Start with a Girl: A New Agenda for Global Health

Much of the frustration that permeates efforts to improve the lives of people in the developing world springs from the fact that the commonly identified roots of the problem are factors that are difficult to change. But one fundamental cause of the social and economic hardships in the developing world can be addressed: the poor health and limited education of adolescent girls.

As a partial glimpse into the hardships that girls face, consider the burdens of their older counterparts. Women’s challenges take different forms across regions, countries, and socio-economic classes, although there are similarities, especially their exposure to discrimination, violence, and poverty. Women comprise two-thirds of the 759 million adults lacking basic literacy skills. Women’s job options are more limited and less remunerated than those for men. More than half a million girls and women die in childbirth every year, often without the benefit of health services and skilled assistance. And all too often, women do not have a voice in the important decisions affecting their lives and those of their children, households, and communities.

To take their rightful place as drivers of economic growth and a healthier tomorrow, women need to be better prepared during their years preceding adulthood—the crossroads of adolescence. Adolescence is a period of risk and opportunity, with lifelong effects on the future of girls and their families. Indeed, the size and strength of tomorrow’s labor force will be shaped by the health of today’s girls, along with their education. It is during adolescence that girls establish patterns of sexual behavior, diet, exercise, tobacco use, and schooling that profoundly affect their lifelong health. And health problems experienced during adolescence, such as sexually transmitted infections, anemia, and gender-based violence, can have long-term consequences.

Most girls are still reachable during early adolescence, when they are 10 to 14 years old, through institutions such as families, schools, and for some, workplaces. When girls are reached during this phase, their behavioral patterns can be shaped to protect their health as well as the health of their future children.

But just as the opportunities are clear, the threats to girls’ health and well-being are numerous and are linked to fundamental injustices present in many societies. A general guide for how to overcome these injustices is emerging from evidence gathered from the actions of a variety of international organizations. National leaders now need to evaluate, support, and expand the lessons that have been learned in order to make a real difference for girls.

Litany of problems

Most girls enter adolescence healthy, but social and biological forces make them vulnerable to illness and disability. What happens during the eight or nine years following puberty (roughly between the ages of 10 and 19) can have long-term consequences.

In many communities across the developing world, most girls steer clear of health services from the age of their last immunization until their first pregnancy. The reasons are many. Girls often lack the financial means and autonomy to seek care when they need it and tend to be even more uninformed than boys about their bodies, ways to maintain their health, and the health services available. The health sector rarely orients services in the way adolescents need them to be: non-judgmental, confidential, and easily accessible. Surveys reveal that even youth-oriented programs, such as youth centers and peer-based programs, often fail to reach the most vulnerable girls. A risky adolescence is the result.

The conditions that girls face during adolescence and the decisions (often involuntary) that they make can affect not only themselves but also can have drastic implications for the health status of their future children. Unhealthy mothers pass on poor health to their children, and young mothers are even more likely than older mothers to pass on poor health to their babies. For example, one study summarizing demographic and health survey results from nearly 87,000 women in 76 countries has shown that age is a risk factor even when controlling for a number of other factors, including education level, socioeconomic status, and residence. Compared with outcomes for children of mothers aged 24 to 26, young mothers were more likely to have babies who were too small (underweight and stunted), anemic, and less likely to survive to the age of 5. Delaying those births by just a few years would have improved the health status and life prospects for many tens of thousands of children.

Understanding girls’ health requires looking beyond epidemiology to the social forces making them vulnerable—the social determinants of health. Examples of the types of social determinants that have major health effects on girls include their need (often forced) to work, child marriage, limited education opportunities, and the inequitable gender norms that lay the foundation for all of these. For girls forced to work, employment options are usually limited to risky and exploitive jobs, which usually come with health risks. Domestic work is the main economic activity for girls under 16. It often takes the form of unregulated employment and exploitation, and sometimes servitude or slavery. Girls in this behind-closed-doors occupation are vulnerable to abuse, often receive little or no pay, do not have access to education and skill training to compete for better jobs, and are isolated from friends and family.

