Adolescent sexual and reproductive health and universal health coverage: a comparative policy and legal analysis of Ethiopia, Malawi and Zambia

Figures & data

Table 1. State-level socio-demographic indicators^a

	Ethiopia	Malawi	Zambia
GDP capita ppp$ [2018]^Citation10	2,018	1,308	4,216
% population urban^Citation11	19.4	16.3	41.9
Poverty headcount ratio [below $./day] (WB)^Citation10	30.8 [2015]	70.3 [2016]	57.5 [2015]
Total population median age [2015] [years]^Citation12	18.3	17.2	16.7
% population aged below 15 years^Citation12	42.2	45.1	46.2
Median age at first sex [females aged 25–49]	16.6	16.8	16.6
% women aged 15–24 married by exact age
15	14.1	9.0	5.2
20	57.8	66.3	46.5
Median age in years at first marriage [females aged 25–49]	17.1	18.2	19.1
Very young adolescent [10–14] fertility rate	1.0	3.0	3.0
Adolescent [15–19] fertility rate	80	136	135
Total fertility rate [females aged 15–49]	4.6	4.4	4.7
% sexually active unmarried women aged 20–24 using modern contraception	47.0	43.7	47.6

^a Unless otherwise specified, data from most recent DHS: Ethiopia (2016), Malawi (2015–2016), Zambia (2018).

Table 2. Key African Union legal and policy instruments that could support the advancement of adolescent SRH services under UHC

Nature of instrument	Year of adoption	Focus	Features pertaining to adolescent SRHR	Strengths and limitations
Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa
Enforceable treaty	2003	Human rights of women	Elimination of discrimination against women; economic and social welfare rights, health and reproductive rights	Recognises the right to health of women including sexual and reproductive rights. Mentions the right to control fertility, the right to decide whether to have children or not. State parties should “protect the reproductive rights of women by authorising medical abortion in cases of sexual assault, rape, incest, and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the foetus”.
Continental Policy Framework on Sexual and Reproductive Health and Rights (CPF)
Policy	2006	Guidance on implementation of ICPD Plan of Action (PoA) and Millennium Development Goals	Includes: maternal mortality and morbidity; contraceptive use and family planning services; unsafe abortion; adolescent reproductive health	Draws on the ICPD PoA and specifically addresses adolescent SRH and unsafe abortion.
Revised Maputo Plan of Action 2016–2030 (MPoA)
Policy	2016	MPoA 2016–2030 designed to operationalise the CPF	Actions include: instituting health legislation and policies for improved access to Reproductive, Maternal, Newborn, Child and Adolescent Health services; investing in SRHR needs of adolescents, youth and vulnerable and marginalised populations	Emphasises the need to ensure adolescents have access to SRH services in accordance with ICPD PoA.

Table 3. Abortion laws and services in Ethiopia, Malawi and Zambia

	Zambia	Ethiopia	Malawi
Grounds for abortion	Life, mental and physical health of pregnant woman; physical and mental health of existing children; foetal impairment. In 2005 Penal Code sections 151–3 were amended to include rape and defilement of female children.^a “The pregnant female child's word must be taken as a matter of fact … not subject to the health care provider's subjective analysis.”	Article 551 of the Penal Code: Life, mental and physical health, of pregnant woman; rape and incest^b; mental or physical disability including due to minority status of pregnant woman; foetal impairment. Includes provision to terminate pregnancies legally on the grounds of being below the age of 18 without requiring proof of age.	Life of pregnant woman.
Availability of safe abortion services	Some availability in public sector facilities; limited availability in the private/ NGO sector^Citation19,Citation38	Widely available in the public, private and NGO sectors.^Citation39–41	Very limited availability^Citation42,Citation43
Standards and Guidelines on safe abortion care: adolescent-specific content	2nd Edition (2017) Adolescent Includes standards to ensure availability of services at the community level for both in-school and out of school adolescents. For a person below the age of legal consent to a medical or surgical procedure (less than 18 years of age), to obtain an abortion procedure, the parents or legal guardian approval to terminate the pregnancy must be documented. The best interest of the minor will take precedence over that of the parents or guardian. The guidelines recognise that supportive counselling may be necessary for adolescents.	2nd Edition (2013) No specific mention of adolescents is included in the Ethiopian guidelines. A provider should secure informed consent for a procedure. However, minors are not required to sign a consent form to obtain an abortion procedure.	Standards and guidelines on abortion care not available

^a Section 152[2]: “Any female child being pregnant who, with intent to procure her own miscarriage, unlawfully administers to herself any poison or other noxious thing or uses any force of any kind commits an offence and is liable to such community service or counselling as the Court may determine, in the best interest of the child.”

^b Women who request termination of pregnancy after rape and incest are not required to submit evidence of rape and incest and/or identify the offender in order to obtain abortion services.

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