Knowledge Brief Health, Nutrition and Population Global Practice HEALTH AND WELL-BEING OF YOUNG PEOPLE: A MULTI-SECTORAL APPROACH TO OPERATIONAL PLANNING Seemeen Saadat and Rafael Cortez May 2017 KEY MESSAGES: • Young people’s (ages 10-24 years) health outcomes are affected by a multitude of factors (or determinants) both within and outside the health sector. These factors affect their life choices, their opportunities, and their life outcomes, including health outcomes. • A multi-sectoral approach to addressing adolescent/youth health is critical to ensuring that interventions address health and social determinants (direct and indirect factors) of adolescent health. Such an approach emphasizes cross-cutting linkages and aims to create synergies between different development sectors. • Key investments in health, education and labor markets, as well as social protection and social inclusion, support adolescent/youth health and well-being. How to prioritize investments and interventions depends on the country context. There are multiple paths, with no one size fits all. Striking the right balance becomes a matter of need, resources, skills, and the political economy. Introduction for this population cohort are important to ensure that they Young people’s health and well-being has strong enjoy opportunities to develop their human capital potential implications for achieving healthy and productive adult lives, to its maximum. This is all the more relevant as countries increasing the potential of future generations, and economic experience demographic transition with declining fertility and prosperity within communities. Adolescents (ages 10-19 improved dependency ratios. With appropriate investments, years) account for 18 percent of the world’s population. these countries have the potential to benefit from a Along with people 20-24 years of age, this cohort of demographic dividend (World Bank 2007; World Bank 2015; population forms the largest share of the global population - Lancet 2016). This requires working multi-sectorally with a a share that is expected to grow over the next several comprehensive approach to improving adolescent health. decades. Adolescence, especially, is a time of transition, and is characterized by physiological and emotional This note presents an overview of the multi-sectoral linkages changes that affect adolescents’ behaviors (Crone & Dahl between young people’s health and its social determinants. 2012). During this critical and vulnerable time, adolescents It highlights key areas of social, educational, and economic also face new challenges as they transition to adulthood. interventions that support their health and well-being. These include decisions surrounding their health and well- being such as sexual activity initiation and family formation Adolescent Health Overview that affect their future health and life opportunities (WDR An estimated 1.3 million adolescents died in 2012, mostly 2007, WDR 2012; Sawyer et al. 2012). from treatable causes. Mortality was higher among older adolescents aged 15-19 years and boys compared to Healthy adolescents and youth who transition to healthy younger adolescents ages 10-14 years, and girls. While the adulthood are more likely to be more productive members of causes of death were multiple, the major burden was due to society. Key investments in health (including sexual and injuries and non-communicable diseases, and in the case of reproductive health), education, and economic opportunities Page 1 HNP GP Knowledge Brief adolescent girls, pregnancy related ill-health. As Figure 1 that affect adolescent and youth health and well-being. Such shows, causes of death differ by both age and gender. an approach emphasizes cross-cutting linkages and aims to create synergies between different sectors. Figure 1: Causes of Deaths among Adolescents, 2013 In recent years there has been greater recognition of the Female Male importance of multi-sectoral approaches for improving Percentage of deaths, ages 10-14 years adolescent health outcomes. The WHO calls for effective responses across a range of actors and sectors to support Hepatitis adolescent health (WHO 2014), an approach that is echoed in the recent Lancet Commission on Adolescent Health and STIs (excl. HIV) Well-Being (Lancet 2016). The World Bank Group and Maternal disorders International Development Cooperation also recognize the Nutritional deficiencies benefits of multi-sectoral approaches. The challenge now is Injuries how to effectively translate the need for multi-sectoral NCDs approaches into action at the country level through social Neglected Diseases &… sector investments in the design and implementation of Infectious Diseases national adolescent health and well-being programs. HIV/AIDS & TB EDUCATION 0 10 20 30 40 Education, and specifically formal secondary education, is a closely related and integral social determinant of health and Percentage of deaths, ages 15-19 years adolescent fertility – a relationship also emphasized by the Adolescent Health Lancet Commission (2016). Injuries NCDs Education affects health through a number of direct and Infectious Diseases indirect channels: increasing knowledge and awareness HIV/AIDS & TB about health and healthy behaviors; developing skills that Neglected Diseases &… improve opportunities for employment and income Nutritional deficiencies generation (provided the education is linked to labor market Hepatitis needs); and contributing to a higher quality of life with better STIs (excl. HIV) access to health services. Secondary education is also a Maternal disorders preventive factor against early pregnancies and risky or 0 20 40 60 violent behavior. Strategic areas where the health and education sectors can Source: IHME 2016, data for developing countries only support each other on adolescent health include:  Collaborating on school health programs at the The burden of disease is