Giving Priority to Adolescents
Youth issues are part of a complex nexus of social and economic change, and must be addressed in a multidimensional and intersectoral manner. Poverty, and uneven patterns of economic growth—variously aided and hampered by the forces of globalization—contribute to high youth unemployment in many settings. The expansion of formal schooling over several decades has provided opportunities and challenges in a dynamically changing workforce.
Epidemiological and nutritional developments have brought advances in health for youth; new diseases, including sexually transmitted infections and HIV/AIDS, raise challenges. Changing population dynamics alter the relative priority that policy makers give to different age groups in their budgets and planning. This complicates the issue of addressing the neglected, transitional adolescent years.
Evaluating the importance of investments in youth is complicated by several factors:
- Many interventions take a long time to have an effect.
- Investments in different areas operate synergistically, so tracing causes and identifying priorities can be difficult.
- Experimental programme designs that would allow comparison of different approaches are rarely applied to many areas of social intervention (including reproductive health and community programmes) for both practical and ethical reasons.
- Youth populations are enormously diverse: strategies must correspond to their life situations (married or unmarried, in or out of school, employed or not, in intact families or not, etc.) and cultural expectations—there are no “one-size-fits-all” approaches. What is valuable in one setting, or for one subgroup of young people, may be less effective in another—even when the costs of inaction are known to be considerable.(31)
It is also difficult to estimate the actual costs of programmes(32) and their diverse benefits (particularly those beyond productivity improvements). Complicating the situation for policy makers, investments may have different benefits for males and for females. Young men might benefit more than young women from programmes addressing tobacco, alcohol and drug abuse, for example. Reproductive health investments more directly benefit women.
As we have seen in Chapter 1 (Table 3), the web of relationships among causes and effects of negative outcomes involving adolescents are complex and mutually supporting. Breaking the links of vicious cycles that capture some people and replacing them with virtuous cycles of mutual positive support often requires combinations of programmatic interventions.
Nonetheless, research in different settings provides important information about the value of investments in youth in terms of their economic consequences.
EMPOWERING YOUNG WOMEN IN BANGLADESH
Shahina Akter, 20, is one of some 1,100 young women
who have completed training courses offered as part of
UNFPA-supported project in Bangladesh and gone on to start
their own businesses. The project aims to alleviate poverty by
providing skills training and small business loans, an approach
pioneered by the Grameen Bank.
Her community, Bibir Bazar, decided to concentrate on
dress making, basket weaving, poultry farming and raising
livestock. “I joined the club out of high school and spent six
months learning to make dresses and scarves,” she explains.
The project also supports other community development
activities and a small clinic which provides basic health services
including reproductive health and family planning.
Intelligent, ambitious and with a flair for business, Shahina
took out a small loan and in no time had recruited another 20
girls for her dress-making enterprise. She sells her products to
stores in nearby Comilla, earning tidy profits. She also trains
girls in dress-making. “There are no dropouts in my class,” she
Village incomes have risen considerably as a result of the
project, and women now have economic clout, can regulate
their fertility, and have fewer, healthier children later than their
peers in less-enabling environments.
Locals credit the project with raising the average age of
marriage in Bibir Bazar from between 17 and 19 to around 24.
The old dowry system has been abandoned entirely. “In this
village,” explains Shahina, “the girls come to marriage with
their own ‘dowries’, earned themselves. Here we are on more
equal terms with men.”
Without this project, Shahina says she “would probably
have married by 19, had a child already, and remained poor
and malnourished.”See Source
COSTS OF EARLY PREGNANCY One key arena for intervention is the prevention of unwanted pregnancy among the young and the promotion of later childbearing.
The cost of having a teenage pregnancy as compared to a pregnancy after age 20 has been estimated(33) by considering:
- Lower lifetime earnings of the mother (reflecting earlier school dropout, childcare demands affecting education and employment, and reduced job experience)—largely private costs.
- Lower tax revenues (due to mothers’ reduced income or consumption tax revenue).
- Child support cost needs (early pregnancies often involve reduced paternal support).
- Higher health care costs (complications of pregnancy are more likely for early pregnancies and later health care costs for the child are higher; these costs then affect the benefits that might be provided to others if the pregnancies had been averted or delayed).
- Additional costs related to disadvantaged children (including the inter-generational impacts of reduced education, heightened risk-taking and poverty and their attendant expenses).
