Towards comprehensive sexuality education: a comparative analysis of the policy environment surrounding school-based sexuality education in Ghana, Peru, Kenya and Guatemala

ABSTRACT

The successful implementation of comprehensive sexuality education (CSE) programmes in schools depends on the development and implementation of strong policy in support of CSE. This paper offers a comparative analysis of the policy environment governing school-based CSE in four low- and middle-income countries at different stages of programme implementation: Ghana, Peru, Kenya and Guatemala. Based on an analysis of current policy and legal frameworks, key informant interviews and recent regional reviews, the analysis focuses on seven policy-related levers that contribute to successful school-based sexuality education programmes. The levers cover policy development trends; current policy and legal frameworks for sexuality education; international commitments affecting CSE policies; the various actors involved in shaping CSE; and the partnerships and coalitions of actors that influence CSE policy. Our analysis shows that all four countries benefit from a policy environment that, if properly leveraged, could lead to a stronger implementation of CSE in schools. However, each faces several key challenges that must be addressed to ensure the health and wellbeing of their young people. Latin American and African countries show notable differences in the development and evolution of their CSE policy environments, providing valuable insights for programme development and implementation.

KEYWORDS:

• Comprehensive sexuality education
• policy
• levers
• barriers
• Africa
• Latin America

Introduction

In low- and middle-income countries, young people aged 10–24 years account for just over one quarter of the population (UN Population Division 2017). As they transition to adulthood, young people need information and skills to enable them to lead healthy and safe sexual and reproductive lives and nurture fulfilling and positive relationships (Biddlecom et al. 2007). Yet many young people lack access to reliable information on sex, gender, relationships and sexuality, manifesting in poor knowledge and inadequate skills to protect their sexual and reproductive health and rights (SRHR) (Woog et al. 2015).

School-based comprehensive sexuality education (CSE) provides a structured opportunity for students to gain knowledge and practical skills, to explore their attitudes and values, and to practice the skills necessary for making healthy informed choices about their sexual lives and relationships (Kirby 2007; UNFPA 2014; UNESCO 2018). CSE programmes that focus on human rights, gender equality and empowerment have been shown to improve young people’s knowledge, self-confidence and self-esteem; positively change attitudes, gender and social norms; strengthen decision-making and communication skills; and build self-efficacy (Gallant and Maticka-Tyndale 2004; Kirby, Obasi, and Laris 2006; Fonner et al. 2014; Haberland 2015; Haberland and Rogow 2015; UNESCO 2015).

Much of the available research on effective CSE has focused on characteristics, quality and inadequacies at the programme level (Kirby 2007; Haberland 2015; UNESCO 2015). Yet several studies show that a key prerequisite for a successful CSE programme is the existence of a sound policy framework (Weaver, Smith, and Kippax 2005; UNESCO 2010). In addition to establishing young people’s right to and need for CSE and catalysing government commitment and action, the policy and legislative context is important in supporting and guiding CSE implementation in schools. Very few studies have examined the policy and institutional environment supporting CSE. The cross-country comparative studies that do exist have focused on developed countries (Lewis and Knijn 2002; Weaver, Smith, and Kippax 2005; Parker, Wellings, and Lazarus 2009). Reports published by international agencies have reviewed CSE policies in Asian countries, but fall short of a comparative analysis (Clarke 2010; UNESCO 2012). In Latin America, a diagnostic study examined CSE policies in various countries, but the paper, which also covered programme content and implementation, did not go in depth into the policy environment (DeMaria et al. 2009). CSE policies have also been systematically analysed using self-reported data for 17 countries in Central and Latin America as part of the evaluation of the Mexico Ministerial Declaration Preventing through Education (UNFPA and DEMYSEX 2010; Hunt, Castrejón, and Mimbela 2015). In Africa, Obare and Birungi (2013) have conducted a comprehensive analysis of policies in Kenya, but it lacks a cross-country perspective.

A 2010 UNESCO review of CSE in China, Jamaica, Kenya, Mexico, Nigeria and Vietnam identified eight levers of success that ‘contribute to successful implementation of effective school-based sexuality education at regional, country or local levels’, based on regional experience, policy analysis and key informant interviews (UNESCO 2010, 7). Several of these levers are related to the policy environment. A recent report on achievements around CSE and SRHR services for adolescents in Eastern and Southern African countries mentions critical policy dimensions similar to those identified by the UNESCO report as contributing to successful implementation of CSE in schools (UNESCO 2016), and many of these levers were also recognised as key to the successful adaptation of a comprehensive curriculum in a case study in Kenya (Dayton 2012). This paper analyses levers of success related to the policy and legal environment in four low- and middle-income countries: Ghana, Peru, Kenya and Guatemala.

These four countries present diverse contexts with respect to sexual and reproductive health issues for young people. The proportion of 15–19 year-olds who have initiated sex ranges from 28% in Guatemala (MSPAS 2010) to 39% in Kenya (Kenya Bureau of Statistics 2015), and few of those sexually active are using contraception, with modern method prevalence as low as 22% in Ghana (Ghana Statistical Service, Ghana Health Service, and ICF International 2015) and 31% in Guatemala (MSPAS 2010). To address challenges related to sexual and reproductive health and rights, these four governments have devised policies that, although varying in scope, include some form of school-based sexuality education. A comparative policy analysis can elucidate the current practices in different contexts and help to understand the degree to which clear policy guidelines, or lack thereof, can enhance or limit the effectiveness of programmes to address the sexual and reproductive health and rights of young people. Such an analysis may also indicate key areas to be addressed in terms of further research and policy action. To our knowledge, this is the first study comparing the CSE policy environment across multiple low- and middle-income countries.