generally higher among girls than national or sub-national levels. boys except for deaths due to injuries, which include injuries  Supporting incentives for girls and boys to stay in due to interpersonal violence and war. However, girls bear school, thereby enhancing secondary school (or higher) a significant burden of disease due to reproductive and completion rates. maternal disorders, including sexually transmitted infections  Supporting technical and vocational education and HIV/AIDS (WHO 2014; IHME 2016; Lancet 2016). opportunities focusing on marketable skills. Risky behaviors such as alcohol and drug use or unsafe sex To maintain focus on multi-sectoral linkages, it is important are the main causes related to injuries, HIV/AIDS and poor to keep track of relevant indicators in the partnering sector. maternal health outcomes. In fact, unsafe sex has been the Key monitoring indicators for education include: fastest growing risk factor, having increased from the 13th  School enrollment rates. to the 2nd highest ranked risk factor between 1990 and 2013  School dropout rates. (Lancet 2016).  School completion rates. Multi-Sectoral Approaches Of particular interest to the health sector is whether Adolescent health outcomes are affected by a multitude of incentives are offered or can be; and if the education system factors or determinants within and outside the health sector. includes provision of health education and if so, the scope These factors affect their life choices, opportunities, and of such education. Targets related to these would also need outcomes, including health outcomes. A multi-sectoral to part of the monitoring and evaluation process: approach encompasses interventions that address health and its social determinants - the direct and indirect factors – Page 2  Number of beneficiaries of incentives programs by need to be adapted to include them as specific beneficiary [primary/secondary/tertiary] level. group(s).  Number of beneficiaries with additional year of education due to the incentives programs. In addition, service packages should be adolescent/youth-  Number of drop-outs from the program and school. friendly, covering interventions that support access to and  School curricula include health education at use of health services for adolescents and youth, taking into [primary/secondary/tertiary] level. consideration their rights to information and privacy.  Health education includes comprehensive sexual and reproductive health education. Within the parameters of a project, consideration to  Support services [by type, such as counseling] exist adolescents and youth (ages 10-24 years) as specific sub- for students. groups should be supported through appropriate monitoring.  Community/parent outreach on health education With this in mind, potential monitoring indicators may curricula by school system. include: In addition, projects should also monitor the quality of health  Out of pocket expenditures on health care. education being provided. Some useful indicators that may  Number of adolescents and youth that are social be used here include: protection program beneficiaries.  Health insurance package covers adolescent/youth-  Standardized curriculum for health education. friendly sexual and reproductive health services.  Curriculum adheres to international standards in  Number of youth who access sexual and reproductive breadth and depth. health services due to insurance/incentives programs.  Number of teachers trained and certified to provide  School health services cover sexual and reproductive health education. health services.  Student learning provided in a safe environment.  Retention of knowledge for school health curriculum. Age is an important dimension for disaggregation for social protection interventions, to ensure that interventions are in For most indicators, gender and age groups (10-14 years, fact reaching adolescents and youth. Data should also be 15-19 years, and 20-24 years) are important dimensions for disaggregated by gender and other measures of inequality. monitoring information. Monitoring indicators should be further parsed by measures of equity such as income, LABOR MARKETS region, and ethnicity. This also aligns with a human rights- Adolescent and youth health outcomes and their future based approach to programming. consequences are also linked to labor market outcomes, even if the relationship may not be direct. From the outset, SOCIAL PROTECTION gainful and stable employment affords households greater Social protection mechanisms facilitate access to health financial stability, which contributes to the health and well- services. They remove financial barriers, especially for the being of household members including children and poorest and most vulnerable, through provision of adolescents. Children in higher income households, for subsidized services and reducing out of pocket expenditures instance, are more likely to be immunized than those in low through mechanisms such as insurance and incentives. income households. Similarly, girls in the highest income households are half as likely to have an unwanted Collaboration on health-focused social protection pregnancy as compared to those in the lowest income interventions can take the form of: households (Gillespie et al 2007).  