations dedicated to improving the health of adolescents.
In Zambia, the approach used for providing AFHS services in health facilities is the
introduction of YFCs at selected health facilities. These YFCs were introduced in 1996,
with significant financial and technical support from the cooperating partners, particularly
UNICEF, UNFPA and the World Vision. Since that time, YFCs have been established in
a number of public health facilities. However, not much progress has been achieved in
expanding this programme to cover all the districts in the country. Currently, there are a
total of xxx health facilities throughout the country. This includes YFCs at hospitals and
health centres. Table 8 and 9 below, present the trends in the introduction of YFCs in
public health facilities in Zambia.
Table 8: Number of Public Health Facilities with YFCs, Zambia
Type of Health
Facility
Total
Facilities
2000
Facilities
With
FCs
Total
% Facilities
2005
Facilities
With FCs
%
Total
Facilities
2009
Facilities
With YFCs
%
Health Posts
Health Centres
1st Level
Hospitals
2nd Level
Hospitals
3rd Level
Hospitals
Total
Table 9: Distribution of YFCs by Province, by Type of Facility, 2009, Zambia
Province
Total
YFCs
Health
Posts
Youth Friendly Corners (YFCs) at:
Health
1st Level
2nd Level
Centres
Hospital
Hospital
3rd Level
Hospitals
Central
Copperbelt
Eastern
Luapula
Lusaka (Capital City)
Northern
Southern
North-Western
Western
Total
In the two districts that were visited, namely Lusaka and Solwezi, it was reported that the
following health facilities had introduced YFCs:
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Adolescent Health Situation Analysis
Table 10: Health Centres with YFCs in Lusaka and Solwezi
Lusaka District:
Solwezi District:
Chaisa Health Centre
Chawama Health Centre
Chilenje Health Centre
George Health Centre
Matero Health Centre
Appendix X presents a complete list of public health facilities in Zambia that have
introduced YFCs.
5.5.1.2 Package of Services Offered
In Zambia there is no standard package of health services being offered in facilities where
AFHS have been introduced. In fact, the only services being provided in such facilities
are those provided by the YFCs. Though none of the facilities visited provided a
document describing the package of services offered by the YFCs, the services outlined in
the discussions were similar. These included:






Peer counseling, education Text Box 7: Testimony of a Chilenje Youth
and referrals in respect of the A 22 years male youth from Chilenje township in Lusaka
general health problems, such confessed that early 2009, he started a relationship with his
current.
as malaria and TB;
Peer counseling, education
Later, when they started having sex, the girlfriend used to
and referrals in various areas, complain against the use of condoms, which she claimed had
including the prevention and chemicals that could cause her some health problems. She
treatment of STIs, male therefore preferred to have unprotected sex. However, the
circumcision,
early boy insisted on the use of condoms, eventhough he himself
pregnancies, early marriages did not know how to convince her that the condoms were safe.
The other problem he had was that of accessing condoms.
and unsafe abortions;
Peer Voluntary Counseling When he heard of the services provided by the YFCs at the
and Testing (VCT) for HIV Chilenje health centre, he visited the centre. There he
and syphilis. Peer education underwent VCT, was empowered with information/knowledge
about condoms, and was provided with condoms. Further, he
on the prevention, treatment was even encouraged to undergo male circumcision, which he
and caring for persons with later did during a Marie Stopes circumcision outreach.
HIV/AIDS, including the fight
Armed with the new knowledge, he managed to convince the
against stigma;
Peer
education
and girlfriend about the use of condoms, which he has continued
to access from the Chilenje YFC, he is now circumcised and is
information
on
family an agent of change. He is now contemplating becoming a
planning, including the correct committee member at the next elections.
use
of
condoms
and
distribution of the same;
Reproductive health services and antenatal care;
Life-long skills programmes in schools. These involve visiting schools to conduct
health education and information activities;
29
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Ministry of Health



DRAFT REPORT
Adolescent Health Situation Analysis
Edu-sport activities within the communities, aimed at attracting youths to attend
educational talks and information sharing on various health related matters, including
promotion of awareness of YFCs and their services;
The use of drama to attract youths to various YFC health education and promotion
activities within the communities; and
Sharing and distribution of various IEC materials relevant to adolescent health.
Most of these services are offered at the
YFC fixed centres, which are located
within the respective health facility or
through outreach programmes within the
communities and schools. The fixed
centres are usually located within the
MCH Units at the respective health
facilities. It is normally a room or open
corner, with basic furniture, which is used
for YFC activities, such as meetings, peer
counseling, VCT and dissemination of
health related IEC materials. Photograph
2 presents a youth conducting peer
education in Solwezi District.