- Higher social support costs (reflecting demand for foster care, child nutrition programmes, food programmes and government housing).
- Social exclusion costs (acknowledging the reduced household and community support for unmarried mothers and their subsequent exclusion from opportunities).
National social costs vary depending on prevailing teen birth levels, local wages and social expenditure levels.(34) There are two components: financial costs (direct expenditures) and economic costs (opportunity costs for alternate uses of resources and marginal effects on other expenditures).(35)
Estimates for seven Caribbean countries of annual aggregate financial costs total $3.6 million per year. Full annual economic cost estimates reach $8.5 million. Both the financial and economic costs substantially exceed the costs of delaying these births to later ages. Direct financial costs range from $28 to $262 per birth annually, depending on their locale. Annual economic costs range from $33 to $363 dollars per birth. The annual cost of averting a birth by using family planning is only around $17.
These estimates do not include the foregone earnings of children later in their lives, as these are more difficult to estimate. (For similar reasons, a wide variety of social costs are omitted.) Detailed studies in Barbados, Chile, Guatemala and Mexico suggest that early childbearing is associated with negative economic effects particularly for the poor.(36) Adolescent childbearers are more likely to end up poor than those who bear children later. This is even observed when the women compared are matched on important dimensions.
Early childbearing is associated with higher fertility, shorter birth intervals, fewer traditional nuclear families(37) and the transmission of a preference for large families to one’s children.(38) These effects are not just transitory. They persist longer the poorer the girl is initially. These effects can be reduced with further education and income, but the challenge of obtaining these is heightened. Among the poor (but not better-off women), adolescent childbearing leads to lower monthly wages. And only among the poor are effects seen on children’s nutrition.
Social policies need to address information and services to prevent unwanted early childbearing and to increase education and income-generating opportunities and access to quality reproductive health education and services for poor young mothers.
COSTS OF HIV/AIDS More than 50 per cent of new HIV/AIDS cases every year are among 15-24 year olds. The proportion of these among 15-19 year olds is being studied but is difficult to specify.(39) The costs of the pandemic in arrested development, lost agricultural output, lost education, excess training costs to provide for personnel losses, health facility overloads, treatment (where available) and care, among others, are enormous. The Commission on Macro-economics and Health estimated the benefits from one averted HIV/AIDS infection in a poor country as $34,600 in settings with annual average earnings of $1,000 per year.(40)
HIV/AIDS prevention, the focus of UNFPA’s work against the pandemic, has been estimated as 28 times more cost-effective than highly active antiretroviral therapy (HAART).(41) Of course, a comprehensive approach to HIV/AIDS recognizes the synergies between prevention and treatment (e.g., HAART reduces the viral load, making transmission less likely) and a balance will be needed between efforts addressing health impacts and those affecting the social and institutional contexts that place people at risk.(42) Detailed local studies are needed to ascertain the particular costs and benefits of specific programmes devised for local conditions.
Few studies of the returns to HIV/AIDS prevention efforts are available. A detailed analysis in Honduras, where HIV/AIDS prevalence estimates are low (around 0.1 per cent), calculated the benefit-cost ratio of a school-based adolescent education programme and found that less than half the costs were recovered in benefits.(43) However, the benefits vary directly with the prevalence level. In populations with 1 per cent prevalence (a far more common time for policy-makers to take notice and institute programmes) the return would be $5 for every $1 invested. In countries with a 20 per cent prevalence, the ratio would jump to $99 for every $1 invested. The exact returns depend on coverage levels and on programme design and implementation.
Coordinated systems of preventive activities oriented towards behaviour change—including for those out of school, outreach to high-risk groups and prevention of mother-to-child transmission—would attain even higher levels of private and social benefits. Analyses that include the additional benefits from reproductive health information programmes (beyond those related strictly to HIV/AIDS incidence) would further increase the expected returns.
In the United States, other studies of returns for efforts preventing risky sexual behaviour have shown significant benefits. A school-based HIV, STI and pregnancy prevention programme estimated returns of $2.65 per $1 expended. A second study on preventing unprotected sexual behaviour found a savings of $5.10 in resources that otherwise would have been expended because of resulting problems.(44) Another study found a return of $5.00 per $1 spent by adding efforts to prevent risky sexual behaviour in a health intervention directed against smoking and substance abuse.(45)
LESSONS FOR THE FUTURE
Programmes to address
adolescent sexual and reproductive health concerns
have advanced considerably since the ICPD in 1994. Sufficient
experience now exists to guide programme planning and identify
key tasks for the future. Some of the lessons learned
- Policy makers, government leaders and civil society leaders
must be involved in establishing positive policies and
- Community support is needed to increase acceptance
and use of youth-friendly services.
