Scaling up, sustaining and enhancing school-based sexuality education

About the subject of my thesis

Sexuality education aims to improve knowledge and understanding. It aims to promote healthy and prosocial attitudes and norms. It aims to build social skills. Its overall aim is to prepare children and adolescents for the choices they will need to make and act on in their sexual and reproductive lives – healthy lives, but also satisfying and happy lives.

There is sound evidence that well-designed and well-delivered sexuality education can contribute to promoting the sexual and reproductive health of children and adolescents, and also that it does not harm them. There is also sound evidence that children and adolescents need sexuality education. They also have a right to it.

With steadily rising numbers of children entering school and completing the mandatory required years of schooling, schools are a very important setting to reach them with sexuality education. There are concerted efforts under way to support schools formulate sound policies to enable and guide school-based sexuality education, and to translate them into effective programmes, fully integrated into the education system. There are complementary efforts to reach school-age children and adolescents who are not in schools with sexuality education outside the school setting.

A growing number of countries have such policies in place. But in many countries, there is huge policy-execution gap. In a number of countries, school-based sexuality education programmes are not implemented or only being nominally implemented. There is a considerable body of literature on the poor state of such programmes and the factors that have contributed to this. I did not set out to add to this.

The focus of my thesis is on countries – or in some cases, states or provinces - that deviated from this norm. They have scaled up, sustained and enhanced sexuality education programmes when others in similar situations have not. I have used the term positive deviant countries for them.

What problem did we set out to study ?

• Children and adolescents need and have a right to sexuality education (SE)
• There is convincing evidence from research studies and project evaluations that SE can prepare children for a healthy and happy sexual and reproductive life, and that it does not lead to early, increased or more risky sexual activity.
• In most low-and-middle-income countries, a large and growing proportion of children and adolescents are in school and could be reached with SE programmes.
• Policies to provide SE in schools are in place in many countries, but there is a big gap between policy and execution. There is considerable knowledge and understanding of the factors that hinder the provision of school-based and community-based SE.
• A small number of countries have scaled up, sustained, and enhanced their school-based SE programmes. But how they did this - when so many countries in similar situations - have not, is not clear.

(Note: Although this is my thesis, it builds on over a decade of work in the UNDP, UNICEF, UNFPA, WHO, WB cosponsored Human Reproduction Programme, which is housed in WHO).

What did we set out to do ?

• To identify low- and middle-income countries (LMICs) that have scaled up and sustained nation-wide school-based SE programmes
• To identify factors that enabled these countries to place the nationwide scale-up of SE on their political agendas
• To identify factors that enabled these countries to implement their policies and strategies, and to scale up, sustain and enhance their SE programmes over time.

How did we do this ?

Learning from studies outside the adolescent sexual and reproductive health and rights field

• We learned how LMICs around the world had scaled up health problems other than in adolescent health. Why ? Because large-scale government led adolescent health programmes in low-and-middle-income countries are a relative new phenomenon.
• We learned from the documentation/evaluation of these programmes, what aspects of the scale up effort they studied, and methods and tools they used ?
  Why ? Because different aspects of scale up have been studied and different methods and tools have been used.

Studying the SE field

• We identified countries that had potentially scaled up SE.
  Why ? Because the list of countries that have done so is not available.

• We studied four different aspects of the scale up of sexuality education using validated checklists and frameworks:

• whether SE had been scaled up and sustained
• how SE was put on national governmental agendas
• how the SE effort was planned and managed
• how support for SE was built and resistance was overcome
  Why? These are the questions the governmental planners and programmers, and organizations that support them want to know.
  
  

What did we learn ?

Yes there are.
We identified the following countries in three world regions.

Sub-Saharan Africa: Nigeria, Senegal
South-Asia: India, Pakistan
Latin America: Mexico, Uruguay

There may well be others.

They achieved nation-wide or substantial sub-national coverage, sustained their programmes for at least three years, and demonstrated some programme results at the programmatic outputs and individual outcome levels.

• Direct transnational influences (especially effective when combined with technical and financial support)
• Domestic advocacy (with overt or covert partnership with external partners)
• In some places, political windows of opportunity emerged and were used.
• Positive deviant countries used available opportunities or created new ones to place CSE scale up on the national agend

They planned the scale up effort meticulously

• They defined what specifically would be scaled up (the innovation), who would be responsible for supporting the scale up effort (resource organization) and who would be responsible for delivering SE (the user organization).
• They did this planning with an intimate knowledge and understanding of the environment they were working in (environment).

They managed the scale up effort actively

• They secured resources - human, material and financial for it; advocated for it; tracked how it was doing and actively worked to keep implementation on track through problem solving and action planning

They used data and implementation experiences to inform the scale up effort

• They used their own learning and that of others to enhance their programmes.

They worked to promote and safeguard sustainability

• In both planning and managing the scale up effort, a key consideration was linking and integrating efforts into existing policy and strategy frameworks, workplans and budgets, and delivery systems.

They worked hard to deepen and extend support.

• They built acceptance/concurrence on how to name their SE programme, who to target, and what content to include. In doing they made compromises.
• They reached out to various stakeholders, especially targeting those who were neither supporters or opposers.

They learned to anticipate and to respond to resistance
Despite this all faced opposition from decision makers or the community at large.

• They learned to move from being reactive only to being proactive.
• They learned to prepare for, anticipate and respond calmly and purposefully.

While there were some innovations, the approaches used by positive deviant countries were largely not new. Positive deviant countries scaled up, sustained and enhanced SE progammes doggedly and cleverly using approaches available to all.

What are our conclusions?

Research conclusion: Studying how countries secured support for scaling up, sustaining and enhancing SE, and how they have actually done it in their respective contexts, provides useful lessons that could be applied elsewhere.

Research conclusion: Currently policy and programmatic guidance draw primarily from experimental & quasi experimental studies. Properly developed case studies of projects and programmes in the real-world contexts can complement the findings of such studies & evaluations, and thereby enrich the guidance.

Research conclusion: In every country studied, the impetus for the effort to scale up, sustain and enhance SE programmes came from civil society bodies who were deeply immersed in SE. They learned by doing & from others (including those within & outside their countries) as & when needed, & grew and developed in expertise, confidence and ability to move the agenda in the process.