Adolescents Peer Education
It should be noted that all the YFC activities are being provided by the youth volunteers
themselves, without the active participation of the health workers. Some of the youths
interviewed explained that they were more comfortable sharing their health problems with
the fellow youths at YFCs, than with professional health workers, who are sometimes too
busy to attend to their special needs for confidentiality and, at times are not friendly
enough. The procedure for accessing YFC services at health facilities, where such
services exist, could be summarized as follows:
Step 1: A young person presents him/herself to the YFC. This is usually a dedicated
room or corner where young peer counselors and educators operate from;
Step 2: The young person is then asked to share his/her problem(s) with one peer
counselor/educator, in a confidential arrangement;
Step 3: The peer counselor/educator provides some counseling, relevant to the problem
at hand and also on common youth problems of STIs, HIV/AIDS, family
planning, sexual reproductive health issues, general health education and
promotion issues, and for female clients, even on unwanted pregnancies, early
marriages and unsafe abortions;
Step 4: Following the peer counseling, the young person is either referred to the
appropriate department within the health facility for attention, or in some cases,
the MCH Coordinator is called in to provide appropriate advice. When a
referral is done, the young person is escorted to see the particular health
worker/Doctor and is not subjected to standing in a queue. Further, all the
youths using the YFCs, as their point of entry, are exempted from paying user
fees; and
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Adolescent Health Situation Analysis
Step 5: Further attention, such as reviews and further treatment or reviews could also be
done through the YFC, depending on each person’s preference.
Youths presenting themselves to the YFCs are also encouraged to promote youth friendly
health services within their communities and among their peers. It was reported and some
of youths interviewed testified that such people often become agents of change.
Apart from the services provided at the fixed centres, located within the health facilities,
YFCs provide various activities through outreach operations. These outreach operations
include, community outreach activities, visits to schools, edu-sport activities, dramaactivities within the communities and at special gatherings, and are at times included in
the health centre maternal and child health outreach activities. The youths reached out
with YFC IEC and peer education activities normally make follow-ups later by visiting
the fixed YFCs for further counseling and, where necessary, treatment.
5.5.1.3 Organisation and Management of AFHS
Overall responsibility for coordination of AFHS in Zambia falls under MOH. In this
respect, MOH is responsible for ensuring appropriate policy, legislation and
implementation guidance to ensure efficient and effective coordination of the national
multi-sectoral response to adolescent health, which includes public health facilities under
MOH, other government ministries and departments, the private sector, cooperating
partners, the civil society, communities and the adolescents themselves.
As indicated in Section 5.5.1.1, in Zambia, AFHS are offered through YFCs. Currently,
YFCs are only found in selected health centres and hospitals, where they have been
introduced. Organisation and management of AFHS within MOH is at five levels,
namely, national, provincial, district, facility and YFC levels, as follows.
National Level: At national level, MOH is responsible for guiding both the multisectoral response to adolescent health, and the implementation of AFHS within its
structures. AFHS fall under the responsibility of the Directorate of Public Health and
Research, Reproductive Health Department. Previously, AFHS were just considered as
other maternal and child health activities and were not allocated a specific focal point
person. However, following the recent restructuring of the health sector, the Family
Planning and Adolescent Health (FP/ADH) Unit has been established, headed by a chief
officer, which position has already been filled. This position reports directly to the
Deputy Director of Reproductive and Child Health.
The role of the Chief FP/ADH Officer is to facilitate coordination of policy,
implementation and, monitoring and evaluation of the adolescent health programme in the
country. In this respect, the holder of this position works closely with the Maternal and
Child Health Coordinators (MCH Coordinators) at provincial level.
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This position is also expected to facilitate efficient and effective coordination and
consultations with the various other health programmes with specific relevance to
adolescent health, such as the HIV/AIDS/TB/STIs, malaria, nutrition and mental health
programmes, relevant government ministries and other players involved in the promotion
of AFHS at national level, including cooperating partners and the civil society.
In order to facilitate inter-sectoral and
multi-partner coordination, MOH has Text Box 8: Current Composition of the ADHTWG, Zambia
established the ADH-TWP, which is InstituInstitution
S/N
Category
Persons
intended to provide for an appropriate 1. Ministry of Health Health Sector
2
Cooperating
1
forum for the various partners to exchange 2. WHO RH
Department
Partner (CP)
ideas and participate in the planning and 3. Unicef
CP
1
management of adolescent health in 4. HSSP
CP
1
Civil Society
1
Zambia. The membership of the current 5. PPAZ
6.
CARE
Civil
Society
1
ADH-TWG is presented in Text Box 8.
