Kenya Adolescent Reproductive Health and Development Policy. Implementation Assessment

Kenya Adolescent Reproductive Health and Development Policy Implementation Assessment Report MAY 2013

Kenya Adolescent Reproductive Health and Development Policy Implementation Assessment Report MAY 2013

ACKNOWLEDGMENTS The Adolescent Reproductive Health and Development (ARHD) Policy Implementation Assessment Report was prepared by the National Council for Population and Development (NCPD), Division of Reproductive Health (DRH), and the Population Reference Bureau (PRB). This publication is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of the IDEA Project (No. AID-OAA-A-10-00009). The contents are the responsibility of NCPD, DRH, and PRB and do not necessarily reflect the views of USAID or the United States government. 2013 Population Reference Bureau. All rights reserved. 2 KENYA ADOLESCENT REPRODUCTIVE HEALTH AND DEVELOPMENT POLICY IMPLEMENTATION ASSESSMENT REPORT

TABLE OF CONTENTS Acronyms... 4 Foreword... 5 Executive Summary... 6 Background and Rationale.... 8 Methodology... 14 Key Findings.... 16 Recommendations and Lessons Learned... 33 Conclusion... 39 References... 40 Table of Contents 3

ACRONYMS ARHD ASRH CSO DRH FGM/C HPI IDEA Project M&E MOE MOH MOYAS MP NCPD NGO PIAT Adolescent reproductive health and development Adolescent sexual and reproductive health Civil society organization Division of Reproductive Health Female genital mutilation/cutting United States Agency for International Development Health Policy Initiative, Task Order 1 Population Reference Bureau s Informing Decisionmakers to Act Project Monitoring and evaluation Ministry of Education Ministry of Health Ministry of Youth Affairs and Sports Member of Parliament National Council for Population and Development Nongovernmental organization Health Policy Initiative s Policy Implementation Assessment Tool POA ARHD Policy Plan of Action 2005-2015 PRB STI TWG USAID Population Reference Bureau Sexually transmitted infection Technical Working Group United States Agency for International Development 4 KENYA ADOLESCENT REPRODUCTIVE HEALTH AND DEVELOPMENT POLICY IMPLEMENTATION ASSESSMENT REPORT

FOREWORD The implementation assessment of the Adolescent Reproductive Health and Development (ARHD) Policy was undertaken from November 2011 to September 2012. The assessment was conducted by the National Council for Population and Development (NCPD), Division of Reproductive Health (DRH), and the Population Reference Bureau s (PRB) Informing Decisionmakers to Act (IDEA) project. A range of additional government agencies and organizations were engaged in the assessment process as taskforce members. A core research team of PRB consultants collected qualitative data for the assessment through key informant interviews and focus group discussions held throughout Kenya. Relevant government policies, strategic plans, and research documents were also reviewed. The draft assessment reports were reviewed by the assessment partners and taskforce members. The findings and draft recommendations were presented to an audience of stakeholders on 20 th September 2012 at the Hilton Hotel in Nairobi, and feedback acquired from the stakeholders was used to finalize the report. The ARHD Policy Implementation Assessment Report is now ready and marks a critical milestone in ARHD Policy implementation. The report will guide future policy reviews and the design of related programs. In 2003, the ARHD Policy was developed to respond to concerns about youth issues that were noted in the National Population Policy for Sustainable Development (2000), the National Reproductive Health Strategy (1997-2010), the Children s Act (2001), and the government s commitment to integrate youth into the national development process. To facilitate the operationalization of the ARHD Policy through a national multi-sector approach, an ARHD Plan of Action (2005-2015) was developed in 2005. Since then, there have been new developments including the formulation of other sectoral policies, implementation of Vision 2030, promulgation of a new Constitution in 2010, and more stakeholders and programs focusing on ARHD issues. In 2007, the Reproductive Health Policy was developed, and the adolescent reproductive health component is the key pillar of this policy. These developments necessitated the need to assess implementation of the ARHD Policy. The assessment report provides valuable findings that will inform policymakers, donors, program managers, and partners about the status of ARHD Policy implementation, and provides explicit recommendations on how to strengthen implementation. The lessons learned during its implementation as assessed will also be used to revise the policy into a new National Adolescent and Youth Development Policy. Mr. Karugu Ngatia Deputy Director National Council for Population and Development Dr. Issak Bashir Head Division of Reproductive Health FOREWORD 5