All working girls are vulnerable to sexual exploitation, but it is a certainty for those working as prostitutes. It is estimated that as many as 10 million girls and boys ages 10 to 17 are exploited within the sex industry, with perhaps 1 million children entering prostitution annually. In emerging market countries, more girls and young women work in industries in which they are exposed to chemical and physical risks, including dirty drinking water, environmental toxins, unsafe conditions, and long hours. Girls often find themselves in such adverse situations because others—mothers, fathers, and husbands—control their mobility, life choices, finances, sexuality, and reproductive decisions.

Child marriage, a manifestation of girls’ powerlessness, makes girls vulnerable in multiple ways. Marriage before the age of 18 is not an isolated practice. Thirty-six percent of all women ages 20 to 24 in the developing world (excluding China) report that they were married as children; in 10 countries, more than half of all girls are married before 18, many much younger than that. In Niger, more than three-quarters of girls are married by age 18. Child marriage is a driver of a number of health risks. Research shows that in addition to being exposed to the risks of early childbearing, married girls in sub-Saharan Africa are 48-65% more likely to be HIV-infected than their unmarried peers. Their increased vulnerability is due to the typical age gap between young wives and their older husbands, as well to the nature of sex during marriage, which is typically frequent and unprotected, with wives unlikely to insist on condom use. Child brides are also less likely to gain education and vocational skills, and often face isolated lives of restricted mobility.

Lack of education poses significant health risks, and many studies have established that simply enrolling and keeping girls in school for at least six years is one of the most effective ways to benefit their health. Completing primary school is strongly associated with later age of marriage, later age of first birth, and lower lifetime fertility. Unfortunately, the impressive global progress in enrolling girls in primary school is not matched by efforts to enable them to continue into secondary school, and only 43% of girls of appropriate age are in secondary school in the developing world. School leaving is frequently followed by cohabitation, marriage, and early pregnancy, with all of their associated risks.

Girls and younger women may actually be at higher risk of gender-based violence than older ones. Studies from varied settings reveal that approximately one-third of girls’ sexual initiations are forced through physical violence by their partners. This age-old but often hidden problem causes injuries, HIV and other sexually transmitted infections, unwanted pregnancies, and in many cases, mental health disorders.

Many adolescent girls, as well as boys, also establish behaviors that put them at elevated risk of developing chronic diseases such as heart disease. These risky behaviors are in some cases reinforced by social conditions and pressures. Unhealthful practices include poor diets and exercise habits, unsafe sex, tobacco use, and substance abuse. Smoking rates are increasing rapidly among girls, and it is estimated that by 2030 tobacco use will be the single biggest cause of death globally. Obesity also is on the rise. Higher rates of overweight generally are associated with increasing urbanization and gross national income. However, a recent survey of women ages 20 to 49 in 36 low- and middle-income countries revealed that most countries had substantially more overweight women than underweight women. The pattern was reversed in other areas where high rates of malnutrition persist, such as in rural areas of India and Haiti, and in certain other areas of the least developed countries.

The health picture

With recent improvements in data availability, a picture is emerging of the direct causes of adolescent girls’ death and disability in different regions. In mortality terms, for girls ages 15 to 19, deaths are most frequently the result of childbearing, AIDS, depressive and panic disorders, and burns, with violence also being a significant problem. Issues related to pregnancy and childbirth, including hemorrhage, abortion, and hypertensive disorders, kill more girls ages 15 to 19 than any other cause.

In terms of regional and gender differences in adolescent mortality, total death rates for adolescent girls and boys are similar in nearly all developing regions, at just under 1 per 1,000 population. The exceptions are South Asia, where death rates are twice as high, and sub-Saharan Africa, where rates are nearly three times as high. For South Asia, infectious disease and injury deaths account for the excess death rate. For sub-Saharan Africa, AIDS, tuberculosis, and maternal deaths account for most of the excess death rate, with contributions from other infectious diseases, violence, and war. In the 10- to 24-year-old group, more males die than females in all regions except Africa and Southeast Asia. In Southeast Asia, the number of injury deaths among young women, particularly from fire-related death and suicide, is pronounced. Although reports from India once attributed many of these deaths to suicide and accidents, the role of violence from family members is now known to be an important factor in many cases.

