How do you promote the health and well-being of adolescent girls? This presentation provides critical insights and strategic considerations based on conversations with people in Mtwara, Tanzania.

1. ‘Falling Through the Cracks’
Adolescent Girls in Tanzania
Insights from Mtwara
Maggie Bangser
Independent Consultant
On behalf of Juárez and Associates, Inc.
March, 2010

2. Scope of Work
Consultancy for USAID/Tanzania
• Compile available information
• Study the extent of the problem
• Assess the underlying causes
• Assess opinions on causes and solutions
• Identify relevant initiatives in place
• Recommend strategies
2

3. Methodology
• Document review
– ~65 reports, studies, policies, guidelines, project materials
• Two week field visit to Mtwara
– Mtwara town, Peri-urban Mtwara, Mtwara Rural
• Interviews with ~150 people
– 73 students, parents, teachers, school officials
– 26 day-laborers/Vibarua/Mama Ntilie
– 26 NGO/INGO, activists, researchers, media
– 8 health workers
– 7 government officials
– 5 donors
– 5 business people and ‘others’ 3

4. Caveats
• Number of people interviewed; sites visited
• Types and number of documents reviewed
• Language
• Timeframe (35 days total)
• Not an independent evaluation
• Not exhaustive
4

5. Key themes
1. Economic and social marginalization of Mtwara
2. Families in flux and on the move
3. Sexuality is alive
4. Education and health - achieving minimal change
5. “Patchy patchy projects”
6. “I want to be a doctor”
5

6. 1. Economic and social
marginalization of Mtwara
6

7. 7

8. % of 15-19 year old females unable to read a sentence
Region 15-19 20-24
Rukwa 65.9 45.5
Tabora 58.7 53.5
Mtwara 36.0 47.0
Kagera 25.1 39.0
Dar es Salaam 10.1 17.2
Zanzibar South 9.5 14.4
Source: PopCouncil/2004-5 DHS
8 8

9. “These people have nothing. Nothing.”
9

10. 2. Families in flux and
on the move 10

11. .
Three quarters of the children I met were
living with one or neither parent. 11

12. “Even if
you want ten
girls now,
you’ll
get them”
12

13. 3. Sexuality is alive
13

14. “ ‘Sexual health’ is having enough sex
and being sexually satisfied.” 14

15. Unyago’s place
Gender roles and
Economic reality
social expectations
Unyago
15

16. “Rituals contribute to sexuality in as much
as they are the ‘teaching tool’ within a larger
model of sexuality and gender roles”. 16

17. 4. Education & health -
achieving minimal change
17

18. Only half the teachers present
18

19. “How are you?”
“YES!”
19

20. Collective punishment
“They don’t know how to
read”, said the teacher. 20

21. Toilets are a serious problem. What
happens to girls who are menstruating?
21

22. “We already gave her a chance”
22

23. Still no national sexual health curriculum
23

24. Official fees
Tsh 20-40,000/yr
Actual
Tsh 250,000/-
24

25. 25

26. “The poor don’t get health services”
26

27. Health care in Mtwara
“No health worker wants to come down here”
Fees a major barrier to care
Nangaruwe Health Centre
200-300 people/day
10 staff including 2 Clinical Officers
No AMOs
7 hour wait to see ‘doctor’.
Community Health Fund
Tsh5,000 per year for family of 8
Many can’t afford, some don’t understand it.
Only government workers can afford health insurance. 27

28. Virtually no ‘adolescent friendly health services’
28

29. SRH for adolescents
• No budget line in the MTEF for adolescent health in
the past two years
• No AFHS in Mtwara, or largely anywhere
• Good guidelines and standards, but no
implementation
29

30. 5. ‘Patchy patchy’ projects
30

31. Who’s working in Mtwara?
• PASHA • EngenderHealth
• Stadi za Maisha • Clinton Foundation
• MAISHA • ActionAid
• EGPAF • AMREF
• Ujana/ISHI • CHAI
• Marie Stopes • Basic Needs
• Fataki • BMAF
• UNICEF • DHIP
• TGSPH • JICA
• INSIST • NEDA
• MEDA • CSSC
• Reproductive Resilience study • HKI
• Sexual coercion study • TASAF
(upcoming) • TMARC/Families Matter
• UMATI • ……………
• WAMA 31