EXECUTIVE SUMMARY Developed in 2003, the Adolescent Reproductive Health and Development (ARHD) Policy was the first in Kenya to focus on improving the reproductive health, well-being, and quality of life of Kenya s adolescents and youth. The ARHD Policy is a foundation for initiatives in Kenya that integrate reproductive health and development concerns for adolescents and youth into the national development process, and enhance their participation in that process. Given the increase in the number of stakeholders and programs focused on ARHD in Kenya over the last decade, and with two years before the end of the ARHD Policy timeframe, stakeholders in Kenya recognized the need to assess implementation of the policy. Therefore, the National Council for Population and Development (NCPD), Division of Reproductive Health (DRH), and the Population Reference Bureau s (PRB) Informing Decisionmakers to Act (IDEA) project conducted an assessment of the ARHD Policy from November 2011 to September 2012. The partners organized a task force of reproductive health professionals and youth advocates from the public and private sectors to provide input for the assessment methodology and tools. The assessment sought to: explore the nature of policy implementation since the ARHD Policy was developed in 2003; assess implementation progress and achievements; identify social, political, and economic barriers for implementation; and promote policy dialogue on ways to strengthen implementation. Using an adapted version of the Health Policy Initiative s 2010 Policy Implementation Assessment Tool (PIAT), a core research team of PRB consultants collected qualitative data from 195 participants in Nairobi, Thika, Kisumu, Wajir, and Watamu from March through June 2012. Individual interviews were conducted with 22 policymakers and 68 implementers. Fourteen focus group discussions were held with 30 service providers, 34 teachers, and 41 youth age 18 or older. The findings of the assessment revealed that since 2003, Kenya s ARHD Policy has led to many perceived improvements in the health and well-being of adolescents and youth. The ARHD Policy has provided guidance for priority ARHD needs and target populations, and for a range of approaches to increase access to and quality of ARHD programs and services. The policy has also helped lay the groundwork for many new guidelines, policies, and strategies. All of this has contributed to more commitment to and funding for adolescent sexual and reproductive health (ASRH); strengthened partnerships between the government and nongovernmental organizations (NGOs) and civil society organizations (CSOs); improved knowledge of and attitudes toward ASRH; and improved empowerment of youth. 6 KENYA ADOLESCENT REPRODUCTIVE HEALTH AND DEVELOPMENT POLICY IMPLEMENTATION ASSESSMENT REPORT

However, ARHD Policy implementation has been limited due to a range of factors and challenges, such as: lack of awareness about the ARHD Policy and the ARHD Policy Plan of Action (POA); lack of coordination among implementers; low stakeholder involvement, including low political will and youth involvement; limited leadership; lack of resources; poverty and unemployment among youth; and limited availability of high-quality ASRH services. Additionally, ASRH remains a contentious issue among some communities, and some cultural and religious practices are barriers for implementation. Adolescents and youth still face challenges, such as completing secondary school, finding employment, postponing marriage, and avoiding sexually transmitted infections (STIs) and unintended pregnancies. Based on the findings, the assessment partners and stakeholders identified seven recommendations as next steps for policy action to strengthen implementation and ensure that the ARHD Policy is put into practice on a large scale: 1. Ensure an Integrated Approach to Policy Development and Implementation. 2. Strengthen Leadership and Coordination. 3. Increase Policy Awareness. 4. Strengthen Implementation Plans. 5. Improve Resource Mobilization and Management. 6. Improve Service Delivery. 7. Ensure Monitoring and Evaluation. This assessment reinforced stakeholder commitment to the policy s goal and objectives, facilitated dialogue on ARHD needs and challenges, and identified next steps to strengthen policy implementation. The assessment partners will use the findings and the recommendations from the assessment to strengthen ARHD Policy implementation during its last two years. The lessons learned will also be used by stakeholders to revise the ARHD Policy into a new National Adolescent and Youth Development Policy to continue to improve the reproductive health and well-being of adolescents and youth, and achieve Kenya s development goals. Executive summary 7

BACKGROUND AND RATIONALE PRIOR TO 2003: LAYING THE GROUNDWORK The 2003 Kenya Adolescent Reproductive Health and Development (ARHD) Policy was a milestone for addressing the health and development concerns of Kenya s adolescents and youth. Prior to 2003, no policy document at the national level explicitly addressed adolescent sexual and reproductive health (ASRH). Several initiatives helped lay the groundwork for the ARHD Policy, such as the: United Nations International Convention on the Rights of the Child, 1989 United Nations International Conference on Population and Development, 1994 United Nations Fourth World Conference on Women, 1995 Kenya National Reproductive Health Strategy, 1997-2010 United Nations World Programme for Youth, 2000 Kenya National Population Policy for Sustainable Development, 2000 Kenya Children s Act, 2001 The Persons With Disabilities Act, 2003 Together, these initiatives and others highlighted the right of adolescents and youth to have highquality health care, including reproductive health; and recognized the influence of the health and well-being of youth on national development. In response to the concerns raised about adolescents in these initiatives and other national and international declarations on ARHD, the Government of Kenya developed and launched the ARHD Policy in 2003. ARHD POLICY GOAL AND OBJECTIVES The goal of the ARHD Policy is to contribute to improvement of the well-being and quality of life of Kenya s adolescents and youth. 1 The ARHD Policy also seeks to integrate the health and development concerns of adolescents and youth into the national development process, and to enhance their participation in that process. According to the ARHD Policy, adolescents are defined as persons ages 10 to 19, and youth are ages 10 to 24. The specific objectives of the policy are presented in Table 1. For the rest of the report, the ARHD Policy will be referenced as the policy. In addition to providing a summary of ASRH challenges and indicators in Kenya in 2003, the policy identifies a set of strategic actions to address the following priority concerns: ASRH health and rights, harmful practices, drug and substance abuse, socioeconomic factors, and adolescents and youth living with disabilities. Table 2 summarizes the health, demographic, and social service targets intended to guide the achievement of policy objectives by 2015. 8 KENYA ADOLESCENT REPRODUCTIVE HEALTH AND DEVELOPMENT POLICY IMPLEMENTATION ASSESSMENT REPORT

