a brief review on ASHR in Nepal

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Adolescents deserve right Information and
quality Service for better ASRH
By
Shiva Ram Khatiwoda
Dec 2017
Summary.................................................................................................................................................1
ASRH in Nepal (Why? What is being done? What can be done?) ..........................................................2
Statement of Problem (lack of information and service) .......................................................................6
Rationale (for Right Information and Quality Service)............................................................................7
References ..............................................................................................................................................8

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Title
Adolescents deserve right Information and quality Service for better ASRH
Summary
Adolescents constitute 24.18% of the population in Nepal. Adolescence is the period of
transition, rapid development and infinite possibility. It is the right of adolescents to get
right information and services regarding important health concerns. The future of the
country depends on the healthy and capable citizens. Instead of leaving the adolescents
helpless, they should be helped with the proper information and services. Sexual and
reproductive health is integral part of overall health. Adolescents cannot become fully
healthy and happy unless they get right information and services related with their personal
and private matter.
Issues related with sexual and reproductive health is often neglected or suppressed, not
shared with parents and teachers in Nepal. Many of the adolescents are not well-informed
about the services availability. This can cause the adolescents suffer from false and harmful
practices. Such practices foster early marriage, early and unwanted pregnancy, STIs, and
different emotional disturbances. This causes low level of education and poor carrier
development. This impacts overall economy of the country due to low level of educational
and carrier development of the adolescents and youth of the country.
As per Child Right Convention 1989, International Conference on Population and
Development (ICPD) 1994, and health policy and strategies of Nepal, adolescents have full
right to right information and needed services. They aim for increasing/improving
availability, accessibility and utilization of needed services in adolescent friendly manner.
Nepal is one of the countries with high adolescent fertility rate (AFR 71) and high school
dropout rate. About half (47%) of adolescent aged 15 to 19 years have unmet need of
contraception. Many lack proper information regarding ASRH, about their health, and
sometimes suffer consequences of harmful practices. Many places lack youth friendly
services. Existing services should be expanded: increasing awareness, ensuring access and
utilization of quality services.

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ASRH in Nepal (Why? What is being done? What can be done?)
(Method of Literature Review:- In addition to reviewing relevant documents of government’s,
PubMed, Google Scholar, and Google were searched using the terms, ‘adolescent, Nepal, Sexual and
Reproductive Health’, separately and in combination. Then relevant literatures were consulted.)
About a quarter (24.18%) of the population in Nepal is adolescent.(1)
Adolescent is the
period of rapid physical and psychosocial development. The health and education of the
population will shape better future by helping in improving socioeconomic status of the
nation.(2)
The future of this and coming generation should be made better by focusing on all
aspects of life, including health and education, of adolescents.(3, 4)
Nepal has to accelerate actions for the concerns of adolescents because Nepal has high
Adolescent Fertility Rate (ASF) and high school dropout rate. Most of the adolescents in
Nepal lack adequate information regarding their important aspect of their health, the sexual
and reproductive health (SRH).(5)
Poor knowledge and utilization of needed services
regarding adolescent sexual and reproductive health (ARSH) services has contributed to
poor health status and poor educational attainment of this important population.
Nepal has significantly reduced maternal and child mortality rates in the decades. But a lot
needs to be done in the sector of adolescent, which is important component of sexual and
reproductive health.(6)
Nepal is one of the countries with high adolescent fertility rate (AFR). Nepal’s AFR is 71
while that of Sri Lanka is 14. ARFs of Maldives, China, Japan and the world average are 6, 7,
3, and 44 respectively. AFR is the number of births per 1,000 women of age 15-19 years.(7, 8)
The risk of neglecting ARSH is great.(9)
When adolescents and youth in other countries are
involved in education, training and career development, Nepalese girls and boys are already
burdened with responsibility of family making.
About half (47%) of adolescent aged 15 to 19 years have unmet need of contraception.(7)
School dropout rate in Nepal is 19% (16% of boys, 22% of girls). One of the reasons of
dropout for girls is child marriage, 35%.(10)