Materials and methods

The four countries were selected such that in each region (Latin America and Africa), one country was at a relatively more advanced stage of implementation of CSE policies and programme (Peru and Ghana), and the other at a relatively earlier stage of implementation (Guatemala and Kenya), based on reviews of policy documents, CSE programme evaluations and other regional reports (DeMaria et al. 2009; Hunt and Monterrosas Castrejón 2012; Population Council 2012; UNESCO 2013; UNESCO and UNAIDS 2013). Each of the four countries has its own history of sexuality education development and possesses unique challenges and opportunities, which together provide diverse and contrasting contexts within which to analyse the policy environment around CSE. In each country, we worked with a research partner selected for its relevant work and national-level expertise in the field of young people’s sexual and reproductive health and rights, and school-based sexuality education.

National laws, policies, guidelines and plans from all sectors (including education, health and youth) directly or indirectly related to sexuality education in schools were systematically gathered during field visits and online on governments’ websites. The relevance and completeness of the documents collected were crosschecked with in-country partners in order to ensure saturation was reached. Inclusion criteria were that documents had to be national and official (emanating from the government or a ministry); to include provisions for sexual and reproductive health education in school; and to still be in force. Additionally, in-depth interviews were conducted with stakeholders holding different opinions on CSE, to obtain information on the political and historical context of sexuality education, and to better understand the processes involved and barriers faced in drafting and implementing policies on sexuality education. Between 20 and 30 key informants were interviewed in each country, including national and regional-level policymakers and programme implementers, national advocates, non-governmental organisation (NGO) representatives, leaders of community-level reproductive health organisations, youth groups, women’s groups and religious groups (Table 1). The interviews were conducted by experienced qualitative researchers between April and October 2015. The interviewers had past experience working on studies with the in-country partners and a proven track record of conducting quality interviews. A semi-structured interview guide was developed based on a literature review incorporating insights on levers of success for CSE (UNESCO 2010), as well as information gathered from various stakeholders during an exploratory field visit to each of the four countries, and the advice of the in-country partners, to ensure all key topics were covered. We endeavoured to keep the interview guides as similar as possible across countries, in order to enable a comparative analysis of the data. After training the interviewers, the guide was piloted with different types of respondents (government, advocate, community) in each country and adjusted accordingly. The interviews were recorded (subject to informed consent) and transcribed, and the data were analysed using thematic and content analysis, following the UNESCO levers of success described below. Quotes from Peru and Guatemala presented in this paper were translated by the authors.

Table 1. Types of key informants interviewed in each country.

	Kenya	Ghana	Peru	Guatemala
Government
Policy-makers	1	1	2	3
Curriculum developers	1	1	1	1
Program implementers (national or local government)	6	3	10	5
International cooperation	1	1	2	1
Civil society
National civil society organizations, advocates	9	2	4	4
Youth organizations	4	3	5	2
Community-based organizations (other than youth)	3	5	3	5
Religious and traditional leaders	2	4	3	4
Total	27	20	30	25

This paper presents the broad environment, history and challenges around CSE policies and their implementation in the four countries, using a comparative lens to identify similarities and differences between countries. Seven levers of success related to the policy environment are discussed in this paper:

1. A tradition of addressing the place of sexuality within the education system, by analysing the process over time that led to the current status of CSE in each country;

2. high-level political support and commitment to CSE reflected in a favourable policy framework, by analysing the policy framework for CSE and governments’ active support of it;

3. government willingness to subscribe to international commitments in support of sexuality education, by analysing international commitments to which governments agreed;

4. availability of appropriate technical support from UN agencies and international NGOs, by analysing governments’ reliance on such support over time;

5. existence of civil society organisations (CSOs) willing to promote CSE even in the face of strong opposition;

6. active involvement of youth-focused groups or organisations, by analysing their presence and roles in supporting CSE;

7. partnerships (and formal mechanisms for these) between different ministries and between State and CSOs, by analysing the existence and scope of multi-sectoral approaches and coordination across ministries.

Key dimensions and indicators for each lever were identified (Table 2) and data by country included in a matrix allowing comparisons across the four countries. The results are structured around these seven levers, grouped into two sections: policy and legal framework (levers 1–3), and actors involved (levers 4–7). The discussion assesses and compares the main challenges across countries and identifies opportunities for developing a more supportive policy environment for effective implementation of school-based CSE.

Table 2. Operationalisation of levers of success related to the policy environment analysed in this paper.

