Case Study Of Adolescent Reproductive Health Policy In China-Policy Process And Feasibility Of Implementation

I. BackgroundICPD identified that adolescent sexual and reproductive health (RH) needs were different from adults, and highlighted the importance and priority of adolescent sexual and RH in1994. With the advocacy by international community, many countries had made their efforts to promote adolescent RH through creating safe and supportive environment, provision of RH information and services, developing personal skills and encouraging youth participation in policy decision.Public policy is defined as’public authorities develop action plans or rules to reach certain goads under specific circumstances’. Health policy belongs to public policy. National health policy plays key guiding roles and has profound impact in promoting adolescent RH.Up to now, there hasn’t been specific national adolescent RH policy in China, and further lacked of adolescent RH policy development and implementation research. With the support from UNFPA, Chinese government implemented country project4th cycle(1998-2002) RH/family planning program adolescent RH program(called CP4ARH program), and expanded the coverage in5th cycle(2003-2005) and6th cycle (2006-2010). CP6ARH program is chosen as our policy case study. We intend to fill the gaps in terms of how actors interact with policy process under specific policy background and the extent of their participation? Whether the policy development process considers key determinants in policy implementation such as human resource, health system and service delivery? Whether policy development makes use of evidence to make policy decision more scientific? Whether there is civil society participation in policy process to make it more democratic? Whether MCH hospital is appropriate for adolescent friendly service implementation from program piloting to scaling up? Our study will provide evidence-based policy suggestion for future national specific adolescent RH policy development.Ⅱ. Research goal To analyze the development and implementation process of adolescent RH policy and to explore the determinants of the policy process by a policy case study; to investigate whether the current MCH care facilities are feasible for adolescent friendly service implementation from a larger scope and finally provide evidence-based policy suggestions.III. Research contents and methodologies1. Case study of adolescent RH policy process in China:non-random, purposive sampling was used to select15key policy informants including politician, civil society organization(CSO), policy-maker, health manager, researcher and development partner at national and program county level. Semi-structured interview was conducted until information saturation, combined with document analysis method. Policy process research framework was designed to analyze the policy development and implementation from the aspects of policy context, policy content, policy actors and policy process, with the focus on the impacts of key determinants of health system, human resource, service delivery, CSO and evidence-based policy making and their inter-relationship on policy process.2. The feasibility of adolescent RH service implementation from a larger scope in MCH hospitals:One component of CP6ARH program was adolescent friendly service. It was implemented within current maternal and child health (MCH) facilities. The previous qualitative study only reflected the result of piloting in1program county. In order to investigate the feasibility of policy implementation in a larger scope, non-random, purposive sampling was used to survey55tertiary and225secondary MCH hospitals, taking into account both stratum, region difference and research condition restriction. Health resource input model was used to evaluate the feasibility of implementing adolescent friendly service within current MCH facilities from the perspective of health financing, physical facilities, materials and equipments, human resources, Information system, youth participation, policies and guidelines.3. Gap and trend analysis of adolescent RH policy system in China:Content analysis was used to review issued policies, laws and regulations related to adolescent RH in China before Dec1st,2011(<China Law Database> of Beijing University). In-depth interview was combined to analyze the gap and trend of current policy system in terms of adolescent RH right, sexuality education, sexual and RH services and unmarried young floating population.4. Policy recommendations:Based on our research results, evidence-based policy recommendation was provided for future specific national adolescent RH policy development.IV. Main results1. Global context values adolescent RH problems; political commitment and the change in the Chinese government’s FP work emphasis; international sponsored program provides policy solutions; adolescent RH problems are prominent in China; and CSOs accumulate successful experiences in adolescent RH education and services; all these lead to finding a good entry point and the opening of policy windows that put the CP6ARH program onto the policy agenda.2. CP6adolescent RH program was initiated by UNFPA. In addition to government sections such as the ministry of commerce, the ministry of health, and China population and family planning committee, development at national level also involved expert panel, China family planning association and China youth network. Implementation at county level was responsible by county leadership group. Family planning, health system and education department all bear various responsibilities. National Coordination Committee and county leadership group were set up to ensure smooth implementation and multi-departmental coordination.3. Human resources, health system, service delivery and CSO are4key determinants existing in the policy process. These factors were considered in an integrated way through reviewing of the CP5ARH program, program leadership and regulation strategy, and M&E strategy. This ensures feasibility of smooth implementation for CP6adolescent RH program. International events and research data/pilot program report were used as evidence in policy process, therefore, the program matched international practices and reinforce the strengths and improve on the weaknesses revealed by previous ARH program. However, barriers in the implementation process had restricted the achievement of policy goals. These obstacles include:the limited participation of the education department, the unclear identification of a program budget (especially for the ARH program), problems regarding human resources, and the implementation system itself.4. Based on<Maternal and Child Health Facility Standards> from the ministry of health in1995, it required that tertiary and secondary MCH facilities should set up adolescent health care outpatient clinics. However, current situation is not optimistic. The