International
This TWG is chaired by the Deputy
Director of Reproductive and Child Health
of MOH, while the Chief FP/ADH Officer Total
plays the role of secretary. The ADH-TWG Source: Ministry of Health, Zambia, 2009
operates in accordance with its terms of
reference, a copy of which is provided at Appendix VII.
Provincial Level: At provincial level, adolescent health services are coordinated by the
respective provincial MCH Coordinators, under the Public Health Unit. They are guided
by the Chief FP/ADH Officer at the centre and work closely with District MCH
Coordinators at the District Health Offices (DHOs).
The Provincial MCH Coordinator is also responsible for coordinating adolescent
programmes at provincial level, including providing guidance and monitoring and
evaluation of implementation of adolescent health programmes by the districts, and
coordination with other government departments, partners and civil society organizations
at provincial level.
District Level: At district level, adolescent health services are coordinated by the MCH
Coordinator. In this respect, they are responsible for coordinating implementation of
adolescent health services in public health institutions, providing policy guidance,
coordination and facilitation of the participation of other government departments,
cooperating partners, civil society organizations and the communities in the planning and
implementation of adolescent health services at community and district levels.
Facility Level: At facility level, provision of AFHS is coordinated by the respective
MCH Coordinators. In this respect, the entry points for provision of AFHS are the YFCs,
which directly fall under the supervision of the MCH Coordinators.
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Youth Friendly Corners (YFCs) Level: In the Zambian context, youths are defined as
young between the ages of 10 years and 35 years, and all the young people meeting this
criteria are eligible to join the YFCs. YFCs are organized as clubs of youths within the
particular communities, with a common interest of improving health services for young
people, taking into account their special health needs that may not always be adequately
addressed through the packages of health services offered to the general public. In this
respect, YMCs comprise of youths from different walks of life and socio-economic
backgrounds, including students, working class, unemployed, the vulnerable, girls and
boys.
Membership to the YFCs is on individual
basis rather than representation of any
particular socio-economic groupings. All
the members of YFCs are volunteers and are
not entitled to any remuneration, such as
salaries, allowances and/or fringe benefits.
Text Box 9: Zambia: Chilenje Health Centre - YFC
Objectives
 To unify the group, promote its well-being,
strive to create a conducive environment for its
members and establish a platform encompassing
all its members;
 To contribute to the health development and
uplifting of the organisation and its members;
 To address health and other macro issues
affecting the youth;
 To include in our activities, the less privileged
and persons of defective intellect;
 To work hand in hand with other cooperating
partners that may be willing to work with us;
 To ensure effective communication and promote
cooperation and networking at all levels
enabling an exchange of ideas experiences with
youths and other members of the society; and
 To amend the Constitution from time to time.
YFCs are organized at two levels, namely at
facility level and at district level. At facility
level, YFCs are established as units under
the MCH Coordinator. In some cases, YFCs
have developed Constitutions to guide their
establishment,
organisation
and
management. In this case, a good example
is the Chilenje Health Centre YFC, which
has developed a Constitution, defining the
scope of their centre and outlining their
Source: Chilenje Clinic YFC Constitution, 2009
vision,
objectives,
organisation,
composition, responsibilities of the committees and their members, procedures for
election of office bearers, financing and financial management, and provisions for
amending the Constitution. Text Box 9 presents the objectives of the Chilenje HC YFC.
Even though not all the YFCs have developed formal policy documents, such as the
Constitution, to guide their establishment, their organisation and management structures
appear to be similar across the board.
In this respect, each YFC comprises of an Executive Committee, Committee Members
and the general membership, as follows:
 Executive Committee: Responsible for the management and implementation of all
the YFC activities, including directing the affairs of the YFCs, representing the centre
at the district coordinating committee and other fora. This committee comprises of:
Chairperson, Vice Chairperson, Treasurer, Vice Treasurer, Publicity Secretary, Vice
Publicity Secretary, and 2 independent committee members. All executive committee
members are elected by the general membership after meeting the minimum
qualifications to stand for elections as stipulated in the Constitution.
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 Committee Members: The committee members are also elected from the general
membership who meet the election criteria. Once elected, committee members
become members of the executive committee and participate in the deliberations of
the executive committee. Committee members also play the role of acting in any
position that falls vacant within the executive committee, as the committee may
decide as and when need be.
 General Membership: This category is open to all the young who are between the
ages of 10 years and 35 years, regardless of their socio-economic background.
At district level, District YFC Boards have been established, even though in some
districts they are none operational. These district boards are for purposes of ensuring
coordination of YFC activities within the respective districts. These boards fall under the
supervision of the District MCH Coordinator at the DHOs. The members of these boards
include the District MCH Coordinator and representatives of all the YFCs within the
district.
