Knowledge for Development Policy Brief: Zambia November 2015 Education Global Practice Adolescent Girls in Zambia: Health, Nutrition, and Population Global Practice Executive Summary Introduction and Overview Figure 1. Actual and Projected Population Adolescence is a Transformative Time. (Ages 10–19) in Zambia and Select Countries in Adolescence (defined here as 10 to 19 years Sub-Saharan Africa, 1950–2100 of age) is a time of transition that fosters 25,000 both challenges and opportunities. Choices 22,500 made during adolescence not only have Youth population (thousands) 20,000 immediate consequences but also greatly influence the economic opportunities, health 17,500 outcomes, and skill sets attained later in life. 15,000 Yet adolescence is also a period when social 12,500 norms create pathways defined largely by 10,000 9.8m gender. During adolescence, gendered roles 7,500 and responsibilities often create opportuni- 5,000 ties for males, but curtail them for girls. 3.7m Adolescents—and Their Decisions—Have 2,500 Important Implications for Harnessing the 0 Demographic Dividend.1 Zambia’s persis- 20 0 20 0 80 21 0 20 0 20 20 0 20 0 20 0 60 80 20 0 20 0 00 19 0 19 0 0 6 9 3 4 5 7 9 1 5 7 19 20 20 19 19 tently high fertility combined with decreasing South Africa Zambia mortality is not only causing high population Malawi Zimbabwe growth but also creating a large share of youth dependents, giving way to higher Source: United Nations Department of Economic and Social Affairs 2011. dependency ratios which result in low investments in human capital and productiv- ity. In Zambia, adolescents make up a substantial 24 percent of the population, The cost of inaction is high for adoles- and the already large number of adolescents cent girls themselves, for the next genera- is expected to more than double in the tion, and for the nation as a whole. In upcoming decades from 3.7 million to Zambia, the high prevalence of child marriage 9.8 million in 2050, adding challenges for and teenage pregnancy contributes to high society to provide health, education and job fertility and population growth and is closely training services to prepare them for a interrelated with a range of economic and productive future (Figure 1). sociocultural determinants (including atti- tudes around various forms of gender-based 1   A demographic dividend is the accelerated economic violence) that perpetuate a vicious cycle growth that may result from a rapid decline in a for the poorest and most vulnerable girls. country’s mortality and fertility rates and the Child marriage and teenage pregnancy also subsequent shift in the age structure of the population. As a country’s working-age population grows in relation contribute to high child mortality and poor to the number of young dependents, a small window of maternal health. A vicious cycle is perpetu- opportunity exists to achieve strong economic growth. ated whereby girls drop out of school earlier 1 than boys, marry too soon, become sexually the next generation. This series of policy active, do not use protection and become briefs focuses on four key areas for action pregnant early on, are exposed to sexually (or pillars): transmitted infections, are unable to partici- pate in productive activities, and eventually (1) Keeping girls in school; are unable to provide adequate care for their (2) Equipping out-of-school girls with skills; children or to break the intergenerational (3) Beginning a family and adopting a healthy cycle of poverty. Delayed marriage and lifestyle; and pregnancy can contribute to a lower fertility (4) Addressing the early childhood develop- and a changing age structure with a smaller ment needs of children born to teenage share of young dependents compared to mothers. working-age adults. In combination with policies to improve education, employment, Under each of the four pillars, the series and governance, this can bring transforma- includes two policy briefs: one that docu- tive changes to Zambia and improve its ments the current situation and trends in prospects for human capital accumulation, Zambia and one that summarizes the global productivity, and economic growth. evidence on what has worked to promote Together with other policies that address positive impacts in this particular area. high fertility, reducing child marriage and teenage pregnancy can contribute signifi- Pillar 1: Keeping Girls in School cantly to the fertility declines needed to Staying in school and completing a quality accelerate the demographic transition and education remains a substantial challenge for ultimately create better life outcomes for adolescent girls in Zambia. Girls are dropping adolescent girls, better opportunities for out of school at double the rate of boys in the next generation, and the potential to Grade 7 and triple the rate of boys by Grade 11. harness a demographic dividend. The Socioeconomic status and geography matter, conceptual framework (Figure 2) for this with adolescent girls from extremely poor series of policy briefs acknowledges the backgrounds and certain provinces most complex, bidirectional nature of the relation- at-risk of leaving school. Early marriage ships that exist among child marriage and disproportionally affects adolescent girls in teenage pregnancies; the opportunities for Zambia and the number of girls dropping out adolescent girls to access quality education, due to pregnancy increases throughout upper jobs or livelihoods, and health and nutrition primary and secondary school. services; the social and cultural norms that While several ongoing initiatives are prevail; and the legal and policy framework in helping to keep Zambian girls in school, the place. It also posits that positive changes in challenge remains to both focus on girls opportunities and norms can lead to delayed before they reach puberty and to ensure that marriage and pregnancy among adolescent they get the support they need to complete girls and foster better opportunities for primary school and transition successfully Figure 2. Conceptual Framework Higher access to Changes in: (and quality of) Social/cultural Legal/Policy norms framework Education Delayed Marriage And/or Jobs/ Livelihoods Health and Nutrition Delayed Pregnancy Better life outcomes for girls and better opportunities for the next