Mortality statistics give some indication of health risks, but death is actually a relatively rare event during adolescence, compared with infancy and older age. In fact, in regions without substantial maternal mortality, rates of female deaths are generally low throughout adolescence. To better understand the direct causes of adolescents’ ill health, it is much more informative to explore their burden of disease, a measure that combines death, illness, and disability. Worldwide, neuropsychiatric conditions, especially unipolar major depression, as well as schizophrenia and bipolar disorders, are the primary cause of girls’ burden of disease. The risk factors driving this mental health burden go beyond identity crises or peer pressure to include exposure to violence, restriction of girls’ opportunities, and poverty, especially where it affects girls’ ability to attend school. Road traffic accidents are the second most important cause of girls’ burden of disease, although they are only half as likely as males to die in this manner. Road accidents are predicted to dramatically increase in India, China, and elsewhere as the use of cars becomes more widespread, but the infrastructure and driving culture fail to keep pace. Injuries, including injuries from gender-based violence, comprise 4 of the 11 leading causes of burden of disease.

Reproductive health concerns deserve special mention because of the defining nature of girls’ reproductive capacity for their lives. Children born to girls between the ages of 15 and 19 account for only 11% of all births worldwide, yet these births account for 23% of the overall burden of disease from maternal conditions annually. (These figures vary considerably by region, but the overall problem is persistent throughout the developing world.) Adolescent mothers have high rates of complications from pregnancy, delivery, and abortion, yet in many cases their contraceptive needs are unmet. One of the most horrifying results of early childbearing is fistula, a devastating consequence of obstructed labor that causes lifelong leakage of urine or feces. This disorder affects approximately 2 million women, mostly in Africa and Asia. Although age itself does not appear to be the key risk factor for this or other poor pregnancy outcomes, adolescents are at higher risk because they are usually having their first baby (first births are riskier regardless of age), and they also are likely to be small in physical size, poorly nourished, already suffering from diseases such as malaria, and relatively uninformed about how to manage a pregnancy and birth.

Adolescent pregnancy and childbirth pose higher risks not only for young mothers but also for the children of these young women as well. In particular, stillbirth and death are 50% more likely for babies with mothers under age 20 than for babies with mothers 20 to 29 years old. As a result of their low birth weights, babies who are born to adolescents and who survive are significantly more likely to suffer from undernutrition, late physical and cognitive development, and adult chronic diseases such as coronary heart disease.

An achievable agenda

Most of what threatens adolescent girls’ health is preventable. But prevention will require a comprehensive response within and outside of the health sector. In some cases, a strong evidence base points to interventions that need expansion. In others, especially where communities are taking innovative action to tackle some of the most insidious causes of ill health, further evaluation and operational research is required to identify and make the case for expanding promising approaches. The recommendations that follow are global and apply to all girls to varying degrees. Their relative prioritization will depend on the specific threats that girls face in a given region or country.

Expanding health services. Adolescent girls encounter multiple barriers in obtaining appropriate preventative and curative health services. Youth-friendly health services are one way to attract more young people to essential care, especially when their introduction is accompanied by demand-creation activities in communities. The hallmark of youth-friendly services is not what services are offered, which will vary by location and burden of disease, but how they are offered. To be youth-friendly, providers and services must be sensitive to adolescent health and psychosocial needs, nonjudgmental, and confidential, and they must operate with convenient hours and locations.

South Africa’s National Adolescent Friendly Clinic Initiative (NAFCI), launched by Lovelife and the South African Department of Health in 1999, is an accreditation program designed to improve the quality of adolescent health services and strengthen the public sector’s ability to respond to their health needs. NAFCI works by making health services more accessible and acceptable to young people, establishing national standards and criteria for adolescent health care in clinics throughout the country, and building the capacity of health care workers to provide quality services. A study conducted at 32 NAFCI clinics from 2002 to 2004 found that clients ages 10 to 19 showed a statistically significant increase in average monthly clinic visits during this period, but the evaluation also showed room for improvement.