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Providing comprehensive education, adolescent friendly services on sexual and reproductive
health and improving awareness in the community are needed to improve the health and
well-being of the adolescents.(11-13)
This will help to reduce teenage fertility rate, sexually
transmitted diseases (STIs), and decrease unmet need for family planning (or
contraception). In the long run this will result in better health of people, educated and
skilled population, and high income status. Thereby, the result will be improved overall well-
being of the population which could be seen through improvement in social development
index and human development index.
Many adolescents in Nepal lack information(5)
about the services for managing their sexual
and reproductive health concerns in relation to their biological and emotional development.
Sexual and reproductive health is integral part of overall health. A person cannot experience
complete physical, mental and social well-being by ignoring issues of sexual and
reproductive health. Because of lack of adequate knowledge and skills to managing SRH
concerns, adolescents will adopt harmful practices. Education is the protective factor in
affecting adolescent reproductive health, lack of education is a risk factor.(14)
Besides
degradation of health, the consequence of adoption of harmful practices will hamper
progress of adolescents in their educational and socioeconomic development.(15, 16)
Poor
health of this population will result in poor development of the country.
International Conference on Population and Development (ICPD) 1994 has accepted young
people’s right to sexual and reproductive health (SRH). Health cannot be complete
neglecting SRH.(17, 18)
Convention on right of Child 1989 declared that children (0-18 years)
have the right to information and services to survive, and to grow and develop to their full
potential.(19)
Nepal has been implementing National Adolescent Sexual Reproductive Health (ARSH) since
2011 to promote sexual and reproductive health of adolescent, and to increase availability
and utilization of information and health services. Nepal’s Reproductive Health Strategy
1998 regarded ARSH as one of the pillars of reproductive health. Nepal endorsed National
Adolescent Health and Development Strategy in 2000.

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Nepal has formulated National Adolescent Health and Development strategy whose
primary objective is to impart knowledge and skills among adolescents and motivate
them for utilizing adolescent’s health and counseling services through increasing service
accessibility and creating supportive environments. In addition, adolescent health
program of Nepal also provide nutrition education and micronutrient services. These
activities are carried out in four different level – family and community level, school level,
work place level and disadvantage group level. Basically Nepal’s adolescent reproductive
health services includes activities like reproductive health information sharing using
standard information package, training to adolescent, service provider and educators,
adolescent friendly health clinics, out-reach services and counseling, rehabilitation services
for substance abuse and needy adolescents, establishing coordination between health
facilities, schools, local clubs and parents to create enabling environment.(11, 20)
The National Health Policy (2014) and Nepal Health Sector Strategy (NHSS) 2016-21 envision
all health facilities providing adolescent friendly health services (AFS). The program aims to
reduce the adolescent fertility rate (AFR) by improving access to family planning information
and devices. As per National ARSH program, 1,134 health facilities in 63 districts are
providing adolescent-friendly services. Organizations like UNFPA, UNICEF, WHO, GIZ, Save
the Children, Ipas and ADRA are working with government to scale up the program.(11)
Nepal’s target is to reduce adolescent fertility rate to 63.3 by 2017, to 55.6 by 2020, and to
30 by 2030.(21)
It is crucial for overall health of the adolescent and the nation.
There are many demand- and supply-side constrains. These have to be addressed properly
to achieve the target of NHSS and SDG.
Adolescents as well as parents lack adequate awareness regarding adolescent sexual and
reproductive health. It is usually a taboo to talk about the issues of sexual and reproductive
health. Many adolescents feel embarrassment or shyness to approach health facility
regarding their sexual and reproductive health concerns. Many of the adolescents do not
know that such issues are dealt in health facility, and their privacy is fully respected. Many
adolescents do not know which service is available in which facility.(5, 22)

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Many married adolescent have high unmet need of family planning in Nepal. Improving
service will catalyze socioeconomic development.(23)
Those living in the remote suffer lack of transportation, and out-of-pocket expense for
transportation and cost of commodity, especially in private health facility, are preventing
many adolescents from access and utilization of needed services. Likewise many factory
workers lack access to required services.(12)
In disaster (like - earthquake) affected area
adolescents, like other people in general, suffer lack of all sort of basic health care services
including sexual and reproductive health.(11, 12, 24)
Almost all (97%) health facilities in Nepal offer (provide, prescribe, or counsel clients on) at
least three temporary methods of modern family planning. Government health facilities are
more likely to offer modern family planning methods than private health facilities.(25)
Combination of relevant activities is needed to make ARSH program effective. Program
cannot be effective unless it reaches the target population. Many of the adolescents are out
of reach; many vulnerable and marginalized populations should be reached by the program.
To increase utilization, there should be enabling environment. Program should act on each
level - Individual, relationship, community and society. Service providers should be well-
trained and non-judgmental and they should provide required service in right way. Health
service delivery point should be welcoming and appealing to adolescents. Availability of
supportive materials like Adolescent Job Aid and pre-service educations on ARSH help to
develop required competencies of the health service providers.(26, 27)
Adolescents should have adequate awareness and they should be willing to obtain the
health service they need. People of the community should be aware of the health service
need of different group of adolescents and support them. Use of mass media and
involvement of school and people of community also helps in enhancing the program.(13, 28-
30)
Besides poor utilization, other problems of the National ARSH program are poor ownership
at local level, poor integration with other health services, quality control, and funding.(11)