generation 2 to secondary school. The most at-risk The majority of skills training programs adolescent girls, including those who have are run by skills training providers and, to dropped out due to pregnancy, will need to a limited extent, by the formal schooling be targeted with comprehensive programs system and industry. Most training institu- including mentorship, financial assistance, tions are run by the public sector, private childcare support, and sexual and reproduc- sector, and churches. Skills training is also tive health services to better ensure that they offered as part of secondary school curricula re-enter the education system and complete to students selected for a technical stream their schooling. at grades 8 and 10, albeit on a small scale. Global evidence indicates that parents are Of note are several skills training programs more likely to maintain adolescent girls in targeting women and girls run by the public school when economic opportunities exist sector and NGOs, such as that run by the for women and when information is available Ministry of Community Development, Mother, to girls and families about the returns to and Child Health which trains vulnerable education. Additional supply and demand- women, mostly between 15 and 35 years side interventions are necessary in contexts of age and with no previous schooling, in where large numbers of adolescent girls selected trades. In addition, the Adolescent dropout of school. On the supply side, inter- Girls Empowerment Program imparts health ventions are needed to provide greater and financial education and life skills to access to “girl-friendly” schools that can girls 10–19 years of age from low-income provide high-quality, safe, and relevant backgrounds. education to female students. On the Skills development offers a range of demand side, interventions to reduce the benefits to out-of-school adolescent girls opportunity-cost of schooling require and alleviates a key obstacle to youth adequate targeting and a mix of incentives employment in developing countries. But do should be used to serve different ages and increased skills lead to delays in early mar- demographic groups in optimal ways. This riage and pregnancy? Not always, according may include conditional cash transfers for to the empirical evidence. Although the global younger girls to encourage school enrollment evidence on skills training is growing and and transition to unconditional cash trans- despite a theoretical basis for the relation- fers after puberty in order to delay early ship between skills, employment, and fertility, marriage and pregnancy. the documented impacts of skills interven- tions on sexual or reproductive health Pillar 2: Providing Out-of-School Girls outcomes are still too limited to draw strong with Skills conclusions. The substantial heterogeneity A strong case can be made for examining in of what constitutes a skills intervention more depth the trends in female adolescent contributes to the uncertainty, and overall employment and the links between employ- the evidence-base under Pillar 2 is less ment and child marriage and early pregnan- conclusive than across the other three pillars. cies. Adolescent girls in Zambia are more The strongest evidence is in support of economically active, more likely to be holistic community-based programs that engaged in part-time employment, to be combine information on sexual and reproduc- unemployed, and to earn less than their male tive health with skills training and other counterparts. Educational attainment and financial and social assets in girl-only or the incidence of skills training is low for both girl-friendly settings. This community-based adolescent boys and girls –58 percent of approach has the potential to be involve key employed adolescent girls have between stakeholders from the start (e.g. parents, one to seven years of schooling, and only husbands, etc.), be cheaper, more effective, 1.4 percent of girls aged 15-19 have received and sustainable. However, more research is skills training. However, very little is known needed to isolate the impacts of various about how these trends affect the choices program components and disentangle the made by adolescent girls and their house- causal pathways leading to delays in marriage holds. What the data do tell us is that more and pregnancy. than a fourth of women cite family responsi- bilities and pregnancy as reasons for being Pillar 3: Beginning a Family and economically inactive. Further analysis of Adopting a Healthy Lifestyle these trends could facilitate the development While there have been some improve- of policy options designed to create potential ments for adolescents’ health behaviors for a demographic dividend in Zambia. and outcomes, substantial gaps remain to 3 be addressed. Zambia has one of the highest using community-based mechanisms to adolescent fertility rates in Eastern and distribute information and supplies for Southern Africa. Married adolescent Zambian family planning; programs that work to girls use modern contraception less than delay marriage via community-level older married women, and over the past engagement; addressing undernutrition via decades, have increasingly reported unmet supplementation during risky periods needs for modern contraception. Adolescent (e.g., pregnancy) as well as food fortifica- girls in Zambia engage in risky sexual behav- tion programs; and improving maternal iors more than older women, putting them at health by strengthening the provision of higher risk for illness and death. Additionally, skilled birth attendance. the higher rates of undernutrition for adoles- cent girls can have adverse effects on their Pillar 4: Early Childhood Development own health and that of their children. It is Early childhood is a critical period of human necessary to address the sexual and repro- development, but children born to adolescent ductive health, nutrition, and behaviors of mothers face many challenges. They are at adolescents, to harness the demographic higher risk of adverse health outcomes in dividend in Zambia. terms of mortality, morbidity and nutrition, A number of policies in Zambia address as well as lower overall development and the health of women and adolescent girls – school readiness by age 6. For Zambia to including