Making services more responsive. Girls need health system changes that make the entire sector more responsive to their needs. Many such changes will require only marginal adjustments that are likely to be low cost. Efforts to strengthen health systems should pay particular attention to improving community-based service delivery, especially delivery of youth-friendly services; training health workers to understand and treat the causes of adolescents’ ill health; and using adolescent-specific indicators to measure health-system functioning. Demand-side financing mechanisms such as micro-insurance and cash transfers can also be modified to ensure that family benefits reach adolescent girls. Collectively, these strategies can make health services more acceptable and accessible and ensure that girls benefit from health sector reforms. As an added gain, all users of the health systems will benefit from changes made in the name of adolescent girls.

A base of broader reforms

Truly altering the equation for girls also will require actions outside of the health sector to tackle the social determinants of girls’ ill health. This will require work in families, communities, workplaces, and schools to chip away the underlying factors that prevent girls from accessing the skills, information, and services they need to navigate adolescence successfully and grow into empowered, healthy women. The complementary actions that need increased support include changing social norms to promote healthy behavior, creating community resources for girls to empower them to manage risk, and increasing the health-related benefits of schooling and other investments in other sectors. But even as this vision is clear, the evidence on best ways to achieve it is slim, although there are encouraging signs. Of the recommendations below, some are derived from solid evidence from a single site, and some are based on promising approaches that need more thorough evaluation as work progresses.

Changing social norms. Firmly entrenched cultural practices, especially those affecting girls with limited power, are hard to alter. Community education and mobilization has had some impact on combating harmful traditional practices such as female genital cutting and child marriage. Tostan, a nongovernmental group that works in a number of countries across West, Central, and East Africa, has carried out numerous community-based efforts that have proved effective in reducing harmful traditional practices. Tostan’s work in Senegal, for example, includes basic education for women on health, human rights, literacy, and problem solving. Among other efforts, the group organizes public declarations where men and women, including local opinion shapers such as religious leaders, speak out in front of their communities to oppose harmful practices. The program appears to have significantly affected community attitudes toward female genital cutting, leading to a dramatic decrease in the number of parents who intend to have their daughters cut. Evaluation results also show positive effects on child marriage.

In changing social norms, it is important to work with the boys and men surrounding girls. A small but growing number of evaluations, often from the HIV/AIDS world, demonstrate the potential of male engagement for girls’ and women’s health, although more rigorous analyses are needed, including on cost effectiveness. Addressing gender norms may prove especially important in preventing the spread of HIV. Currently, HIV prevention efforts too often fail to tackle the underlying causes of girls’ vulnerability: gender inequality, the typical age gap and power imbalances between girls and their sexual partners, and girls’ biological vulnerability. As a result, girls and young women have come to bear a disproportionate HIV/AIDS burden. In parts of sub-Saharan Africa, for example, young women 15 to 24 years old account for three of every four new HIV infections.

Working in Brazil, the nongovernmental group Promundo has applied a number of strategies to reduce gender inequity and thereby prevent violence and reduce HIV transmission. Interventions have included conducting group education and lifestyle social marketing that incorporate gender-equitable messages to promote condom use. Study results have demonstrated that improving gender attitudes was associated with improvements in at least one HIV risk outcome.

Changing the social norms around tobacco use, diet, and exercise will be critical in reducing the chronic disease threat emerging in the developing world. The most effective route to reducing smoking’s attractiveness to young people is to increase pricing through taxation, which has beneficial population-wide effects because it also reduces smoking among adults. Although evidence from the developing world on effective approaches to reduce obesity are extremely limited, integrated campaigns that make healthy diets and regular exercise more appealing and feasible appear to be the most effective approach. Brazil’s Agita São Paolo program targets schoolchildren, older adults, and workers in an effort to expand physical activity by 30 minutes of moderate activity at least five times a week. The program uses special events, informational materials, mass media outreach, training for physical educators and physicians, worksite health promotion, and cooperative ventures with public agencies from several sectors. By working through this multipronged approach, the Agita program has achieved measurable gains in reducing overweight and obesity among the target populations.