Levers of success	Key dimensions	Indicators
Tradition of addressing sexuality within the education system	Process over time that led to the current status of CSE in each country	stages influences of HIV and other international trends current situation (movement towards improving CSE in schools; stagnation; movement towards more conservative approach; unclear)
(2) High-level political support and commitment to CSE reflected in a favourable policy framework	Policy framework for CSE and governments’ active support of it	document status (CSE as part of a general policy (such as HIV) versus CSE-specific policy, general versus more specific and more binding provisions, higher versus lower policy level) coherence across policies from different sectors scope and comprehensiveness of documents
(3) Government willingness to subscribe to international commitments in support of sexuality education	International commitments to which governments agreed	number of commitments signed scope of commitments compliance mechanisms
(4) Availability of appropriate technical support from UN agencies and international NGOs	Governments’ reliance on such support over time	duration level of involvement impact on policies (as reported by stakeholders)
(5) Existence of civil society organisations (CSOs) willing to promote CSE even in the face of strong opposition	Presence and roles in supporting CSE	existence of these groups at the national level influence on policies active involvement in advocacy and policy-making process
(6) Active involvement of youth-focused groups or organisations	Presence and roles in supporting CSE	existence of these groups at the national level influence on policies active involvement in advocacy and policy-making process
(7) Partnerships (and formal mechanisms for these) between different ministries and between State and CSOs	Existence and scope of multi-sectoral approaches and coordination across ministries and with CSOs	number of active partnerships status (ad hoc, systematic) formally defined (or not) number and diversity of actors involved stages of policy development

Results

Policy framework supporting CSE in schools

Lever 1: tradition of addressing sexuality within the education system

A tradition of addressing sexuality within the education system contributes, over time, to building openness, understanding, legitimacy and technical competence for including CSE in the school curriculum. The analysis of trends in the development of sexuality education in schools since the 1960s shows that all four countries went through four periods in the evolution of their policy environment. At the start of the first period (1960-1980), young people’s SRHR was of low public priority, and the main focus of sex and reproduction education was biological (Dirección de Tutoría y Orientación Educativa 2008). In response to concerns over population growth, in the 1970s countries adopted population policies that often included population education (Falconier de Moyano 1997; Dirección de Tutoría y Orientación Educativa 2008). In the second period (1980–94), sexuality education incorporated population issues and moved beyond human reproduction in all four countries (Quashigah et al. 2014; Monzón et al. 2017; Motta et al. 2017). This is exemplified by the establishment of the Guatemala Association of Sexuality Education (AGES) in 1978 (Luna Manzanero 2010; Alfaro 2015), the Peruvian National Programme for Population Education (1980–90) and the Ghana School Health Education Programme (SHEP) in 1992. The third period (1994–2000) is characterised by a paradigm shift from a population and development perspective towards a more holistic approach to reproductive health that emphasised social aspects of sex and sexuality (Motta et al. 2017). The 1994 Cairo International Conference on Population and Development defined goals not only in demographic terms but also with regards to human rights, and clearly addressed the specific needs of young people (Galdos Silva 2013). The emergence of HIV as a global crisis affecting young people provided an additional impetus for governments to address sexual and reproductive health and rights among young people. In Ghana in 1998, the Life Skills curriculum was expanded to include HIV and AIDS, and in Guatemala HIV prevention and rights became part of the curriculum in 2000. The more holistic concept of ‘comprehensive sexuality education’ (CSE) became the new standard. In Kenya, this evolution occurred during the next period. The fourth period (2000–2015) is characterised by a focus on human rights, including child rights, gender and sexual rights, and the right to education – issues at the forefront of the Millennium Development Goals and the Sustainable Development Goals. In Guatemala, high rates of violence against women provided a rationale for embedding CSE in broader violence prevention (Ministerio de Educación 2012; Alfaro 2015). In all four countries, government interest in CSE was further fuelled by high rates of pregnancy among young people, which were seen as socially undesirable, negatively impacting on girls’ health and jeopardising their future prospects.

Although all countries went through these four periods, they have followed different internal dynamics. For example, in the two Latin American countries, during the first period health professionals formally organised to promote a more comprehensive approach to sexuality education with the establishment of the Regional Committee of Sex Education in Latin America and the Caribbean (CRESALC) in 1975 and the Federation of Latin American Societies of Sexology and Sex Education (FLASSES) in 1980 (Luna Manzanero 2010). In the third period, strong national women’s movements further advocated for a rights-based approach to CSE (Falconier de Moyano 1997; Cáceres, Cueto, and Palomino 2008). This legacy of activism is evident today in the rights-based and gender-sensitive leaning of many CSE programmes in Latin America. Meanwhile, in countries with higher HIV prevalence like Ghana and Kenya, the need for HIV prevention education was a driving force for the development of sexuality education beyond a biological perspective during the third period. However, these historical roots in HIV prevention hindered these countries’ transition into the fourth period, and have led to programmes still focused on prevention of negative outcomes, as opposed to the promotion of rights-based goals (Awusabo-Asare et al. 2017; Sidze et al. 2017).

Lever 2: high-level political support and commitment to CSE reflected in a favourable policy framework

Government support and commitment to addressing CSE through policies and laws is central to creating an enabling environment (UNESCO 2010). While all four countries have various policies on sexual and reproductive health and rights for young people that include provisions for CSE, none of the countries has a national policy specifically dedicated to school-based CSE (Table 3), and the policies that do mention CSE are not always adequately implemented:

These policies are good, they create a positive environment or an enabling environment for us to be able to do our work. However, implementation… the policy may be very progressive, but when you come to the ground and you look at the implementation, it is very, very behind. And again: these policies, they exist, but the policy-makers, some of them don’t know about it. (Youth-focused civil society organisation, Nairobi, Kenya)

Table 3. Overview of national legal and policy framework for provision of CSE in schools.