5.5.1.4 Planning and Budgeting
Currently, there is no strategic framework or roadmap to guide the implementation of the
adolescent health programme. This has made it difficult to focus the efforts on
implementation of this programme.
YFCs are considered to be units under the MCH Sections of the respective health
facilities. During the planning cycles, YFCs are requested to submit their planned
activities and budgets, which are then incorporated into the MCH action plans and
budgets. However, it was observed that in these action plans and budgets, adolescent
health activities are not prioritized and given separate sections and budget lines, as they
are just considered as some of the activities under MCH. This weakness is replicated at
district, provincial and national consolidations of the action plans and budgets. As such,
no specific funding is allocated to adolescent health, making it difficult to implement the
planned activities. In this respect, currently, AFHS/YFCs services are not given the
prioritization they deserve and are not funded.
5.5.1.5 Partnerships
The National Health Strategic Plan 2006/10 (NHSP) has identified “partnerships” among
the key principles upon which it is founded. This is aimed at ensuring efficient and
effective participation of all the partners for better results and synergies.
In this respect, the government is committed to promoting the development and
sustenance of strong, efficient and effective partnerships with all the main stakeholders,
including the communities, other government ministries, faith-based health sector, the
private sector, the civil society and the international community.
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At the time of introducing YFCs in 1996, there was significant involvement of
cooperating partners, particularly the UNICEF, who provided financial and technical
support towards the opening of the initial 5 YFCs in Lusaka, Copperbelt, Eastern,
Southern and North-Western provinces. Later, more YFCs were opened, particularly in
Lusaka and the Copperbelt. More partners also came on board, such as CARE
International, SIDA Sweden, the World Vision and later, HSSP and CARE International.
These partners provided both technical and financial support towards the establishment
and sustenance of YFCs. This support included financial support towards:
 Training of youths in peer counseling, health education and VCT;
 Allowances for outreach activities;
 Office operational costs, including stationery;
 IEC materials.
UNICEF also provided a vehicle to the Lusaka DHO to support adolescent health
outreach services. This vehicle is controlled by the District MCH Coordinator. Even
though this vehicle is still operational, it is too old and costly to maintain.
Support programmes from these partners have since come to an end, resulting into
significant financing gaps. As a result, the operations of YFCs over the past 5 years have
been on a decline and no expansions have been achieved. Currently, only a few
cooperating partners are supporting the public YFCs facilities. Of particular mention
were Marie Stopes, who have helped in revamping the Matero YFC and have continued
to involve youths in rolling out their sensitization on male circumcision activities, Afya
Mzuri, who have been providing support in form of IEC materials.
Apart from the YFCs at public health facilities, there are currently a number of
international non-governmental organizations that are actively involved in providing
YFCs or related services. These include: the Planned Parenthood Association of Zambia
(PPAZ), Child Fund (CF), CIDRZ, Marie Stopes and others. These are further discussed
under Section 5.6.
5.5.2 Services Offered in Non-AFHS Health Facilities
Apart from the health facilities offering YFC services, adolescents also have access to
other health facilities which offer standard packages of health care services to the general
public. These services are offered at all the levels of health service delivery, including
community, district, secondary and tertiary levels. Appendix XII presents a summarized
analysis of the packages of health services currently available to adolescents at nonoffered at the different levels of health care.
However, such facilities do not necessarily offer specially-tailored services for the
adolescents. In this respect, adolescents have equal access to all the health services
offered to the general public by public health facilities. This in some cases presents
significant barriers, especially in cases like TB and mental health, which are usually
subject to stigmatization. Adolescents may not also feel comfortable to access RH
services with adults.
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5.5.3 Availability and Adequacy of Resources for Adolescent Health
Availability of adequate critical inputs, such as infrastructure, human resources, essential
drugs and medical supplies, and financial resources, is a critical factor in ensuring
efficient and effective planning and implementation of adolescent health programmes.
Zambia is a developing country with a high disease burden and limited resources to
adequately support the health sector. The current situation regarding availability and
adequacy of these resources for adolescent health is discussed below.
5.5.3.1 Infrastructure and Equipment
One of the key requirements for AFHS to flourish is appropriate infrastructure.
Adolescent friendly health facilities should be conveniently located, appropriate to
adolescent health needs and capable of providing for a safe environment, with an
appealing ambience, offer privacy and avoid stigma, and provide for convenient working
hours. In Zambia, in health facilities where AFHS/YFCs have been introduced, these
centres usually operate from a single room environment. The rooms used for YFCs are
allocated by the MCH unit and are not always convenient and appropriate for adolescent
health activities.