32. Or we just need more
guidelines and materials?
32

33. 6.
“I want to be a
doctor”
33

34. Moving Forward
Some options
34

35. What, precisely, IS the
motivation to stay in school?
35

36. Or not to get pregnant?
36

37. Option 1: Targeted interventions
1. Support a life-skills program for youth that fundamentally
addresses vulnerability
Expand reach of in-school extracurricular materials
Develop, implement, evaluate an out-of-school PASHA
2. Cautiously test ‘influencing’ unyago
3. Assess and scale up pilot interventions reaching marginalized
girls, often linking SRH with financial literacy and skills
Safe spaces (e.g., Binti Pamoja/Kenya; Biruh Tesfa/Ethiopia)
Married girls clubs (e.g., Berhane Hewan/Ethiopia)
Out of school girls’ needs (e.g., Ishraq/Egypt)
Girls’ empowerment (e.g., Girls Power Initiative/Nigeria )
(Source: Population Council) 37

38. Option 1: Advantages and Risks
Advantages?
• More focused, specific, possibly more measure-able
• More akin to standard ways of operating
Disadvantages?
• Reach a limited number of girls
• Likely be more “patchy patchy” projects
• Unlikely to yield broad, sustained and deep impact
38

39. Option 1b: broadened sector-wide programming
1. Family planning including particularly for youth
A renewed commitment to accessible, affordable and quality family
planning services is urgently needed in Tanzania
2. Post abortion care (PAC)
PAC services could be scaled up across Tanzania to save lives,
with potentially significant gains for women and girls’ wellbeing
3. Adolescent Friendly Health Services (AFHS)
Secured and sustained funding is needed for AFHS, through the
MTEF for direct implementation of AFHS; training, supervision and
monitoring

40. Option 2:
Sustained and systemic
Seven strategic approaches
to strengthen rights,
equity and accountability
for adolescent girls
40

41. 1. Deploy teachers and
health workers equitably

42. Harmful pattern of deployment
General Budget Support note, 2008
• HR distribution remains highly uneven and the gap has
widened
• Many needier and poorer Tanzanians are underserved
compared to better off
“Lower allocations to poor local authorities correlate with worse pupil
teacher ratios, enrolment rates, and exam pass rates even while
controlling for the direct effects of poverty on performance.”
• Main underlying causes
Attracting/retaining workers to under-served areas
Continued recruitment and transfers to better served districts
• Measures needed to change patterns
Incentives
Limit transfers…

43. 2. Agree and rigorously enforce
measures of accountability

44. Measuring change
• Target outcomes, not inputs or outputs
• Require an independent, evaluation by an
entity that has nothing to gain
• Examine policy and service delivery change
Are pregnant school girls being re-admitted?
Are life-saving services e.g. family planning and post-
abortion care being expanded significantly, and
accessed by the poorest women?
• Determine who is not being reached
• Dis-aggregate data on adolescents 44

45. 3. Get resources to the
school and facility level 45

46. Make money work locally
• Capitation grant not reaching schools at agreed
levels
• Increases pressure to fill the gap
Schools struggling to make up the difference
Families forced to fund what government is
supposed to provide
Coercion reported
• What about a ‘capitation grant’ for health facilities?

47. 4. Invest in water
and sanitation
47

48. Decent environments
• Few, if any, water points and toilets at schools
despite PEDP funding
Rarely at health facilities too
• Most money going to classrooms and teachers’
housing (and even that is often shoddy)
• Ensure government plans and allocations for water
and sanitation are explicit, and monitored

49. 5. Institute positive incentives
for performance 49

50. Reward what (and who) works
• ‘Cash on Delivery’ or ‘Pay for Performance’
Quick example…
$50/child who passes Div III
$100/child who passes Div II
3/4 the funds to the school; 1/4 the funds to the teachers
• President Kikwete has reportedly endorsed
• Center for Global Development (Washington)
ready to assist
• No doubt, there are huge challenges,
but taking the risk could have big pay-offs

51. 6. Pilot an information and
transparency ‘platform’ in Mtwara 51
'Falling Through the Cracks' 51

52. Information access
• Publicly available, widely disseminated information
(print, radio, on-line)
• Data on budgets, allocations, performance results,
infrastructure, etc.
• Stories, photos, innovations
• Strong link to local/national media
• Private company manage

53. 7. Explore savings, microfinance
'Falling Through the transfers
and cash Cracks' 53 53

54. The link to livelihoods
Economic vulnerability drives behavior,
including high-risk sex,
so get to the root of the problem
• Savings programs for adolescent girls
– Bring together life-skills and financial opportunity
• Cash transfers for poor families (e.g., Progresa/Mexico)
• Micro-credit