Ghana	Peru	Guatemala	Kenya
1969: National Population Policy, first edition (National Population Council). Provides framework for introduction of reproductive health education in schools throughout the 1970s, with an emphasis on abstinence. 1994 National Population Policy, revision (National Population Council). Adds HIV/AIDS 1996: National Reproductive Health Service Policy and Standards (MOH). Indicates government’s commitment to the health and wellbeing of women, children and adolescents. Included in policy’s strategies is integration of Family Life Education into school curricula. 2000: Adolescent Reproductive Health Policy (National Population Council and MOH). Adopted a multi-sectoral framework for the development of adolescent reproductive health programmes for in- and out-of-school youth. Led to inclusion of a reproductive health component in junior and senior high school curricula (Bekoe and Eshun 2013; Quashigah et al. 2014) 2010: National Youth Policy of Ghana (Ministry of Youth and Sports). Aims to improve youth knowledge about preventive health care and help them avoid early and “irresponsible” sexual activities and exposure to HIV/STIs. 2013: National HIV/AIDS and STI Policy (Ghana AIDS Commission). Advocates for integration of age-appropriate SRH education into curriculum, including lessons on HIV/AIDS and other STIs. 2015: Adolescent Reproductive Health Policy (MOH), revision of 2000 Policy.	1980–90: National Programme for Population Education (MOE). Incorporates content on sexuality education into Family Education and Civic Education classes. 1985: Law on National Population Policy. States that education sector is in charge of promoting and delivering programmes related to population and sexuality education in schools. 1996–2000: National Sexuality Education Programme (MOE). In addition to family planning, emphasised topics such as STIs, sexual violence and adolescent pregnancy. 1998–2002: National Population Programme (Ministry for Promotion of Women and Human Development-PROMUDEH). Aims to ensure young people know about SRH, can identify risks and prevention strategies for STIs/HIV, expand coverage of National Sexuality Education Programme to all public secondary schools and half of private schools. 2007: Law of Equal Opportunities between Men and Women no 28,923. Recognises right to CSE in article 6l (Gobierno del Peru 2007). 2008: Education Guidelines and Pedagogical Orientations for CSE (MOE). Offers guidance on CSE implementation in junior high school (Educación Básica Regular). States that MOE is in charge of implementation of CSE; but lacks detailed proposal for teacher training (Dirección de Tutoría y Orientación Educativa 2008) 2013: Multi-sectoral Plan for the Prevention of Pregnancy in Adolescents (2013–2021) (MOH). Objective 3 is to ensure inclusion of CSE in national curricular framework and teacher training programmes (Ministerio de Salud 2013).	2000: General Law for fighting HIV/AIDS and promoting, protecting and defending human rights in the face of HIV/AIDS (Decree 27–2000). Includes these topics in curriculum. 2001: Law on Social Development (Decree 42–2001). Indicates obligation to provide counsel and education to adolescents on sexuality, human rights and multiculturality and prohibits exclusion of pregnant adolescents from school; recognises right to CSE. 2005: Law on Universal and Equitable Access to Family Planning Services and their Integration in the Sexual and Reproductive Health Programme (Decree 87–2005). Indicates that content on rights and responsibilities for addressing health, sexuality and unintended pregnancy should be included in the curriculum. 2010: National Policy on Youth 2012–2020 (Ministry of Social Development-MIDES). Promotes better CSE coverage and quality in all school cycles with a focus on human rights, gender and ethnicity. 2010: Law on Healthy Pregnancy (Decree 32–2010) establishes strategy for including CSE in national curriculum, and aims to prevent adolescent pregnancy, guaranteeing pregnant students’ right to remain in school and detecting cases of violence.	2003: Adolescent Reproductive Health Development Policy (MOH). Aims to incorporate adolescent SRH education into the curricula of all education and training institutions. Promotes HIV/AIDS education programmes for adolescents in and out of school. 2004: Policy Framework for Education and Training (MOE). Emphasises giving young people the knowledge and skills to lead effective lives, and developing teachers’ communication skills, attitudes and values to help them better connect with students. 2004: Education Sector Policy on HIV and AIDS (MOE). Integrates life skills and HIV & AIDS education into curricula for all school levels, including co-curricular activities, using rights-based content. 2009: National School Health Policy (MOE & MOH). Provides framework for multi-sectoral approach to ensure that children are taught and helped to acquire positive values and life skills, including on SRH. 2013: Education Sector Policy on HIV and AIDS, revised (MOE). Re-emphasises need to provide age-appropriate and relevant information to prevent HIV among learners at all levels. 2015: National Adolescent Sexual and Reproductive Health Policy (MOH). Provides guidance to enhance SRH of adolescents and contribute to realization of their full potential, with specific objective of increased access to ASRH information and age-appropriate CSE.

Notes: MOE = Ministry of Education; MOH = Ministry of Health

One potential reason for inadequate implementation is that many of the policies that address CSE emanate from national ministries of health, and therefore do not contain detailed provisions for delivering school-based CSE. CSE delivery is addressed at a lower normative level, through national guidelines (such as the Education Guidelines and Pedagogical Orientations for CSE in Peru), curricular frameworks and syllabi, and some national education and health programmes such as the Ghana School Health Education Programme. Their lower level restricts their reach:

I think CSE policies need to be proposed from the highest level […] so that they can reach congress with laws, bills, high-level documents such as decrees, which oblige ministries to develop policies. And then that these should have their economic correlate, because things can’t progress without economic support. […] The programme – sexuality education- didn’t have any ministerial resolution, let alone a decree. (Ministry of Education official, Peru)

Ultimately, governments in all four countries have generally not been proactive enough in promoting CSE and addressing opposing voices, and in effectively implementing existing supportive policy frameworks.