Table 1: ARHD Policy Objectives 1. To identify and define adolescent health and development needs. 2. To provide guidelines and strategies to address adolescent health concerns. 3. To promote partnership among adolescents, parents, and community. 4. To create an enabling legal and socio-cultural environment that promotes provision of information and services for adolescent and youth. 5. To promote and protect adolescent reproductive rights. 6. To strengthen inter-sector coordination and networking in the field of adolescent health and development. 7. To promote participation of adolescents in reproductive health and development programmes. 8. To identify and define monitoring and evaluation indicators for ARHD. 9. To advocate for increased resource commitments for adolescent and youth health and development programmes. Source: Republic of Kenya, Adolescent Reproductive Health and Development Policy (Nairobi, Kenya: National Council for Population and Development, Ministry of Planning and National Development and Division of Reproductive Health, Ministry of Health, 2003). Table 2: ARHD Policy Targets Health Targets I. To double the contraceptive use rate among adolescents (ages 15-19 years) from 4 percent in 1998 to 8 percent in 2015; and among youth (20-24 years) from 19.9 percent to 40 percent. II. To increase the proportion of facilities offering basic essential obstetric care to adolescents and youth from 15 percent to 30 percent; and comprehensive essential obstetric care from 9 percent to 18 percent by the year 2015. III. To increase the proportion of facilities offering youth-friendly services from baseline to 85 percent by 2015. IV. To increase the proportion of mothers below age 25 receiving at least two doses of tetanus toxoid during pregnancy from 25 percent to 85 percent by 2015. V. To increase antenatal attendance by mothers below age 25 from the baseline to 85 percent by 2015. VI. To increase the proportion of mothers below age 25 delivering in a health facility from baseline to 60 percent by 2015. VII. To increase the minimum antenatal care visits by mothers below age 25 from baseline to 80 percent by 2015. Demographic Targets I. To reduce the proportion of women below age 20 with a first birth from 45 percent in 1998 to 22 percent by the year 2015. II. To raise the median age at first sexual intercourse from 16.7 for girls and 16.8 for boys to 18 for both by 2015. III. To reduce the maternal mortality ratio by 50 percent in the 15-24 age group by 2015. Social Service Targets I. To achieve universal primary education by 2003 and education for all by 2015. II. To achieve gender equity in education by 2015. Source: Republic of Kenya, Adolescent Reproductive Health and Development Policy (Nairobi, Kenya: National Council for Population and Development, Ministry of Planning and National Development and Division of Reproductive Health, Ministry of Health, 2003). Background and Rationale 9

POLICY IMPLEMENTATION PLANS The policy includes implementation strategies to address the priority concerns, including: advocacy, behavior change communication, provision of reproductive health services, research, capacity building, resource mobilization, networking and community participation, and monitoring and evaluation (M&E). A multisectoral approach for implementation is recommended, and the roles of various stakeholders are outlined. The Ministry of Health (MOH) and the Ministry of Planning for National Development and Vision 2030, specifically NCPD, are designated as the lead agencies responsible for coimplementation. 2 The MOH is responsible for the coordination and implementation of all health activities and programs, and NCPD is mandated to coordinate population and development activities. 3 Other government agencies and stakeholders called upon for policy implementation include: Office of the President. Ministry of Home Affairs and National Heritage. Ministry of Gender, Sports, Culture, and Social Services. 4 Ministry of Justice and Constitutional Affairs and the State Law Office. Ministry of Education, Science, and Technology. Ministry of Tourism and Information. Ministry of Environment, Natural Resources, and Wildlife. Ministry of Agriculture and Livestock Development. 5 Ministry of Labour and Human Resource Development. NGOs, Community-Based Organizations, and the Private Sector. Religious Institutions. Family and Community. Mass Media. Young People. Political Parties. Universities and Colleges. ARHD POLICY PLAN OF ACTION 2005-2015 The ARHD Policy Plan of Action 2005-2015 (POA) was developed in 2005 by NCPD and the MOH to facilitate the implementation of the policy through a national multisectoral approach. 8 The objectives of the POA are to: Spell out strategies of implementation. Identify priority activities and major implementers of the national ARHD program up to 2015, based on the stipulations of the policy. Provide an avenue and basis for resource mobilization and management of a sustainable national ARHD program. Outline a logical framework for implementing the policy that will also be used for monitoring and evaluation purposes. Four strategic areas are identified in the POA: advocacy; health awareness and behavior change communication; access to and utilization of sustainable youth-friendly services; and management of implementation by national coordinating agencies. A logical framework details all the outcomes, outputs, and lead activities with the verifiable indicators, sources of verification, and responsible parties. An M&E framework is also included in the POA 10 KENYA ADOLESCENT REPRODUCTIVE HEALTH AND DEVELOPMENT POLICY IMPLEMENTATION ASSESSMENT REPORT