a multisectoral National Population reap its full demographic dividend, it will be Policy and a multisectoral National Youth necessary to ensure improved health and Policy, as well as a number of health sector early childhood development outcomes—­ specific policies such as the National particularly given the large number of chil- Health Policy, Adolescent Health Strategic dren born to adolescent mothers currently Framework, National Child Health Policy, and in the coming decades. National Reproductive Health Policy, and Zambia has various policies to address National Food and Nutrition Policy. A multi- ECD and health, including the National tude of partners were involved in the develop- Population Policy, National Health Policy, ment and implementation of these policies, National Child Health Policy, National Child and although respondents perceived broad Policy, National Education Policy, and buy-in to the policies, they expressed con- National Early Childhood Education Policy. cerns about the depth of commitment from However, existing ECD programs are limited the government (primarily attributed to in scope, especially those focusing on early low resource mobilization). New institutions stimulation and learning for young children, have been created within several ministries and too few children are benefiting from to support these activities, but stakeholders programs that address their overall develop- reported that several are not fully operational. ment needs (including in the physical, cogni- The policies are largely accompanied by tive, linguistic, and socioemotional areas). detailed implementation plans and account- While the poorest children are at greatest ability mechanisms, and the process has risk of lagging behind early in life, several reportedly been evidence-driven although types of ECD interventions have been proven normative change, necessary to achieve effective to improve their development and progress on health indicators, remains slow. life-long prospects. Programs to improve The global evidence indicates that to infant and child health are most effective improve the key health behaviors and when they combine maternal health and outcomes discussed above, the most nutrition interventions, community-based promising interventions in the health sector distribution of health supplies, integrated combine social and behavior change service delivery, and postpartum counseling communication with increasing access to on infant feeding practices. Before and health services. Examples include targeting during pregnancy, programs that address communication change to adolescent girls women’s reproductive health and nutrition themselves, as well as to their social are essential for healthy gestation and a networks, families and community mem- strong foundation. For children 0–2 years of bers; providing comprehensive sexuality age, programs that combine early stimulation education (both in-school as well as for and nutrition are most likely to yield long- out-of-school adolescents); offering term effects. Center-based care can also youth-friendly sexual health services at promote child development while freeing up health facilities and training providers on caregivers’ time, but quality is paramount providing care to this unique population; to ensure positive outcomes. For children 4 3–6 years old, preschools can be a highly Zambia’s policies and programs show cost-effective way to enhance school readi- promise for improving opportunities for ness and success later in life, as long as a adolescent girls and their families, but sufficient level of quality can also be ensured. substantial improvements in their imple- Cash transfers can alleviate financial and mentation are needed to achieve results. time constraints at the family level but are Current policies covering education, youth, more likely to have an impact on child children, and reproductive health all aim to development outcomes when combined with protect and support the needs of adoles- access to health services, parenting educa- cents in Zambia. Ongoing initiatives such as tion, and/or preschools. Finally, children are secondary school bursaries, skills training, likely to benefit most when fathers and other and ECD programs skills are helping to family members in addition to the mother address these needs. However, programs also receive ECD information and services, may need to consider expanding their scope especially if the mother is not the primary and scale in order to reach a wider network caregiver or the main decision maker on of vulnerable youth and their families, and child-rearing practices. new policies will need adequate financial and human resources in order to be fully opera- Conclusions tional. The global evidence for each pillar Looking ahead, a sharper and stronger encourages comprehensive multisectoral focus on the needs and strengths of approaches that are anchored at the commu- adolescent girls will be needed to meaning- nity level, specifically targeted to the needs of fully shift the current paradigm from high adolescent girls (and their children) depend- costs of inaction to evidence-based posi- ing on their ages and demographic groups. tive impacts. Reducing the prevalence of Ultimately, successful implementation will child marriage and teenage pregnancy in require sufficient resources to be allocated in Zambia will not only improve the life trajecto- the context of long-term policy implementa- ries of adolescent girls and their children, tion, robust M&E systems, the encourage- but will greatly benefit the nation as a whole ment of agents of change (for example, through advancing human capital accumula- Traditional Chiefs, high-level champions, and tion, economic growth, and productivity. also boys and men at the community level) However, the current and projected popula- to be an active part of the solution, and tion trends for Zambia indicate the urgency strong coordination and partnerships with which action is required in order to between Government and non-state actors benefit from a potential demographic to reach the maximum number of girls with dividend. relevant, evidence-based interventions. © 2016 International Bank for Reconstruction and Development / The World Bank. 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