Lever 3: government willingness to adhere to international commitments in support of sexuality education

International commitments provide benchmarks to governments for acting and to civil society for lobbying and advocating, and contribute to holding governments accountable (UNESCO 2010). The four countries have signed on to several international agreements that mention CSE, such as the Convention on the Rights of the Child (1990), the Cairo Plan of Action (1994), the Beijing Platform of Action (1995), and the UNGASS Declaration of Commitment on HIV/AIDS (2001).

In addition, Ghana signed the commitment drafted at the Abuja Regional Conference on HIV/AIDS (2001) and the Maputo Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (2003). Ghana’s most recent regional commitment on adolescent sexual and reproductive health and rights also emphasises the need for CSE in paragraph 25 (ACSHR 2016). While these commitments include provision for CSE, they lack time-bound targets. Regional meetings specifically focused on CSE have recently taken place in both Africa and Latin America, culminating in two regional commitments. In December 2013, ministers of Education and Health from 20 Eastern and Southern African (ESA) countries, including Kenya, signed the Ministerial Commitment on Comprehensive Sexuality Education and Sexual and Reproductive Health Services for Adolescents and Young People in Eastern and Southern Africa (Ministries of Education and Health 2013), which set specific targets for school-based CSE to be achieved in 2015 and 2020. In 2008, Education and Health ministries from 33 countries in Latin America and the Caribbean, including Peru and Guatemala, signed the Mexico Ministerial Declaration Preventing through Education, which sought to promote collaboration between Education and Health ministries, with a goal to reduce by 75% the number of government-run schools that do not provide CSE by 2015 (Coalición Mesoamérica 2008). The Declaration was reported to have had a positive impact on policy-making in Peru and Guatemala:

This declaration is very important because it gives guidelines, […] it includes accountability. Each department needed to establish a Bureau, you needed the Education one, the Health one, and a joint Bureau. In the case of Education, they ask every departmental directorate to make a strategy, a plan for the department, of how they are going to progress in the implementation of CSE and prevention of violence. (International agency, Guatemala City)

Actors involved in shaping the current policy and legal context (levers 4 to 7)

The types of actors and their degree of involvement in CSE policy-making can influence the scope and reach of the policies that emerge (UNESCO 2010; Alfaro 2015). In all four countries, governments and international agencies have had the strongest impact. Community leaders, religious groups, and CSOs, in particular those representing youth, also play a prominent role in shaping CSE policies, supporting or hindering their implementation, and influencing public opinion. The active involvement of different types of actors in favour of CSE creates a diverse supportive constituency that can be mobilised to contribute to consensus-building and inclusive collaborative processes in defining and implementing CSE policies and programmes.

Lever 4: availability of appropriate technical support from UN agencies and international NGOs

The involvement of experts outside government can help ministries of education develop fact-based policies and resist ideological pressure. All four countries rely on technical and financial support from international agencies, and more sporadically from bilateral development agencies. In Kenya, the Ministry of Education worked with several international agencies to adapt UNESCO’s International Technical Guidance on Sexuality Education (UNESCO 2009) to the local context through a collaborative review process (Dayton 2012). Ghana revised and expanded the School Health Education Programme in 2014 with support from UNICEF, UNFPA and UNESCO, and the Ghana Education Service is currently undertaking a revision of the CSE curriculum with technical support from Planned Parenthood Association of Ghana, the United Nations Population Fund, the National Population Council, Palladium/UK Department for International Development and the University of Cape Coast (Awusabo-Asare 2017). In Guatemala, assistance from UNFPA from 2010 to date has been catalytic in supporting the Ministry of Education (MoE) and civil society coalitions such as the National Campaign for CSE (in the past) and the National Platform for CSE (MENEIS) currently. Several agencies jointly supported the Peruvian Ministry of Education for several years to develop CSE in schools:

For example UNFPA and UNESCO have been supporting the Ministry of Education all these years – and comprehensively, as part of their strategy to make sure sexuality education does not disappear. (Education policy consultant, Lima, Peru)

In all four countries, technical support by international agencies is considered necessary but not free of risks, as this support often comes – and goes – hand in hand with financial support. Key informants mentioned problems of sustainability and quality of CSE over time as agencies withdraw and governments are not prepared to allocate public funds, nor have the expertise, to continue the work.

Lever 5: existence of civil society organisations willing to promote CSE, even in the face of opposition

Conservative opposition to CSE exists in all four countries and has been effective in slowing down progress toward more comprehensive sexuality education in schools. Yet progressive civil society organisations have been challenging these conservative segments of society. In Peru and Guatemala, progressive civil society groups are more active and vocal than in Ghana and Kenya, and have led strong national advocacy campaigns in favour of CSE in schools. Organised into large coalitions¹, they have ensured CSE remains on the political agenda, shaped policies and educated the public, opinion leaders and policy-makers:

I think it has largely been efforts on the part of civil society, women’s organisations, feminist and youth organisations that have spurred on progress in the implementation of this topic. As I mentioned earlier, the National Campaign for Sexuality Education – I think they have been very involved in creating impact in this area. (National NGO, Guatemala)

In Kenya, the government has involved a few national and local NGOs in policy processes, mainly through task forces. CSOs advocating for CSE recently formed a national consortium as part of the multi-country partnership ‘Right Here Right Now’. In Ghana, several groups such as the Planned Parenthood Association of Ghana, the Adventist Development and Relief Agency, Marie Stopes International (Ghana) and Ipas support CSE in schools, although they are not organised into a formal coalition, and their contributions are more at the classroom implementation level.