to be implemented through the ASRH Technical Working Group (TWG) under the direction of NCPD and DRH. The POA recommends regular monitoring of program performance and outcomes and includes an M&E plan and calendar. The POA provides an estimate of the total resources required to achieve the goal and objectives outlined in the policy. The cost estimates cover the first five years (2005 2010) of implementation. These costs are based on an ideal situation and standard costing models rather than past and ongoing programmatic experiences. Realistic estimates for the second half (2010 2015) are to be determined on the basis of the experiences from the first half. 6 ARHD OVER THE LAST DECADE Ten years since the policy was developed, Kenya has witnessed tremendous advancements and changes in the social, economic, and political environment for ARHD. 7 The policy has helped lay the groundwork for several policies, strategies, and guidelines that emerged over the last decade, such as the examples listed below. All of these initiatives reinforce the importance of reproductive health for adolescents and youth. National Guidelines for Provision of Youth-Friendly Services, 2005 Kenya HIV & AIDS Prevention and Control Act, 2006 Sexual Offences Act, 2006 Ministry of Youth Affairs and Sports (MOYAS) Service Delivery Charter, 2007 Gender Policy in Education, 2007 National Youth Policy, 2007 National Reproductive Health Policy: Enhancing Reproductive Health Status for All Kenyans, 2007 Kenya Vision 2030, most notably the First Medium Term Plan, 2008-2012 Ministry of Youth Affairs and Sports Strategic Plan, 2008-2012 National Reproductive Health Strategy, 2009-2015 Reproductive Health Communication Strategy, 2010-2012 The Constitution of Kenya, 2010 Kenya Health Sector Strategic Plan III, 2012-2017 Population Policy for National Development, 2012-2030 Both the government and the private sector have increased efforts to address the reproductive health and development needs of adolescents and youth. The government has identified key priorities for ASRH programs and is working with a range of partners to establish high-quality care, provide comprehensive and integrated youth-friendly reproductive health services, promote a multisectoral approach to ASRH, and strengthen partnerships and referrals with NGOs and faith-based organizations, especially in hard to reach areas. Youth-friendly SRH services are being provided in youth centers that were established in the constituencies, and adolescent sexual education is being implemented under a life-skills training curriculum. 8 A broad range of ARHD programs for adolescents and youth either have been or are currently being implemented throughout the nation by the government, international NGOs, and CSOs, including some faith-based organizations. 9 Some projects are focused explicitly on ASRH service delivery, advocacy, education, research, or peer counseling, while others have a more integrated approach with crosscutting health or development initiatives. 10 Other programs are focused on broader adolescent development priorities, such as education, other health initiatives, and job preparedness. For example, some programs connect adolescents to various Background and Rationale 11

career opportunities to enhance capacity for income generation. By building a strong economic base, these programs have sought to reverse poverty and ensure that adolescents have a better chance for productive and healthier lives by addressing factors associated with risky behaviors or outcomes. 11 As called for in the POA, an ASRH TWG was created in 2007 under the direction of DRH and NCPD. The ASRH TWG is comprised of program implementers from various government agencies and NGOs, and meets quarterly to coordinate efforts focused on ASRH program implementation and research, and to share progress and lessons learned. There have been some notable improvements in several ARHD indicators over the last decade. For example, from 2003 to 2009, the median age at marriage for women in most provinces increased, and teenage pregnancy and childbearing among young women declined. The median number of years of schooling has increased slightly for both men and women, and the proportion of children and young adults who have never attended school has decreased. Additionally HIV prevalence among both women and men ages 20 to 24 has decreased from 6 percent in 2003, to 5.2 in 2007, and to 4.2 in 2009. 12 However, there continues to be a high need for improved ASRH. For example, more than one out of four young women is married by age 18, increasing their likelihood of having children at an early age. Nearly one-half of births to young women under age 18 are the result of unintended pregnancy. Nearly one out of three young women has an unmet need for family planning, meaning they wish to delay childbearing, but are not using any method of contraception, and are at risk for having an unintended pregnancy. Furthermore, among youth ages 15 to 19 who had sexual intercourse in the last 12 months, nearly 60 percent of young women and nearly 100 percent of young men engaged in higher-risk sex, meaning they had sexual intercourse with a partner who was neither their spouse nor lived with them. Among these youth ages 15 to 19 who had higher-risk sexual intercourse in the last 12 months, only 40 percent of the young women and 55 percent of the young men used a condom during their last higher-risk intercourse. 13 A longer list of ASRH indicators from the 2008-09 Kenya Demographic and Health Survey is presented Table 3. Table 3: Kenya Adolescent Sexual and Reproductive Health Percent Women ages 20-24 married by age 18 26 Women ages 20-24 who had sex by age 18 48 Men ages 20-24 who had sex by age 18 58 Women under age 20 whose most recent birth was an unintended pregnancy 47 Women under age 20 whose most recent birth was not delivered by a skilled attendant 52 Women ages 20-24 who gave birth by age 18 26 Women ages 20-24 with an unmet need for family planning 30 Women ages 20-24 living with HIV 6 Men ages 20-24 living with HIV 2 Sexually active women ages 15-19 who had higher-risk sex in last 12 months 56 Sexually active men ages 15-19 who had higher-risk sex in last 12 months 98 Source: Kenya Demographic and Health Survey 2008-2009 (Calverton, MD: Kenya National Bureau of Statistics and ICF Macro, 2010). 12 KENYA ADOLESCENT REPRODUCTIVE HEALTH AND DEVELOPMENT POLICY IMPLEMENTATION ASSESSMENT REPORT