Support to public health insurance for all members of a household. However, labor market interventions can also contribute to  Cash and in-kind transfers that encourage use of adolescent and youth health and well-being. For example, a health services. recent evaluation of a community-based Empowerment and  School-sponsored health programs that provide Livelihood for Adolescents in Uganda found that increasing basic health services to students at no or low cost. girls’ participation in self-employment improved their control over their own bodies and shifted gender norms in favor of It should be noted that except for school-sponsored health girls’ empowerment (WBG Africa Gender Lab, 2016). On the programs, these interventions do not directly target other hand, a study on youth in Southern Eastern Europe adolescents. Often, the discourse on health insurance or found that lack of employment opportunities exposed youth cash transfers for health, focuses on the poor or vulnerable to risky behaviors such as violence, substance abuse, groups such as ethnic minorities. While rightly so, unsafe sex, and early pregnancies (La Cava et al 2006). adolescents as a specific age group are rarely the target population. To ensure adolescents (ages 10-19 years) and Interventions that are relevant from the health sector’s youth (ages 15-24 years) are covered, targeting perspective relate to market opportunities for adolescents mechanisms and monitoring and evaluation frameworks and youth, and include: Page 3 HNP GP Knowledge Brief  Supporting better working conditions for adolescents  Investing in safe spaces for adolescents and youth to and youth such as healthy work spaces. spend their leisure time productively (e.g. playing sports,  Awareness building through workplace programs such learning a skill, or volunteering), and learning about as on prevention of sexual exploitation. health.  Ensuring legal frameworks promote fair wages and These types of interventions will also contribute to violence reduce exploitation of children, adolescents, and youth. prevention (including gender-based violence) and reducing  Supporting part-time employment, volunteer or other negative behaviors. Moreover, there will be greater internship opportunities that channel focus on opportunity of reaching out-of-school adolescents, who are productive activities and prevent negative or risky often at the highest risk of poor health outcomes. behaviors.  Supporting education interventions that align Indicators collected in adolescent-focused health surveys, learning with labor market needs, including such as Knowledge, Attitudes, and Practice (KAP) surveys opportunities within the health sector itself (such as for originated by WHO, measure inclusion through assessing: health extension workers).  Ease of access to health services (measured through Some readily available, key monitoring indicators, are: location, distance, hours, and cost).  Labor force participation ages 15-24 years.  Level of privacy and confidentiality in use of health  Employment by sector ages 15-24 years. services.  Unemployment rate ages 15-24 years.  Perceptions about provider behavior.  Age dependency ratios.  Perceptions about personal behaviors such as unsafe sex, avoiding pregnancies. As with others, disaggregated data by gender and age should be collected where possible. While intermediate Monitoring and evaluation indicators can be adapted to indicators will depend on a given project, having an highlight inclusion, by collecting data along the dimensions adolescent/youth oriented focus is important. of exclusion such as ethnicity, language, gender, and location by age. Measures of equity such as for income and SOCIAL INCLUSION education are also critical. Finally, at the aggregate level, Social norms and attitudes play a pivotal role in how, when, measures of well-being such as the human development and where adolescents and youth access the health system. index, the gender empowerment index, and the multi- Understanding the conditions or norms that govern the dimensional poverty index have potential to capture social inclusion and exclusion of adolescents and youth in seeking inclusion. and receiving healthcare, especially sexual and reproductive healthcare, is an important part of understanding the political economy. Conclusions Since social inclusion is a vast area, country context This note discusses avenues for multi-sectoral approaches becomes all the more important in understanding the unique and strategies to address adolescent and youth health. social barriers for adolescents to access health services. It Successful application of any multi-sectoral approach also helps to understand factors that cannot be quantified requires strong and continuous partnerships with different easily but affect health outcomes, such as provider attitudes. stakeholders including within the Bank. It requires building Social norms can be complex and take time to change. effective multi-sectoral teams with dedicated resources that Understanding these norms can help to identify can build bridges across different sectors within the Bank complementary interventions that can be implemented to and at the country level. While opportunities for facilitate supply, access, and use of health services in the collaboration depend on country contexts, keeping short-term and that will contribute to behavior change in the adolescents and youth at the center of an intervention will long-term. Focusing on inclusion as part of health projects help align and define multi-sectoral actions across different will help with the provision of well-planned adolescent and areas. youth-friendly services and creating a supportive environment through: This HNP Knowledge Brief highlights part of the key findings from the Bank’s  Addressing social and cultural barriers that inhibit Economic Sector Work “Investing in Adolescent Sexual and Reproductive adolescents and youth on the basis of gender, ethnicity, Health: Standards of Practice in Operations” conducted by the Health Nutrition and Population Global Practice and financed by the Nordic Trust and residency, and other dimensions of exclusion. Fund (NTF). This Knowledge Brief was prepared by a WBG team composed  Community out-reach for creating buy-in and demand of Rafael Cortez (World Bank’s Team Lead), and Seemeen Saadat. for adolescent/youth health and social services. The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the Regions. For more information on this topic, go to: www.worldbank.org/health. Page 4 Page 3