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With the help of UNFPA, government of Nepal is giving comprehensive sexual health
education through schools. To raise the awareness level of the adolescents, mobilization of
peer educators in the community through NGOs can be done. To improve the quality of
health services the area of work are infrastructure development, training of health workers,
integrating services, improved management and financing.(12)
There is also need of greater
coordination between Family Health Division (FHD) and Ministry of Education, National
Health Education, Information and Communication Center (NHEICC), and I/NGOs. Similarly
improved linkages between schools and AFS centers will help to strengthen referral network
to increase awareness and demand for services.(22)
Statement of Problem (lack of information and service)
About a quarter (24.18%) of the population in Nepal is adolescent.(1)
The future of this and
coming generation should be made better by focusing on all aspects of life, including health
and education, of adolescents.(3)
Most of the adolescents in Nepal lack adequate
information regarding their important aspect of their health, the sexual and reproductive
health (RSH).(5)
Nepal is one of the countries with high adolescent fertility rate (AFR). Nepal’s AFR is 71 per
1,000 women of age 15-19 years. (7, 8)
About half (47%) of adolescent aged 15 to 19 years
have unmet need of contraception.(7)
The risk of neglecting ARSH is great.(9)
People still
suffer consequences of harmful practices just due to lack of right information and services.
Poor knowledge and utilization of needed services regarding adolescent sexual and
reproductive health (ARSH) services has contributed to poor health status and poor
educational attainment of this important population. Sexual and reproductive health is
integral part of overall health. A person cannot experience complete physical, mental and
social well-being by ignoring issues of sexual and reproductive health. Without working on
both demand and supply sides, health status of adolescent won’t improve thereby resulting
in poor health and development of the nation.(3, 4, 28)

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Rationale (for Right Information and Quality Service)
Education is the protective factor in affecting adolescent reproductive health, lack of
education is a risk factor.(14)
To increase access and utilization of ARSH, combination of
activities including increasing awareness in the community (including adolescents, parents,
and teachers) and improving quality services in the health facility is necessary.(11-13, 22)
To increase access and utilization of adolescent sexual and reproductive health is people
should be well informed.
The National Health Policy 2014 and Nepal Health Sector Strategy (NHSS) 2016-21 envision
all health facilities providing adolescent friendly health services (AFS). The program aims to
reduce the adolescent fertility rate (AFR) by improving access to family planning information
and devices. Nepal’s target is to reduce adolescent fertility rate to 63.3 by 2017, to 55.6 by
2020, and to 30 by 2030.(21)
It is crucial for overall health of the adolescent and the nation.
Without increasing access and utilization of ASRH, we cannot obtain the desired targets.(29)
What can be done? Something is being done. These programs should be expanded / scaled
up. Demand and supply sides should be addressed well. Supply sides can be improved
through expanding services and further strengthening health facilities by provision of
adequate and friendly quality services. Demand side can be improved by raising awareness.
People need to be empowered by improving awareness and enabled by improving service
availability. Then they can adopt proper practice/behavior after being aware and
responsible through right information, by cultivating right knowledge. Sharing right
information can be done more effectively through mass campaigns like – street drama, role
plays, sharing information kits/booklets, radio/TV programs, school health campaigns etc.
Government and community organizations can work together to bring out better outcome.
Conclusion: Improving the health of adolescents and youth impacts overall health and
economy of the nation. It helps achieve SDGs. The need of hour is enabling people
(adolescents and youth, and their parents as well) make right decision and adopt healthy
practices through awareness programs (through information sharing, knowledge building
activities) and expanding and improving the supply of services (youth friendly ASRH services)
throughout the country.

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References
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Statistics, National Planning Commission Secretariat, Government of Nepal, 2012.
2. Nepal Population Report 2016. Kathmandu, Nepal: Ministry of Population and Environment,
and Population Education and Health Research Center, 2017.
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commission on adolescent health and wellbeing. The Lancet. 2016;387(10036):2423-78.
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foundation for future health. The Lancet. 2012;379(9826):1630-40.
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Nepal: Government of Nepal, National Planning Commission, 2015
22. Assessing Supply Side Constraints Affecting the Quality of Adolescent Friendly Health
Services and the Barriers for Service Utilization. UNFPA, UNICEF, CREPHA, and Family Health Division,
2015.

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23. Aguilar AM, Cortez Rafael Family Planning: The Hidden Need of Married Adolescents in
Nepal. The World Bank, 2015.
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benefit. Bulletin of the World Health Organization. 2017;95(2):90.
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ICF, 2017.
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