ASSESSMENT PURPOSE Given the increase in the number of stakeholders and programs focused on ARHD over the last decade, and with two years before the end of the ARHD Policy timeframe, stakeholders recognize the need to assess implementation of the policy. This policy assessment sought to: explore the nature of policy implementation since 2003; look at implementation progress and achievements; identify social, political, and economic barriers to implementation; and promote policy dialogue on ways to strengthen implementation. As a result, NCPD, DRH, and PRB s IDEA project conducted an assessment of the policy from November 2011 to September 2012. The findings of the assessment will be used to inform stakeholders about policy implementation so lessons learned can be applied to the remaining implementation of this policy and other policies in Kenya. The findings will also be used to revise the policy in the coming years. Background and Rationale 13

METHODOLOGY As a first step, NCPD, DRH, and PRB invited a core group of reproductive health professionals and youth advocates from the public and private sectors to join a task force that met in November 2011 and January 2012 to design the assessment methodology and tools. The Health Policy Initiative s 2010 Policy Implementation Assessment Tool (PIAT) was adapted by the partners and task force members for this assessment. The PIAT gathers information about the dynamic and multifaceted process of policy implementation, and the process by which a policy is carried out to achieve its goals. 15 The PIAT is comprised of interview guides that gather quantitative rankings using Likert-like scales and qualitative information based on the participants experiences. 16 The interview guides address seven dimensions of policy implementation, including: (1) the goals of the policy, its formulation, and dissemination; (2) social, political, and economic context; (3) leadership for policy implementation; (4) stakeholder involvement in policy implementation; (5) implementation planning and resource mobilization; (6) operations and services; and (7) feedback on progress and results. 17 The interview guides were adapted by the assessment partners and task force to focus specifically on the ARHD Policy; to use language appropriate for the study participants; and to prioritize social, economic, and political factors identified as most appropriate for the Kenya context. From March through June 2012, a core research team collected qualitative data from 195 participants. Individual interviews were conducted with 22 policymakers and 68 implementers. Fourteen focus group discussions (FGDs) were held with 30 service providers, 34 teachers, and 41 youth age 18 or older. Unless observations are noted between the groups, in this report the policymakers and implementers are collectively referred to as key informants and the service providers, teachers, and youth are collectively referred to as FGD participants. The partners and task force members selected policymakers and implementers to participate in key informant interviews if they were at least partially familiar, if not very knowledgeable, with the policy and its implementation. Service providers, teachers, and youth ages 18 or older were selected for FGDs because the partners and task force members recognize these groups as key stakeholders for policy implementation, and preferred to gather qualitative information from them through in-depth group discussions. Interviews were conducted in Nairobi, Thika, Kisumu, Wajir, and Watamu. Based on discussions with the task force and previous research, the partners selected these locations to gather data from areas representing districts where ARHD services are widely available and ASRH indicators are best (Nairobi, Thika, and Kisumu), and where ARHD services are not widely available and ASRH indicators are worst (Wajir and Watamu). Analysis of Key Informant Interviews With Policymakers and Implementers Once the data collection was complete, the core research team tallied and reviewed the Likert-like scaled responses. The research team reviewed the transcripts to identify themes that summarized 14 KENYA ADOLESCENT REPRODUCTIVE HEALTH AND DEVELOPMENT POLICY IMPLEMENTATION ASSESSMENT REPORT