The rooms used for YFCs are in most cases small and lack in space and basic equipment,
such as appropriate desks, chairs, filling cabinets, computers and printers, laptop
computers, access to the internet for accessing appropriate IEC materials, television sets,
public address systems for outreach activities, LCD equipment for making presentations
and transport. In some cases, these rooms are not even fully dedicated to YFCs, but are
shared with other health programmes. In most cases, such rooms are also too close to
where maternal and child health services are conducted, making it difficult for some
youths to access for fear of being seen and probably questioned by the adults attending
those services.
Currently, there are only xxx out of a total of xxx public health facilities that have
introduced YFCs, or xx%. There is therefore significant scope for scaling up these
services to all the health facilities in the country. In health facilities where YFCs have not
been introduced, there are no special facilities or services for the adolescents. In this
respect, adolescents are treated just like any other client, without necessarily taking into
account the special health needs of this age group.
5.5.3.2 Human Resources
Zambia has continued to face a critical shortage of qualified health workers at all the
levels of healthcare delivery, with significant implications on the standards of healthcare.
This is despite the fact that the total number of health workers has increased from 23,523
in 2005 to 31,048 in 2008, or 60% of the total needs currently estimated at 51,414,
including medical and non-medical personnel.
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Even though the HRH crisis affects the whole sector and all the provinces, it has been
observed that the rural hard-to-reach areas are the most affected. Maternal health services
have also been severely affected due to shortages of mid-wives. Adolescents are equally
affected by the general shortages of health workers. As members of the general public
accessing public health services, the adolescents experience the same difficulties in
accessing the services of health workers, just like other members of the general public.
Even in facilities that have introduced YFCs, adolescents are affected by the shortages of
health workers. Currently, YFCs are literally operated by the youths themselves with
minimal active participation of health workers, as there are no health workers that are
permanently assigned to YFCs. The MCH Coordinator plays the role of overseeing the
activities and is only summoned in particular instances. Further, even after the peer
counseling and referral to appropriate medical attention, adolescents are affected by the
shortages of health workers to promptly attend to them. However, the current practice
whereby adolescents accessing health services through the YFCs are allowed to skip the
queues is an important motivating factor for the adolescents.
Apart from the critical shortages of health workers, there is a problem of lack of training
of health workers in the provision of adolescent friendly health services and the youths in
peer counseling and other health skills needed. Most of the health workers have not been
trained in such skills and therefore may not be in a position to appropriately respond to
adolescent health needs. The youths themselves are also not receiving the much needed
training to maximize their impact on the health of the peers. During the field visits, it was
reported that the last training for youth peer educators was last conducted in 2004, with
support from World Vision.
5.5.3.3 Essential Pharmaceuticals and Medical Supplies
Availability of essential pharmaceuticals and other medical supplies is an essential factor
in ensuring efficient and effective health services. Even though significant improvements
have been recorded in the past few years in the procurement logistics management and
distribution of essential drugs and medical supplies, supply of these commodities is not
always optimal.
Significant progress was reported regarding the availability and distribution of drugs and
medical supplies from MSL to all the levels of health service delivery. However, the
levels achieved were still not optimal and shortages were still reported by some facilities.
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It is estimated that approximately 30% of the health facilities experienced stock-outs of
tracer drugs and 16% of vaccines (HMIS 2008). There were also problems to do with the
composition of the health centre drugs kits under the current “Push” system, which in
some cases was leading to artificial shortages of some drugs and supplies and in the other
cases, excess supplies (Joint Annual Review 2008 Report). Shortages of these
commodities have also continued to affect the standards of health services provided to the
general public and the adolescents.
5.5.3.4 Financing
Financing of adolescent health services in Zambia is a major challenge. Currently, the
YFCs are not supported with budgetary allocations from MOH. Even though these
activities are included in the action plans and budgets for MCH, they just considered as
any other activity under MCH and not allocated specific budgets. In this case, when the
funds are disbursed, adolescent health activities are not prioritized and end up without any
specific funding. Further, currently there is no project-based technical or financial
support from the CPs, except for the limited support to a few YFCs from Marie Stopes
and Afya Mzuri. It can be concluded that currently there is a major financing crisis for
AFHS/YFCs.
Generally, the public health sector in Zambia is funded through four main sources,
namely budget grants from the treasury, direct health sector basket support under the
Sector Wide Approach (SWAps) support from the CPs, earmarked funding from CPs and
direct project support from CPs. Despite the significant increases in the both the domestic
and external financing, the resources available to the health sector has continued to be
below the needs, which has implications on the coverage and standards of health services.
