Youth and Sexual and Reproductive Health: A Q&A with EngenderHealth’s Ana Aguilera

Ana Aguilera is a life-long advocate for the sexual and reproductive health and rights of young people everywhere. She’s helped to promote their education, entrepreneurship, health and well-being, and most recently, their sexual and reproductive health and rights. As EngenderHealth’s Deputy Director of Adolescent and Youth Sexual and Reproductive Health and Rights, Ana shares some thoughts on strengthening health systems, increasing access to contraceptive services, and why youth matter.

(Photo credit: Jon Thorpe / EngenderHealth)

EngenderHealth has a long history of working to strengthen health systems around the world. Why does EngenderHealth focus on systemic health systems changes in developing countries?

EngenderHealth believes that strengthening health systems is critical to any sustainable global health effort, especially any reproductive health initiative. While every country is different, we have learned through decades of experience that weak health systems severely limit country governments’ abilities to reach vulnerable populations with quality healthcare. To reach unserved and underserved groups—such as adolescents, rural populations, and people with disabilities—we cannot rely on one-off initiatives and approaches to revamp health systems.

The availability of contraceptives and reproductive health services is largely dependent on the functionality of a health system. Sustainable service delivery approaches are needed to reach adolescents, youth, women, and couples. Only when we build health systems to respond to the diverse needs of their populations can we create long-term change.

Can you tell us about a few of EngenderHealth’s accomplishments in this area?

We have decades of experience building the capacity of national, regional, and district-level health systems to help women and girls access reproductive health services. Last year alone, we trained more than 17,000 healthcare providers to deliver quality reproductive health services.

We are particularly proud of the comprehensive tools and techniques that we share with the healthcare community and local governments. For example, our COPE® (client-oriented, provider efficient) technique is a simple and low-cost way to evaluate and improve service delivery to satisfy client needs. COPE® has been introduced and scaled up in 50 countries, including Nigeria, where it has been integrated into the health system’s quality improvement protocols.

Our REDI framework is a similar example of our efforts to improve quality of care. As a client-centered counseling framework, REDI offers a comprehensive approach and training curriculum to strengthen contraception counseling by empowering health providers to better recognize and respond to clients’ needs. The REDI counseling framework has been adopted into the Ethiopian and Ugandan health systems as the national family planning counseling framework.

Our Reality Check™ tool helps district and national health systems track critical information to support advocacy and planning efforts to reach national family planning goals. Reality Check™ was used during the development of Malawi’s first Family Planning Costed Implementation Plan and is still used by local governments in Uganda for contraceptive prevalence rate projections.

Globally, more than 200 million girls and women do not have access to modern contraceptives and family planning methods. At the same time, more than 800 women die from complications in childbirth every day. How is EngenderHealth helping to address these issues?

First, we have seen the importance of being intentional when designing programs. We seek to fully understand the specific context of a girl or woman who wants to access family planning services. We have learned that we must avoid cookie-cutter approaches, which fail to consider the specific context that affects if, how, and when women can access reproductive health services. We also make it a point to reach girls, women, and couples who are considered “never users” as they make up more than half of the population needing family planning services.

We also work to increase full, free, and informed choice. Girls, women, and couples must have the accurate and appropriate information to make the best decisions about the number, timing, and spacing of pregnancies for themselves and their families.

With these approaches, we see success every year. For example, in the past year, we helped more than 17,428 healthcare providers reach over 6.2 million clients with contraceptive services and prevented over 50,813 child deaths and 5,457 maternal deaths.

How have your colleagues improved the quality of health services?

Quality of services is at the core of a healthy population. Poor quality care is now a greater barrier than lack of access to health services. In my work, I see how underserved groups, like adolescent girls, often have access to a health center but fail to receive the quality reproductive health services that they deserve because those services are poor quality and not youth-friendly.

Our quality-centric approach to working with health systems is grounded in principles of gender equity and emphasizes sustainability and self-reliance. It places the adolescent girl or woman at the center and understands and addresses all the barriers that get in the way of her receiving high-quality reproductive or maternal health services.

Our global quality improvement team of expert clinicians and technical experts, based in our regional and country offices, work globally to strengthen health delivery systems and improve the quality of care. This includes monitoring services and strengthening quality improvement systems; mobilizing communities to hold their local health system accountable for delivering high-quality care that responds to their needs; and clinical monitoring and coaching using a whole-site training approach that ensures skills standardization and strengthens the entire quality of care ecosystem.

You have a strong background in serving youth. Why do you think targeting youth is so important?

The obvious answer is that today there are 1.8 billion young people between the ages of 10 and 24 years in the world, including 1.2 billion between the ages of 15 and 24 years. This is the largest population of young people the world has ever seen!

Perhaps more importantly, we have 1.8 billion adolescents and youth with hopes, dreams, and aspirations. Along with these aspirations, come specific challenges they face to reach their full potential. One of the major challenges they face is limited access to reproductive and maternal healthcare information and services. Adolescent girls and young women in many societies aren’t able to make decisions about their own bodies, and as a result, have limited agency and power over their lives. The current and future potential of young people is limitless, if we can more effectively reach these young people with accurate, appropriate information and services that respect, protect, and fulfill their human rights.

Given this reality, it is no longer acceptable to decide whether or not you will reach adolescents and youth in reproductive health programs. This is a must and we need to shift the conversation to talk about how we will do this, not whether or not we will do it.

You also help lead EngenderHealth’s efforts to increase access to adolescents and youth sexual and reproductive health information and services. Can you tell us more about how EngenderHealth hopes to accomplish this?

At EngenderHealth, we firmly believe that we must work to respect, protect, and fulfill the sexual and reproductive health and rights of adolescents and youth through two complementary goals:

First, we must increase access to high-quality, gender-equitable sexual and reproductive health and rights information and services for adolescents and youth. When we talk about quality, we aren’t just referring to international clinical guidelines and standards—although those are important. When we think of quality, we are looking at the entire client experience—from the moment they decide to access reproductive health or family planning information and services to the follow-up care they receive later. For adolescents and youth in particular, we emphasize that high-quality means evidence-based, respectful, and appropriate care, recognizing the many additional barriers that they face in accessing family planning and reproductive as compared to other people in their communities.

On a recent trip to Tanzania, I had the pleasure of meeting Rehema, a youth-friendly public sector health provider in Arusha. Rehema is a compassionate, nonjudgmental provider who takes the time to get to know every adolescent girl and young woman that seeks health services from her. She makes a world of a difference and exemplifies the importance of working within health systems to change provider attitudes, biases, and norms in order to fully support young people’s health and rights.

Second, we must increase the gender-equitable and socially inclusive participation and leadership of adolescents and youth. You might be wondering why we qualify this participation. The biggest reason is that we do not want to reinforce the harmful gender and social norms that have traditionally prevented girls and other marginalized youth groups from participating equally in the family planning or reproductive health initiatives targeting young people. We want our programs to promote gender- and youth-transformative approaches that look at all young people as assets and experts in their own sexual and reproductive health and rights. For example, in Ethiopia, we have developed a meaningful youth participation strategy for all phases and result areas of project implementation. Youth participation and leadership is not limited to a single activity or intervention, it is an important cross-cutting and effective approach for all our work. Our strategy includes incorporating activities that are designed by young people for young people—particularly activities related to increasing access to sexual and reproductive health and rights information, assessing youth-friendly health services at public facilities, and fostering an enabling environment where adolescents and youth can exercise their rights.