the open-ended responses, and counted the number of times a theme was mentioned for each response. The themes were ranked according to frequency for each question, and compared between policymakers and implementers. Although policymaker and implementer responses were coded as separate groups, the team used the same themes for each group to the extent possible. Analysis of Focus Group Discussions With Service Providers, Teachers, and Youth The team reviewed the transcripts for each group by region to create key themes that summarized the responses, and compared the responses by group and region. Although each group and region was coded separately, the team used the same themes for each group to the extent possible. Challenges and Limitations In most of the regions visited, policy awareness was mainly at the provincial level, and the policy was not well-known beyond this, especially in more rural areas. This made it challenging to identify assessment participants, especially for FGDs in the regions. The policy was also not well-known among implementing agencies and government agencies with high turnover of personnel. Another challenge was finding policymakers who were familiar with the policy and available to participate, resulting in a low number of policymaker participants. The policy has contributed to an enabling environment for ASRH, and many adolescent and youth programs were initiated after the policy was developed. The core research team noted that during the interviews, it was sometimes difficult to distinguish between participant accounts of policy implementation versus program implementation. For example, some participants may have referred to program implementation when asked about barriers or successes regarding policy implementation. Therefore in this assessment, participant descriptions of policy versus program implementation may sometimes be indistinguishable. The core research team noted that some participants did not distinguish between adolescents and youth, and the terms adolescent, youth, or young person were sometimes referred to interchangeably. The findings of this assessment are the perceptions and beliefs of the key informant interviews and FGD participants. Therefore, the participants perceptions of ARHD in Kenya and what is included or not included in the policy may not reflect the actual content of the policy, or what other analyses have revealed about ARHD in Kenya. Recommendation Development The core research team and assessment partners met several times after the analysis to review the key findings and develop recommendations to go forward. The assessment partners presented the key findings and draft recommendations to an audience of task force members and multisectoral stakeholders in Nairobi on September 20, 2012. The key findings and recommendations were discussed by meeting attendees, and feedback was provided for the recommendations before they were finalized for this report. Methodology 15

KEY FINDINGS The key findings are presented in sections representing the PIAT s seven key dimensions of policy implementation, in addition to an overall assessment of policy implementation. A summary of the findings is provided at the beginning of each section. SECTION 1 POLICY FORMULATION, CONTENT, AND DISSEMINATION Policy formulation, content, and dissemination lay the groundwork for successful policy implementation. The first section of the interview guides assessed the process of policy formulation, policy content, and the extent of policy dissemination to various stakeholders, implementers, and beneficiaries. SUMMARY OF POLICY FORMULATION, CONTENT, AND DISSEMINATION The policy goal and objectives are achievable within the policy timeframe, but they are missing some of the key ARHD issues in Kenya. The identification of implementation strategies and resources are limited in the policy. Stakeholders were involved with policy formulation, but their level of participation during policy formulation was limited. Dissemination of the policy was limited, especially in areas outside of Nairobi, among implementers at the subnational level, institutions with high turnover, and policymakers. All policy assessment participants were shown the policy goal and objectives during the interview. A majority of key informants, including policymakers and implementers, think the policy goal and all of the objectives are achievable within the timeframe established by the policy. However, most policymakers and implementers (72 out of 89 key informants; 81 percent) also think the policy goal and objectives are missing some or most of the key ARHD issues in Kenya. The key issues mentioned most frequently as missing by both key informants and FGD participants include: a policy implementation framework, guidance for coordination among implementing government agencies and organizations, and resource mobilization plans. Participants also noted that the policy is missing information about religious and cultural barriers for implementation, poverty and socioeconomic challenges, barriers for youth to access ARHD information and services, and the diverse needs of vulnerable youth, including those with special needs. The identification of appropriate implementation approaches and resources are limited in the policy. As presented in Figure 1, policymakers and implementers were most likely to report that the policy identifies most appropriate approaches for implementation, but only eight out of 89 policymakers and implementers (9 percent of key informants) think the policy identifies all appropriate approaches for implementation. In Figure 2, only three out of 89 policymakers and implementers (3 percent of key informants) think the policy identified all of the resources required for implementation. 16 KENYA ADOLESCENT REPRODUCTIVE HEALTH AND DEVELOPMENT POLICY IMPLEMENTATION ASSESSMENT REPORT

Figure 1: The Extent of Identification of Appropriate Approaches for ARHD Policy Implementation Number of Respondents 50 40 Policymakers Implementers 30 20 10 0 Does Not Identify Identifies Some Identifies Most Identifies All Don t Know No Response ARHD Policy Identification of Appropriate Approaches for Implementation Figure 2: The Extent of Identification of Appropriate Resources for ARHD Policy Implementation Number of Respondents 45 40 35 Policymakers Implementers 30 25 20 15 10 5 0 Does Not Identify Identifies Some Identifies Most Identifies All Don t Know No Response ARHD Policy Identification of Appropriate Resources for Implementation During the process of formulating the policy, nearly half of policymakers and implementers (40 out of 89 key informants; 45 percent) think there was only limited or moderate involvement of stakeholders. Eleven out of 89 policymakers and implementers (12 percent of key informants) think there was extensive involvement of various stakeholders. Interviews with policymakers and implementers and FGDs revealed that dissemination of the policy was limited. As presented in Figure 3, policymakers and implementers were most likely to think policy dissemination was limited (47 out of 89 key informants; 53 percent). Twenty-one percent of policymakers and implementers (19 out of 89 key informants) think the policy was disseminated widely, but only 10 percent (9 out of 89 key informants) think the broad dissemination included forums for discussions about how to put the policy into practice. The core research team also observed limited policy knowledge and lack of policy dissemination during the process of identifying assessment participants. It was especially challenging to identify participants familiar with the policy in areas outside of Nairobi, among implementers at the subnational level, among institutions with high turnover, and among policymakers. Key findings 17