These advocacy activities continue despite strong resistance to CSE from conservative groups. In Peru and Guatemala, the Catholic Church, and more recently some Evangelical Churches, have opposed CSE in schools. These groups are active and vocal, and exert their influence within state institutions themselves:

Of course there are very conservative groups […] often within the political establishment. The Church as an institution, in the time of Fujimori, was a clear actor that gave its opinion. Today, no, but it’s like it’s integrated itself into all decision-making processes. (Education professional, Lima, Peru)

In Kenya and Ghana, conservative groups also oppose the inclusion of certain topics in CSE. As they are less likely to be openly challenged by progressive groups (who are fewer and less organised than in Latin America), they are able to remain behind-the-scenes, where they are effective in slowing down progress:

I think we have the political will from the government, […] but within, you see the government has other stakeholders which also have to expect and contribute, so we cannot wish away the religious and cultural views. (International agency, Nairobi, Kenya)

Lever 6: active involvement of youth and youth-focused organisations

Young people’s engagement in the policy development and implementation process is key to ensuring their needs are taken into account. All four countries have organisations representing youth involved in CSE, but their influence varies greatly. While these organisations are mostly active at the local implementation level, supplementing existing programmes, some organisations lead national policy advocacy activities, and have been instrumental in stimulating public debate on CSE in recent years in Guatemala and Peru (Monzón et al. 2017; Motta et al. 2017). In Guatemala, the organisation Red IncideJoven, created in 2005, is leading CSE campaigns. In Peru, youth and CSE advocacy groups are represented in the national alliance Sí Podemos.

In Ghana and Kenya, youth-focused groups (such as the Planned Parenthood Association and Curious Minds in Ghana, and the Forum for African Women Educationalists and the Centre for the Study of Adolescence in Kenya) are advocating for sexual and reproductive health and rights, and several Kenyan youth organisations are represented in the national consortium Right Here Right Now. However, youth-focused organisations have less public and media presence than in the Latin American countries, and are mostly involved with the health sector. Although they participate in policy development processes, they are not always consulted on implementation:

When it comes to the implementation of the National [HIV] Strategic Plan, we have not been involved, even though we have been actively engaged in drafting the strategy and even the youth strategy.” […] There should be increased and meaningful engagement of young people in all these processes, because this essentially is about young people. (Youth national NGO, Greater Accra, Ghana)

Lever 7: partnerships between key actors and formal mechanisms for these

Partnerships between education and health ministries and between State and CSOs constitute yet another lever of success in creating an enabling policy environment for CSE (UNESCO 2010). In Ghana, a wide range of stakeholders is consulted in the process of curriculum development (Awusabo-Asare et al. 2017). The multi-sectoral approach recommended in the Sexual and Reproductive Health Policy for Young People in Ghana is implemented in the School Health Education Programme, which the Ministry of Health runs in collaboration with the Ghana Education Service (Ministry of Education) in schools nationwide. The Ghana Education Service recognises the Ministry of Health’s Adolescent Reproductive Health Policy, but there are still inconsistencies between education and health sectors in how it is implemented:

The Ghana Education Service has its own policy, which is contrary to the views expressed in the main policy [the Adolescent Reproductive Health Policy]. So you cannot apply that policy in the education curricula. So what we need to do is to have a dialogue with the Ghana Education Service. In fact we should have one policy on adolescent sexual reproductive health. […] I think that lack of coordination in itself is a bullet in our foot trying to kill us. (International agency, Ghana)

In Peru, civil society stakeholders, including the alliance ¡Sí Podemos!, are consulted by the government in their policy-making on a regular basis (Motta et al. 2017). However, a multi-sectoral approach has not yet been formalised. Several Peruvian key informants mentioned the lack of coordination between the education and health sectors results in somewhat erratic and disorganised implementation and undermines the quality and effectiveness of CSE.

In Guatemala, the ministries of education and health signed a commitment to cooperate in 2010 (MINEDUC and MSPAS 2010), and in 2014, a ministerial agreement to standardise the regulatory guidelines to implement CSE within the Ministry of Education (Acuerdo Ministerial 1120–2014). Regular channels of communication with Ministry of Education decision-makers are established through the National Platform for CSE (MENEIS), created in 2015. The Observatory for Reproductive Health (OSAR), an alliance of academics, civil society and legislative bodies created in 2008, monitors and supervises the implementation of policies related to reproductive health, including CSE.

In Kenya, collaboration on CSE between government and civil society was lacking until the creation of the advocacy consortium ‘Right Here Right Now’. Although the National School Health Policy (2009) provides a framework for a multi-sectoral approach, this approach has not yet been defined between the education and the health sectors. The Ministry of Health manages the Adolescent Sexual and Reproductive Health Policy (on which CSE relies) and the Ministry of Education is in charge of curriculum development. There is a lack of collaboration and coordination between the two ministries in the development of CSE policies and curricula.

There is a wide gap between the policy at Ministry of Education level and at Ministry of Health level because the ASRH policy is more owned by the Ministry of Health […] For instance, the Ministry of Health, under that policy says that any young people, I think from fourteen years, have a right to access condoms, but when you go to schools, condoms are not allowed to be supplied in schools. (National NGO, Nairobi, Kenya)

Where are we now?