In 2008, budgetary allocations to MOH nominally increased by 25%, from K1.2 trillion in
2007 to K1.5 trillion in 2008. This level of funding represented 11.4% of the total
national budget, which was still lower than the Abuja declaration recommended threshold
of 15% of the national budget. Approximately 65% of the budget was expected to come
from the central treasury (general budget support) and the balance of 35% from sector
specific donor support. In addition to this funding, the sector also expected other forms of
support such as project funding, particularly from the USA/PEPFAR Programme, the
GFATM and other project based CPs, estimated to be in the range of US$200 million.
However, these funds are normally disbursed to the projects.
5.5.4 Current Health Information Systems Related to Adolescents
The Zambian Health Information System (HIS) comprises of routine and survey-based
information systems. Routine information systems include the Health Management
Information System (HMIS), Integrated Disease Surveillance and Response (IDSR),
Human Resource Information System (HRIS), Drug Logistics Management Information
System (DLMIS) and the Financial Administrative Management System (FAMS).
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Non-routine, survey-based systems include the Zambia Demographic and Health Survey
(ZDHS), Living Conditions Monitoring Survey (LCMS), Malaria Indicator Survey (MIS),
Sexual Behaviour Survey (SBS), Health Facilities Census (HFS), National Health
Accounts (NHA) and other health related surveys.
Both the routine and survey-based information systems are considered important, as they
capture critical data on the health of the general population and adolescents. Generally,
the reporting systems on adolescent health are weak. This also explains why none of the
districts and centres visited could provide any statistics on the performance of their YFCs,
highlighting numbers of clients and trends.
5.5.4.1 Health Management Information System (HMIS)
The HMIS is of critical importance to adolescent health. HMIS management and
implementation structures cover all the levels of health service delivery, i.e. facility,
district, provincial and national levels. However, even after the recent upgrading, the
system does not adequately address adolescent health reporting needs. Even though the
system provides for disaggregation of data by gender and by different age bands, the
routine indicators and reports do not report on adolescents.
5.5.4.2 Integrated Disease Surveillance and Response (IDSR)
The IDSR is considered as a complimentary system to the HMIS and reports at national
level, providing analysis on the areas/provinces affected. The IDSR currently focuses at
11 notifiable diseases, which include Acute Flaccid Paralysis (AFP), Measles, Neonatal
Tetanus, Dysentery, Cholera, Plaque, Rabies, Typhoid Fever, Yellow Fever, TB and
Human Influenza. IDSR is an important tool for capturing data on adolescents affected
by epidemics. However, the IDSR reporting does not necessarily isolate data on the
adolescents.
5.5.4.3 ZDHS and Other Survey-based Systems
The ZDHS, LCMS and other survey-based systems normally analyse data at district,
provincial and national level, and in some cases even provide regional and international
comparisons. The ZDHS and LCMS capture data on morbidity, mortality, determinants
of health and socio-economic status, coverage, access, health seeking behavior, and
disease burden. These systems are relevant to adolescents and are considered appropriate
in that they cover major health issues and are adequately disaggregated, providing data on
adolescents of different age groupings and ages.
5.5.4.4 Special YFC Reporting Performance Assessment Forms
During the field visits, it was observed that some quarterly performance assessment forms
for YFCs have been developed. These forms are completed by the District Health
Management Teams (DHMTs) on a quarterly basis. A copy of the reporting form is
provided at Appendix VI.
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This format is considered useful, however there are a number of weaknesses, including:



5.6
Data captured is not included in the routine information systems;
This reporting arrangement represents parallel reporting and an additional reporting
burden to the health workers; and
There was no evidence of aggregation and reporting on the trends.
Extent of Coverage by other Sectors and Partners
Adolescent health is a cross-cutting issue, which may not be restricted to the public health
sector, as it requires a coordinated multi-sectoral response, to ensure efficient and
effective participation of all the relevant sectors and partners. Apart from the public
health sector, there are other sectors and partners implementing adolescent health related
activities. These include other government ministries and departments, and civil society
organizations. Health services provided by these players include the establishment and
management of YFCs, family planning and reproductive health services, condom
promotion services, HIV/AIDS services, school health and nutrition activities, and peer
education.
5.6.1 Other Government Ministries/Departments
Appendix XIII highlights the other government departments involved in the provision of
adolescent health related services, and the type of services provided.
5.6.2 Other Partners Providing Services Relevant to Adolescent Health
There are a number of partners implementing various programmes that are relevant to the
promotion of adolescent health. Some of these institutions are providing AFHS/YFC
services, while others are just providing services to the general public, which are among
the priority health services for the adolescents. The analysis of identified partners and the
relevant services that they provide or have provided in the past is presented at Appendix
XIV.