Figure 3: The Extent of ARHD Policy Dissemination to Implementing Agencies Number of Respondents 50 40 Policymakers Implementers 30 20 10 0 Not Limited Disseminated Disseminated Dissemination Widely With No Forums for Discussion Disseminated Widely With Forums for Discussions Don t Know ARHD Policy Dissemination to Implementing Agencies No Response SECTION 2 SOCIAL, POLITICAL, AND ECONOMIC CONTEXT Implementers and FGD participants identified the social, political, and economic factors that help facilitate policy implementation, and the factors that have a detrimental effect. Depending on the context, several factors have both positive and negative influences on policy implementation. SUMMARY OF SOCIAL, POLITICAL, AND ECONOMIC CONTEXT International agreements facilitate implementation by establishing goals and guidelines that align with the policy, such as the MDGs. Global assistance and donor support help to facilitate implementation by mobilizing support and providing guidance. Global assistance or donor priorities can have a hindering effect when: there is not enough financial support; donor priorities change and projects are discontinued as a result; efforts are duplicated due to lack of coordination; there is donor dependence; and a donor s priorities are not aligned with priorities at the local level. Devolution and county governments may help to facilitate implementation by expanding implementation in rural areas, bringing resources and ownership to the local level, and increasing engagement at the local level. Accountability and good leadership are essential, otherwise devolution can hinder implementation. Changes in government have helped facilitate policy implementation over time, but only when the new leaders have been supportive of ARHD, and when changes do not happen too frequently. The policy environment may facilitate implementation, but only when policies and programs are aligned with similar goals, and partners work together. Prioritization of poverty alleviation facilitates implementation because it increases the availability of services for low-income adolescents who are most in need of ARHD information and care. Cultural practices and gender norms can hinder implementation because the influence they have on behavioral expectations for men and women are often not aligned with policy objectives. Religious practices and beliefs frequently hinder implementation because of opposition to life skills education, specifically comprehensive sex education, and access to ASRH services. However, sometimes they facilitate implementation by encouraging adolescents to abstain from sex, or fostering life skills education. 18 KENYA ADOLESCENT REPRODUCTIVE HEALTH AND DEVELOPMENT POLICY IMPLEMENTATION ASSESSMENT REPORT

SUMMARY OF SOCIAL, POLITICAL, AND ECONOMIC CONTEXT (continued) Migration hinders implementation when it is more difficult to reach people with services because either the providers or the clients are constantly moving. Migration facilitates implementation when the providers or the clients move to an area where it is more beneficial or easier to provide ARHD services. Poverty and unemployment hinder implementation because they increase the risk of school drop-out, engaging in risky behaviors, and other barriers to ASRH information and services. FACTORS THAT FACILITATE POLICY IMPLEMENTATION A majority of implementers believe these factors facilitate policy implementation: international agreements; global assistance mechanisms and donor priorities; devolution and county governments; changes in government; policy environment; and prioritization of poverty alleviation. The FGDs with service providers, teachers, and youth provided more detail regarding factors that facilitate policy implementation. According to the FGD participants, some of these factors may facilitate or hinder implementation depending on the context. International Agreements Facilitate Implementation The FGD participants, especially teachers, generally agreed that international agreements facilitate policy implementation by establishing goals and guidelines that tend to align with the policy, such as the MDGs for universal education, poverty reduction, human rights, and others. However, the participants note that awareness of these international agreements and goals is more common at the national level, and it is lacking at the county levels. According to the youth, international agreements put pressure on the government to be more accountable to the public regarding the commitments they sign. International agreements also help set standards for ARHD service provision. Global Assistance Mechanisms and Donor Priorities Facilitate Implementation in Certain Circumstances According to the FGD participants, global assistance and donor support for ARHD help facilitate policy implementation. Global assistance is often goal-oriented, and this helps mobilize support and provide guidance for policy implementation. For example, the targets set by the MDGs help mobilize support for their achievement. Youth had a favorable view of global assistance and donor priorities, because they believe most policy implementation is being done by NGOs with donor support, and implementation would be minimal without it. In Watamu, the youth noted that donors provide materials that would otherwise be unavailable. Global assistance or donor priorities can have a hindering effect when there is not enough financial support, when donor priorities change and projects are discontinued as a result, when there are duplicated efforts due to lack of coordination, or when there is dependence on donors for financial support and no sustainability. In Nairobi, teachers noted the importance of donor accountability. Financial support from donors can have a facilitating effect on policy implementation when there is reporting from the implementer to the donor. However, if there is no accountability, then the money may be misused and the donor support will discontinue. For example, in Wajir, teachers discussed the misappropriation of funds for free primary education that resulted in donor withdrawal. Key findings 19