In Ghana, a sound policy foundation exists and a national programme offers sexuality education in all secondary schools, but more can be achieved. CSE is not currently part of the national policy debate; politicians consider the matter closed. Laws and policies are in place to implement sexuality education in schools, and topics are included in the curriculum and complemented by co-curricular activities. However, the various syllabi do not adequately address gender, sexual diversity, rights and practical skills. The general approach is still fear-based and abstinence-focused (Awusabo-Asare et al. 2017). While UN agencies, NGOs and the media are calling for more to be done, they have limited influence.

In Peru, the State has gradually taken on the responsibility of guaranteeing CSE in schools, adopting a fairly broad rights-based and gender-focused approach. Opposition to CSE from the powerful Catholic Church and evangelical groups makes it difficult to build a strong political consensus. The implementation of the 2008 Education Guidelines and Pedagogical Orientations for CSE has stalled due to a lack of political support and weak executive power following organisational changes within the Ministry of Education. Despite an intensification of activities by opposition groups in the past few years, the adoption in 2016 of a new national curriculum that included more CSE topics could herald new progress (Motta et al. 2017).

In Guatemala, important advances were made between 2008 and 2010, and a clear policy framework, the National Strategy on CSE, exists on paper. However, its implementation is slow and remains a challenge due to lack of political will. The government is still facing strong opposition to CSE from conservative groups, but civil society has strengthened its collaboration in response to this situation, and in promising recent developments, the Ministry of Education approved the guidelines developed by the Technical platform created to implement the Mexico Ministerial Declaration in 2014 (Alfaro 2015), and reopened discussion on the National Law on Youth (which could include the right to CSE) in 2016.

In Kenya, the policy framework for CSE is fairly strong, and technical support from international agencies is available. Although the government has been quite supportive of CSE, implementation has been hindered by the prioritisation of core subjects, and opposition to some CSE topics has limited the scope of the programmes. The ‘deafening silence’ surrounding sexuality matters (as reported by key informants), coupled with the lack of a strongly organised and vocal civil society, may explain why public debate on CSE is limited. Moreover, the education sector has narrowly focused on life skills and HIV, largely following an abstinence-only prevention-based approach, and the available curricula are still lacking comprehensiveness (Population Council 2012).

Evidence from assessments of CSE provision in schools in the four countries suggests that much remains to be done. Surveys conducted in 2015 with principals, teachers and students aged 15–17 in three regions in Ghana (Awusabo-Asare et al. 2017), Peru (Motta et al. 2017), Guatemala (Monzón et al. 2017) and Kenya (Sidze et al. 2017) show that programme implementation in schools is weak and the range of sexuality education topics taught in the classroom is still limited in all four countries: only between 2% (in Kenya) and 9% (in Peru) of students surveyed reported learning about all 18 key topics that constitute CSE. The implementation evaluation of the Mexico Ministerial Declaration Preventing through Education (Hunt, Castrejón, and Mimbela 2015) indicates that the number of government-run schools in Guatemala that had institutionalised CSE increased by 54% between 2008 and 2010, but only by 3% between 2010 and 2015; for Peru these numbers are 40% and 16% respectively. In both countries, the education provided is still far from comprehensive. According to an evaluation of achievements by 2015 of the ESA ministerial commitment (UNESCO 2016), progress by the Kenyan government has been slow between 2013 and 2015, with the number of schools that provided life skills-based HIV and sexuality education in the previous academic year going from 45% to 51% for primary level and from 32% to 39% for secondary level.

Discussion

In the four countries, although the policy framework is considered favourable and supportive, serious weaknesses still exist. Legal and policy provision for the delivery of school-based CSE is included in general policies, but there is no national policy specific to CSE. Moreover, the frameworks defining the scope of CSE in schools are of a lower normative level, such as CSE technical guidelines (in Peru) or national curricula and syllabi (in all four countries). In Kenya and Ghana, while the policy framework offers a supportive environment for school-based CSE, sexuality education is not defined comprehensively enough and focuses largely on life skills and HIV without addressing topics such as contraceptive methods, sexual orientation and rights. In Peru and Guatemala, guidelines and curricular frameworks are more rights-based and gender-focused, but remain to be translated into practice. In all four countries, policies and laws containing sexuality education provisions lack consistency. Health sector policies tend to be more comprehensive and ambitious than those promulgated by ministries of education. The main challenge in all four countries remains one of implementing supportive and unequivocal policy frameworks due to insufficient government commitment to championing CSE, inadequate or non-existent budgeting to effectively implement CSE, weak monitoring and evaluation systems, lack of coordination across ministries, and inadequate partnerships and coalition-building mechanisms among actors.

Recently, governments in these four countries have shown a relative openness to CSE, reflected in their adoption of ambitious regional commitments. Young people and parents are generally supportive of CSE in schools in all four countries (McDonald, Papadopoulos, and Sunderland 2012; Católicas por el Derecho a Decidir 2013; UNFPA 2015; Awusabo-Asare et al. 2017; Monzón et al. 2017; Motta et al. 2017; Sidze et al. 2017). Yet opposition to CSE, although coming from a minority of the population, still succeeds in slowing down the implementation process and limiting the comprehensiveness of programmes.