Creating community resources. Working in the social environments in which girls live is essential for effectively protecting their health by empowering them to manage risk. Community resources are particularly important for the most marginalized girls, who are at greatest risk of ill health but the least likely to attend school or to have access to health services or friendship networks. The creation of “safe spaces” for the most socially isolated girls is an important strategy for the poorest, most vulnerable girls, yet it remains critically underfunded. This approach is about creating spaces where girls can to gather with a mentor on a regular basis to learn about their bodies and rights, learn skills, make friends, and discuss their lives.

In Ethiopia, the Berhane Hewan Safe Spaces project reached out to girls who were out of school, married, and working as domestic servants to link them to mentors, friendship networks, and services through clubs that met regularly. Researchers found that over a relatively short period of involvement, the girls, who had no other access to institutional support, showed improvements in their lives in all areas targeted by the project, including participation in friendship networks, school attendance, reproductive health knowledge and communication, and contraceptive use. Statistical analysis also revealed considerable effects on increasing the age at marriage for younger girls, an effect believed to be due to giving them a few extra years to do other socially acceptable activities, such as expanding their social networks, attending school, and learning more skills.

Increasing investments in education. Ensuring that girls complete secondary school is one of the most efficient actions governments can take to improve girls’ chances for good health. Governments should expand their focus beyond primary school to encompass access to and quality of lower secondary education programs through age 16. Governments and the private sector, with donor support, need to increase formal and informal schooling opportunities by extending primary school facilities, offering scholarships, expanding household cash transfer schemes to disadvantaged girls, and offering alternative learning programs. Ridding schools of violence and sexual harassment is another important strategy for making schools safe and accessible for girls. Schools need to offer comprehensive sexuality education, which should include gender equality and human rights education in order to be effective.

A sound investment

Important in its own right, improving adolescent girls’ health is a feasible investment, although estimating costs is a challenge because information on costs is available from only a small number of programs. In an exercise undertaken for the report Start With a Girl: A New Agenda for Global Health, an estimate of distinct components of a comprehensive set of interventions suggests that the total cost of providing girls ages 10 to 19 years old living in low and low-middle income countries with essential health services and comprehensive sexuality education (through a variety of efforts, including community-based services and mass media campaigns) is $360 per girl per year. For roughly a dollar a day, then, a generation of adolescent girls could be protected from factors beyond their control that limit their life chances and that of the next generation.

Without information on what is currently spent—and there is no source of such information—it is impossible to know how much of this funding would be additional, although it is reasonable to guess that much of it would have to be. But even so, the real bottom line is not the costs of the activities alone, but their net cost, taking into account the benefits of investments within and outside of the health sector. In broad terms, it is reasonable to expect that scaled-up programs for girls’ health would yield medium- and long-term reductions in maternal and infant mortality, HIV incidence, cervical cancer, and chronic disease, along with increases in girls’ education and women’s labor market productivity. These are high pay-offs for a relatively modest investment.

To date, the international community has issued many high-level statements and policy documents on the importance of helping girls navigate the critical juncture of adolescence. But the rhetoric has not been matched by specific, high-impact actions through government policies or donor support, and as a result girls’ needs remain overlooked. The international community now must align its talk with its walk.

Leadership at the national level is paramount. Girls’ health should be a high priority for ministers of health as well as ministers of finance and planning officials. International donors and technical organizations must encourage and support leadership at national levels by providing knowledge on effective approaches within and outside of the health sector, as well as a share of the financial resources to step up action for girls’ health. Civil society groups must marshal advocacy to solve girls’ health problems in ways tailored to local needs. Above all, adolescent girls need support to be their own advocates. Healthy, empowered girls who speak up for their own rights and those of their sisters will be most effective in bringing about sustained change.