percentage of establishing adolescent health care outpatient clinic is40.0%and11.1%among tertiary and secondary MCH facilities (P<0.01). The percentage in various regions in China is different (P<0.05). The highest is not more than25%in middle and north China region, then east China; south China and west-south China regions are close to20%; east-north and west-north regions are the lowest, being12.2%and3.6%respectively.5. Adolescent health care outpatient clinics all belong to women’s department, gynecology department, or RH department. No matter tertiary or secondary MCH facilities, they all have some common problems:service providers still use adult health care model; time is not appropriate for clients; poor advocacy and waiting for clients passively; male adolescent are excluded from services; environment is not attractive for adolescent; confidentiality is not properly protected; no enough free contraception; health education materials is not easy to reached; lack of youth participation; lack of clinical guideline; cost of service is not acceptable by adolescent; service providers’attitudes and skills need to be upgraded, etc. Most MCH facilities are not feasible for implementation of adolescent friendly services.6. Multiple linear regression shows that environment being friendly to adolescent, multiple advocacy strategies, integrated service modes and youth participation in clinic design&service provision are associated with higher average score of a MCH facility. Being involved in CP6adolescent RH program and receiving some fund support for the clinic is not sufficient enough to improve the feasibility of implementing adolescent friendly service. It confirms the result from chapter II:although international ARH program provide technical feasibility, without inspiring mechanism, adolescent friendly service is very difficult to implement. As a result, sustainability of adolescent friendly service must reply on good policy and financial support.7. Adolescent are citizens of our country. They should possess civic rights authorized by law. Though current policy and regulations contains some contents of adolescent health and development, there hasn’t been national adolescent RH rights policy.8. The Chinese government has made progress in setting up a legal framework for sex education for adolescent. However, problems such as definition of sexuality education being inconsistent between policies; policies being not operational; teachers’ knowledge and skill needs to be improved; poor teaching system; and Lack of policies on sex education for young migrants and out-of-school populations all influence the effect of policy implementation. Sexuality education policy has lagged behind society advances, and needs to be improved.9. Provision of RH/family planning services for people at childbearing age is our basic state policy. However, adolescent/unmarried youth have been excluded from this system. Their RH needs have been largely ignored in the legal framework. A governmental plan in provision of clinical services for adolescent/unmarried youth is still unclear. How to ensure their access to RH/family planning services should be the focus for future policy development.10. Being as vulnerable population, unmarried floating young people are facing more complicated RH risk compared with city residents. Although current legal framework has some articles in principle to improve RH education and services for them, what public RH services are available for them, who are responsible for implementation, how to implement and financial support are all not clear. Improving family planning basic public service equalization for floating population should ensure that unmarried youth enjoy the same RH rights as married couples.11. Adolescent RH promotion needs to be worked both from the perspectives of supportive policy environment, education and service. It’s implementation requires long term cross-sectoral cooperation. Only the barriers of government departments are broker through, can adolescent reproductive health policy achieve positive result and sustainable effect.Ⅴ. Policy suggestionsWe suggest that adolescent RH should be set up as higher priority within state public policy agenda, and our government should issue specific national adolescent reproductive health policy focusing on following aspects:1. Advocacy towards policy makers should be improved. Adolescent reproductive health should be put onto the state strategic development agenda to ensure it is embodied in policy content.2. Adolescent reproductive health rights should be highly emphasized and clearly identified in legal framework. At the same time, implementation system should be designed to ensure their access to appropriate and acceptable RH information, education and services.3. Sexuality education policy system should be improved in terms of clear identification of its strategy and goal, developing national unified teaching guideline and contents, improving teaching system, strengthening teachers’ training, establishing legal framework addressing sex education provision for young migrants and out-of-school youth, and developing&implementing an effective monitoring and evaluation system.4. Developing specific adolescent reproductive health service policy including involving adolescent reproductive health care into state basic public health services, setting up appropriate reproductive health care system for adolescent/unmarried youth, strengthening service providers’capacity and information system building, encouraging youth participation in service provision, building reputation for health facilities, developing adolescent reproductive health care guideline, and give full scope of CSO’s active roles.5. Unmarried young migrants RH needs should be paid attention to. Government should clearly identify related departments’ responsibilities and functions. Department of health care, family planning system, labor and social security and other departments should cooperate to establish better education and service system for them.6. The government should develop law and regulations to ensure youth participation in policy decision from strategic and long term perspective.7. Improve virtuous interaction between CSOs and government. Our government should authorize more functions to CSOs and direct them from ’passive participation’ to ’active participation’, and further’institutional participation’. For those independent CSOs, government should provide financial and technical support. CSOs should enhance organization consummation and capacity building, make full use of their advantages, and actively interact with policy process in order to propose their own interest and policy suggestion. 8. National Working Committee on Children and Women should take the leading role to promote collaboration between government departments, CSOs and government so as to create supportive environment for promoting adolescent RH.