Lack of consensus-building to reach agreement on the needs of young people and how best to meet them represents another major challenge in implementing CSE, with a tension between a rights-based approach that recognises the need for comprehensive information and services, and conservative approaches that focus on abstinence. In Kenya and Ghana, the weak presence of civil society organisations willing to actively promote CSE, and of youth-focused organisations, may also hinder progress. Inability to rely on civil society support also makes it more difficult for governments to build robust coalitions and partnerships and to promote stronger CSE policies and achieve successful implementation. In Guatemala and Peru, civil society and youth organisations actively advocated for many years for CSE in schools and organised themselves into broad and strong coalitions. Their expertise is recognised and they are actively involved in the policy-making process. They also represent a resource for the government to rely on in the face of conservative opposition to CSE. Nevertheless, a disconnect remains between the needs and aspirations of the majority of young people and the moralistic approach still influencing CSE policies in all four countries.

Other bottlenecks to effective implementation of CSE policies are not specific to CSE and reflect wider systemic problems in education: insufficient teacher training and support, teacher shortages, overcrowded curricula, and insufficient teaching materials that are culturally relevant and in local languages (UNESCO 2010, 2013). The lack of financing provisions in policies and laws affects implementation of many programmes, not only CSE, and reliance on fluctuating financial support from international agencies often makes programmes in general unsustainable.

Limitations

A number of limitations regarding this analysis should be mentioned. First, the inclusion of only four countries limits the scope of diversity, and it is important to examine more countries to get a broader picture of the CSE policy environment globally. Second, as the goal here was to focus on CSE policy frameworks, the analysis considered only levers related to policy aspects and the role of actors in influencing those policies. Several other levers identified by UNESCO and in other studies (Samuels et al. 2013; Huaynoca et al. 2014; Svanemyr, Baig, and Chandra-Mouli 2015; Chau et al. 2016) should be considered to resolve the gap between a supportive policy framework and the successful implementation of CSE in schools. These include budgeting for adequate teacher training, the development and dissemination of appropriate materials, and the sensitisation of heads of schools and community members to the value of CSE (UNESCO 2010). While all types of levers are necessary to achieve successful CSE implementation, weaknesses on a specific lever can still indicate where action is necessary. Further research could identify which levers are most critical to success and should be prioritised.

Third, levers of success are challenging to operationalise, evaluate and compare across countries due to the qualitative nature of the information. Comparing levers of success in school-based CSE versus out-of-school CSE programmes could provide more evidence on what has worked elsewhere – for example, how multi-sectoral approaches can enhance support for CSE, or how inclusive processes may reduce conservative opposition. Further research is needed on monitoring and evaluation of policy implementation, for processes and outcomes, which was mentioned as an important issue by most key informants in the four countries.

Finally, although we endeavoured to interview a range of informants from various sectors, information collected through interviews provides only a partial picture. Since the analysis focuses on levers of success, obstacles to CSE are not discussed in depth; however, they are touched upon, as each lever of success connects to a range of barriers that need to be overcome.

Conclusions

Despite shortcomings, all four countries benefit from a policy environment that, if properly built upon by government, could lead to stronger CSE implementation in schools. Governments should not underestimate conservative opposition to CSE, even when the majority of the population, youth and parents support CSE in schools. National authorities need to lead the building of a wide consensus by addressing opposition and fostering acceptance among all stakeholders, teachers, parents, students, religious and community leaders. Analyses of CSE programme scale-up to the national level in other low- and middle-income countries show that an ongoing and adequately funded advocacy strategy is key to forging a common understanding, building broad social and political consensus around CSE and generating support among stakeholders, including opposition groups, but it also requires time and sustained efforts (Samuels et al. 2013). Advocacy needs to occur at all stages of development and implementation, and should ideally be carried out by a consortium of actors including national government and education sector personnel, civil society and youth organisations, teachers, students, parents and community leaders. Close collaboration with the media is also necessary to get the message across (Samuels et al. 2013; Huaynoca et al. 2014; Svanemyr, Baig, and Chandra-Mouli 2015; Chau et al. 2016).

Governments may find it helpful to strengthen civil society and youth organisations willing to promote CSE; in return, these organisations can support the ministry of education through their expertise and influential national and international connections, playing the role of technical experts and advocates (Huaynoca et al. 2014). By supporting the building of coalitions that include these civil society and youth organisations, governments could lead the way in promoting inclusive policy-making and implementation processes with all stakeholders (Samuels et al. 2013). Involvement of young people can contribute to addressing the disconnect between youth needs and the moralistic conservative approach to CSE.

Stronger and formal ongoing mechanisms for multi-sectoral collaboration between relevant ministries could support the better integration of CSE in the national curriculum and strengthen synergies among the different government agencies, leading ultimately to a better use of available resources and consistency of policies from different ministries. Governments showing leadership and openness to the needs of young people, and willingness to adjust to new realities and evolving values, may find it possible to set goals for CSE that go beyond addressing adverse consequences of sexual activity, and promote policies that are truly responding to young people’s diverse needs: protecting their rights to receive information and services free of discrimination, and giving them the tools to make safe and healthy choices regarding their sexual and reproductive lives.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This study was made possible by grants from the Dutch Ministry of Foreign Affairs and the Swedish International Development Cooperation Agency. The findings and conclusions in this article are those of the authors and do not necessarily reflect the positions and policies of the donors. Additional support was provided by the Guttmacher Center for Population Research Innovation and Dissemination (NIH grant 5 R24 HD074034).

Notes

1. See for example the CSE alliance ¡Sí podemos! in Peru, and the Campaña Nacional por la Educación Sexual in the past and currently the Mesa Nacional por la Educación Integral en Sexualidad-MENEIS in Guatemala.