- Youth participation and youth-adult partnerships are
essential for programme relevance, ownership and effective
- Gender awareness and equity need to be an integral part
- Increasing the legal age of marriage, supported by social
mobilization for its implementation, will be one of the
efforts needed to aid young people—men and women—
to better satisfy family, economic and social
- Prevention of too-early childbearing and of STIs and HIV
should be addressed together educationally and in
service programmes, with an emphasis on safer sex
practices and dual protection.
Some key needs for future attention include:
- Basic information about programmes, including cost
data, needs to be collected systematically and made
available so all can learn from disparate experiences.
- Basic programmes, such as sexuality education and
youth-friendly services, need to be scaled up, especially
if infrastructure exists to build on.
- Better programme models for reaching out-of-school
youth need to be developed and tested.
- Models need to be tested for programming in traditional
- Documentation and evaluation efforts need to be
COSTS OF EDUCATION PROGRAMMES Estimates of additional resources needed for quality and coverage improvements in basic education are as high as $30 billion per year.(46) The benefits of education programmes are diverse and substantial. Detailed national studies produce estimates related to their programme particulars. A scholarship programme in Colombia has been estimated to produce $3.31 in benefits for each $1 in costs.(47) An adult basic education and literacy programme in Colombia has been estimated to return $19.90 per $1 in costs.(48)
These levels of return are high relative to investments in several other development sectors (including forestry, irrigation, livestock and several agricultural programmes).
Investment in education and health, including reproductive health services, bring high returns. Benefits include: lower fertility, reduced levels of STIs, increased age at marriage, greater ability to use health and nutritional information, enhanced life skills (with appropriate curricula), and improved gender equality and equity. These many outcomes directly benefit individuals, families and nations. Disentangling these components is problematic, but it is clear that the direct and indirect pathways through reproductive health are important both for the person educated and their children. Girls’ education produces higher returns.
Today, more than 1.2 billion adolescents are coming of age. Their success and happiness depend on the support, the examples, the education, the opportunities and the resources with which they are provided. They must be empowered to make responsible and healthy choices and provided with information and services. Investing in the well-being and ensuring the participation of the world’s largest youth generation will yield benefits for generations to come.
GLOBAL CONSENSUS ON ADOLESCENT REPRODUCTIVE
The United Nations’ five-year review of the
ICPD Programme of Action called on governments to meet
adolescents’ needs for “appropriate, specific, user-friendly and
accessible services to address effectively their reproductive
and sexual health needs, including reproductive health education,
information, counselling and health promotion strategies”. The
goal is “to enable them to make responsible and informed
choices and decisions . . . in order, inter alia, to reduce the number
of adolescent pregnancies”.
The 1999 agreement also states:
- Governments should “ensure that parents and persons
with legal responsibilities are educated about and
involved in providing sexual and reproductive health
information, in a manner consistent with the evolving
capacities of adolescents”.
- “Sexually active adolescents will require special family
planning information, counselling and health services, as
well as [information and services on] sexually transmitted
diseases and HIV/AIDS prevention and treatment.”
- “These services should safeguard the rights of adolescents
to privacy, confidentiality and informed consent,
respecting their cultural values and religious beliefs and
in conformity with relevant existing international agreements
- “Those adolescents who become pregnant are at particular
risk and will require special support from their families,
health-care providers and the community during pregnancy,
delivery and early childcare. This support should
enable these adolescents to continue their education.”
- Countries should “ensure that programmes and attitudes
of health-care providers do not restrict the access
of adolescents to appropriate services and the information
they need, including for the prevention and treatment of
sexually transmitted diseases, HIV/AIDS and sexual
violence and abuse”.
- Governments and donors, by 2005, should “ensure that
at least 90 per cent, and by 2010 at least 95 per cent, of
young men and women aged 15 to 24 have access to the
information, education and services necessary to develop
the life skills required to reduce their vulnerability to
HIV infection. Services should include access to preventive
methods such as female and male condoms,
voluntary testing, counselling and follow-up.”