Also problematic is when there is a lack of alignment between a donor s priorities and priorities at the local level. For example: They (donors) come with fixed mind that this thing should be done the way they want, but they really do not understand the context. Whatever they are doing can hinder whatever the program is intended for. So if our policies are not in line with what they want you ll find that it will hinder it A teacher in Kisumu Devolved Structure of Government Is an Opportunity to Ensure Effective Implementation According to FGD participants, decentralization will facilitate policy implementation, but only if there are accountability measures. Service providers stressed the importance of accountability for the allocation and use of funds at the county level. Without accountability, decentralized resources may result in the misallocation or misuse of funds. Teachers noted that devolution will help expand ARHD services to rural areas, and bring resources and services closer to the people at the county level. However, they also discussed the potential hindering effect of devolution in situations where there is lack of leadership at the county level, where the priorities of the new local governments are not aligned with the policy, and when changes in the structure of the new government disrupt or slow ARHD policy initiatives. The youth discussed the benefits of devolution on policy implementation, including new youth representatives in county governments, and new youth forums through which more youth will learn about their rights and services. This youth engagement will lead to more awareness and empowerment among adolescents and youth, which will result in an increased demand for and access to information and services. Changes in Government Facilitate Implementation in Certain Circumstances Some FGD participants think changes in government have helped facilitate policy implementation over time, but only when the new leaders have been supportive of ARHD. Service providers in Nairobi noted positive changes in government because leaders have signed international agreements that are committed to youth development. Other FGD participants, especially teachers, noted that when leaders are not aligned with the goals of the policy, or when changes in leadership happen too frequently, then there is a detrimental effect on policy implementation. New leaders come with new priorities and policies, and this often leads to fragmented or discontinued projects: I think sometimes when there is change in government, offices change, and management change, so whenever there is a project like this, other people come in and undermine, so some things get lost in between because people change hands, and it slows down the implementation of such projects. A teacher in Nairobi Aligned Policies Facilitate Implementation More Than Policies That Stand Alone Opinions about the influence of the current policy environment on policy implementation varied among the FGD groups. According to FGD participants, the policy environment can facilitate policy implementation, but only when policies and programs are aligned with similar goals, and partners work together. Some participants noted there are lots of policies, and when policies are not aligned, the effect can be detrimental. Compared to the other groups, service providers were most likely to discuss the hindering effect of the policy environment because they think there are too many policies, and the policies often contradict each other, which makes implementation a challenge. In comparison to other districts, Watamu 20 KENYA ADOLESCENT REPRODUCTIVE HEALTH AND DEVELOPMENT POLICY IMPLEMENTATION ASSESSMENT REPORT

participants were most likely to think the policy environment hinders implementation because of conflicting policies. For example, teachers mentioned the conflicting goals of the ARHD Policy compared to other policies that do not mention or prioritize life skills education in schools. According to youth in Nairobi, ASRH is often neglected because there are too many policies focused on other issues that are prioritized over reproductive health. Prioritization of Poverty Alleviation Facilitates Implementation The FGD participants generally agreed that prioritization of poverty alleviation has facilitated policy implementation because it increases the availability of services for low-income adolescents who are most in need of ARHD information and care. Some policy initiatives have made it easier for lowincome youth to access a range of health care services, and stay in school. For example, in Watamu, the provision of meals in schools has helped increase school enrollment for low-income students. A focus on poverty alleviation also contributes to economic empowerment of youth, which helps reduce some risky behaviors associated with poverty, such as sex in exchange for money. FACTORS THAT HINDER POLICY IMPLEMENTATION A majority of implementers believe these factors hinder policy implementation: cultural practices and gender norms; religious practices or beliefs; migration; and poverty and unemployment. The FGDs with service providers, teachers, and youth provided more detail regarding factors that hinder policy implementation. According to the FGD participants, some of these factors may hinder or facilitate implementation depending on the context. Cultural Practices and Gender Norms Hinder Implementation Most FGD participants agree that cultural practices and gender norms frequently hinder implementation because the influence they can have on behavioral expectations for men and women are often not aligned with the policy objectives. According to service providers, cultural practices and gender norms often diminish women s decisionmaking power, teach women to be submissive to men and male sexual desires, and prevent women from seeking health care without a man s permission or presence. Cultural practices sometimes interfere with legal rights when traditional practices are employed to handle situations such as rape. In Wajir, women are often perceived to have lower social status than men, and men are sometimes hesitant to seek medical care or guidance from female service providers: Gender hinders the implementation of the policy, women are not allowed to speak to strangers even if they are visiting health care facilities. They are expected to disclose their health issues/problems to men, who should explain her health issue to the health care provider. A service provider in Wajir According to teachers, some cultural practices and gender norms restrict communication between girls and boys, and between girls and male teachers, especially in regard to ASRH topics. Additionally, cultural practices and gender norms can restrict empowerment of women and infringe on the rights of the girl child by promoting preferential treatment for boys. Some sociocultural and religious practices condone sexual discrimination and harmful practices against girls and young women, including female genital mutilation/cutting (FGM/C), early marriage, and forced marriage after pregnancy. According to youth, boys and men, and girls and women, are expected to have different roles in society which can pose challenges for policy implementation. Women are expected to play a secondary, submissive role to men where sexual matters are concerned, and men are expected to be Key findings 21