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Adolescent Health Situation Analysis
STRENGTHS, WEAKNESSES, OPPORTUNITIES AND THREATS (SWOT)
The main findings of this analysis are summarized in the SWOT Analysis presented in
Table 11 below, which seeks to identify the main strengths, weaknesses, opportunities
and threats of the Adolescent Health Programme in Zambia. It should be noted though
that this is not intended to be exhaustive, as a more detailed analysis would be conducted
with the participation of the key stakeholders during the process of developing a national
strategy and roadmap for adolescent health in Zambia.
Table 11: ADH Situation in Zambia: SWOT Analysis
STRENGTHS
WEAKNESSES
A) Political will
 Political will from the central government  Even though there is political commitment
and MOH. Zambia is a signatory to a
from the central government, this
number of global and regional protocols on
commitment is not adequately interpreted
child and adolescent health, rights and
into a well coordinated support to
development, including the UN Convention
adolescent health.
on Children’s Rights and other initiatives,
and establishment of the Ministry of Youth,
Sport and Child Development, to provide for
holistic approach to youth and child
development.
B) Policy and Legislative Framework
 Availability of national policies relevant to  Adolescent health and development issues
adolescent health, including:
National
are found in various policies, but there is no
Population Policy; National Youth and Child
single policy focusing at the adolescents.
Development Policy; National Reproductive
This has contributed to the fragmentation of
Health Policy; and Child Health Policy.
approaches among the sectors and weak
coordination.
 Availability of legislation relevant to
adolescent health have been developed,
including the
C) Organisation and Management
 Establishment of the Family Planning and  Weak coordination of the adolescent health
Adolescent Health (FP/ADH) Unit at the
programs
at
multi-sector,
national,
MOH Headquarters, through the recent
provincial, district and facility levels.
health sector restructuring.
This has
Several sectors and NGOs involved, but
strengthened national leadership and
weak coordination.
coordination.
 No health workers assigned to the YFCs,
 MCH Coordinators at provincial, district and
except for MCH Coordinators. This means
facility levels assigned to supervise and
that the YFCs are entirely run by the youths
coordinate adolescent health at their
themselves.
respective levels.
 Lack of training for health workers in the
 ADH-TWG established at national level.
provision of adolescent friendly health
services.
 Inadequate training opportunities for the
youths in peer counseling and education.
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D) Planning and Financing
 YFCs requested to submit proposed activities  Lack of prioritization of adolescent friendly
for inclusion in the facility action plans.
health services, at planning, financing and
implementation stages. No specific funding
 Some support from CPs/Partners to YFC
provided to YFCs by MOH.
activities.
 Inadequate support from CPs/partners.
 Support from CPs/partners not coordinated.
E) Partnerships
 Existing partnerships with WHO, UNFPA,  Inadequate support from the international
UNICEF, HSSP, that have been providing
partners. Most of them are no longer
technical and financial supported to
providing support.
adolescent health programmes.
 There are several NGOs involved in the
 There are several NGOs providing
provision of some aspects of AFDH
adolescent health related services. Major
services, but no coordination of these
ones include PPAZ, Youth Alive and Afya
efforts.
Mzuri.
F) Implementation/Monitoring and
Evaluation
 YFCs established in a number of districts.  Inadequate health facilities providing
These will provide important lessons and
Adolescent friendly health services.
experience towards strengthening of the  Most of the facilities used for YFCs are not
adolescent health programme.
appropriate in size and are not conveniently
located for adolescent friendly health
services.
 YFCs poorly equipped.
Inadequate
furniture, no computers and access to
electronic youth friendly IEC material, no
TVs, and no basic office equipment and
accessories.
 M&E of adolescent health services is weak
and not structured.
OPPORTUNITIES
THREATS
A) Global Level
 Global interest and commitment towards  Lack of an aggressive international
strengthening of adolescent health. WHO
initiative
aimed
at
ensuring
the
has taken keen interest in encouraging
prioritization government funding.
member countries to strengthen adolescent  Impact of the global financial/economic
health services in their respective countries.
crisis on the national economy and on the
potential donors for adolescent health
programmes.
B) Country Level
 Zambian government’s commitment to the  Unclear policy on adolescent health.
health and development of children and
Several policies addressing various aspects,
adolescents in the country. This presents
but no unified direction.
opportunities
for
strengthening
and  Weak economy, leading to: high poverty
streamlining policy and legislation towards
and unemployment among the adolescents.
improving
adolescent
health
and  No multi-sector response framework.
development.
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 Opportunities for improving coordination of  High disease burden and impact of HIV,
adolescent health programmes at all the
Malaria, TB, STIs on the adolescents.
levels, through strengthening of the ADH-  Myths,
misconceptions
and
unsafe
TWG and lower level coordination, like the
traditional practices.
District Youth Boards.
 Existence of various health programmes  Lack of funding.
whose services have significant relevance
and impact on the adolescents, including the
HIV/AIDS/STIs programmes, Reproductive
Health, Child Health, Nutrition/National
Food and Nutrition Commission, and Health
Promotion, which could be approached to
support the adolescent health programme.
 Existence of some CPs and NGOs who are
willing to help in strengthening adolescent
friendly health services.
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Adolescent Health Situation Analysis
RECOMMENDATIONS
Based on the above review, the following recommendations are considered appropriate.
7.1
Policy and legal framework



7.2
Planning and Development



7.3
Revise the National Child Health Policy and rename it into “National Child
and Adolescent Health Policy”;
The revised policy should adequately address both the child and adolescent
health issues, including: definitions, identification of major adolescent health
problems and their determinants, roles and responsibilities of stakeholders,
multi-sector coordination, organisation and management, partnerships,
financing, monitoring and evaluation; and
The revised policy to also establish appropriate linkages with the other
policies relevant to adolescent health.
Develop a Strategic Plan for Adolescent Health, to provide for a unified way
forward, it is recommended to develop a strategic plan for adolescent health in
Zambia;
Prioritise and identify adolescent health in the National Health Strategic Plan
(NHSPs), Medium-term Expenditure Framework (MTEF) and Annual Action
Plans (AAPs); and
Ensure participation of adolescents in planning.
Implementation Framework
7.3.1



7.3.2



Institutional Framework
Fully operationalise the ADH-TWG. Review the membership, redefine the
terms of reference, ensure that MOH takes leadership, and meetings take
place as scheduled;
Ensure that the structures of the ADH-TWG accommodate all the key
stakeholders, including government departments, CPs and civil society; and
The ADH-TWG should have a dual reporting arrangement, one to the InterAgency Technical Committee on Population (ITCP) at the MOFNP, for
sector-wide coordination and to the MOH Sector Advisory Group (SAG), for
health sector leadership and implementation.
Organisation and Management
Maintain the structure provided for in the approved MOH organizational
structure;
Formally establish YFCs at facilities, based on standard terms of reference
(TORs), to be developed by the ADH-TWG;
Consider increasing the participation of health workers in the YFCs;
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Ministry of Health


7.3.3



7.3.4





7.3.5



7.3.6
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DRAFT REPORT
Adolescent Health Situation Analysis
Establish district youth boards in all districts. TORs to be developed by the
ADH-TWG;
Introduce a package of incentives for youth volunteers in involved in YFCs,
in similar limes as the other community health partners.
Infrastructure
Ensure that appropriate and convenient premises/offices are allocated to
AFCs. Revise construction guidelines for health facilities to include
adolescent friendly facilities;
Basic infrastructure and equipment relevant to AFHS should be defined,
prioritized and provided; and
AFHS/YFCs should be scaled out to all the districts.
Financing
Allocate ADH with a specific sub-code in the NHSP and AAPs/Budgets;
Ensure that adolescent health is included and specifically allocated funding in
the budget;
Ensure that all the funds intended for adolescent health are not diverted to
other activities;
Lobby for financial and technical support from the CPs towards AFHS; and
Provide for high standards of transparency and accountability.
Partnerships
Through the ADH-TWG, encourage and strengthen partnerships and
coordination;
Effectively market the prioritization of adolescent health in NHSP to attract
partnerships and CPs’ support; and
Enhance partnerships at national, provincial, district and facility levels, by
encouraging participation in planning, implementation, and monitoring and
evaluation.
Procedures
No charging user fees to youths accessing health services through the YFCs;
No queuing to see health service providers/Doctors; and
Introduce the adolescent health week, in similar lines with the Child Health
Week.
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7.4
Monitoring and Evaluation



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DRAFT REPORT
Adolescent Health Situation Analysis
Define the reporting needs at different levels, and a set of key indicators;
Engage with the M&E Sub-Committee of the health Sector Advisory Group
(SAG) to incorporate key adolescent health indicators into the existing
routine reporting systems;
All performance evaluation systems, such as the provincial performance
assessments, Joint Annual Reviews (JARs), Mid-term Reviews (MTRs) and
End of Term Reviews should specifically comment on the performance of the
adolescent health programme.
APPENDICES
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