This documentation will:
a) Outline the process, strategic framework and evidence used to arrive at the national AH strategy in Belize;
b) Describe the results from the strategic planning process and the implications for adolescent health programming in Belize;
c) Discuss the key success factors and lessons learned from the process in Belize. The document will not answer the question “why” but “how”.
1. Background
In 2018, as a major contribution to Belize’s development priorities delineated in the Belize 2016-2019 Growth and Sustainable Development Strategy (GSDS), in Horizon 2030, and in the United Nations Multi-Country Sustainable Development Framework (UN MSDF) “Healthy Caribbean” pillar, together with UNFPA and Pan American Health Organization (PAHO), UNICEF supported the Ministry of Health (MOH) for the development of the National Adolescent Health Strategic Plan (2019-2030). It is against this backdrop and within the context of the Government of Belize (GoB)’s international and national commitment as well as its national policies and strategies, inter alia the UN Convention on the Rights of the Child (UNCRC), PAHO/WHO Plan of Action for Women's, Children's and Adolescents' Health (2018-2030), Every Woman, Every Child, Every Adolescent Strategy (EWECEA), Belize Children’s Agenda 2030, that the Government of Belize under the leadership of the MOH with oversight from the Adolescent Health - Technical Working Group (AH-TWG) and support from UNICEF and other partner agencies commissioned the development of the Adolescent Health Strategic Plan (2019-2030).
Belize is among the first countries globally to adopt the global guidance Accelerating Action for Health of Adolescents (AA-HA!). In 2017, UNICEF, UNFPA and Belize Family Life Association (BFLA) participated in a Regional Adolescent Health workshop for the Caribbean. Prior to the meeting, the delegation met with CEO of the MOH to brief and prepare for participation. The preparatory meeting discussed the MOH vision to strengthen adolescent health, identified priority issues to highlight in the meeting and agreed on steps for follow- up. Based on the AA-HA! Guidance, UNICEF and partner agencies, supported the government and defined a national roadmap outlining steps that can be taken. (Fig 1)
2. Key Process
There is no ideal, one-size-fits-all package of adolescent health programme and services to meet the needs of every country. The AA-HA! Guidance suggested to evaluate adolescent health needs before developing the adolescent health programme. This involves three key steps: needs assessment, landscape analysis and setting priorities. (Fig 2)
The AH-TWG completed a comprehensive needs assessment and review of data to define key threats to adolescent health, followed by a landscape analysis and evidence-informed prioritization of interventions for a strategic programme response. In November 2018, two national and four sub-national consultations with 233 adolescents and service providers (duty bearers) were conducted to allow the opportunity for inputs from adolescents and service providers. At both national and sub-national levels the inputs were taken into consideration for the development of the national strategic plan. In January 2019, a three-day workshop on Validation of Adolescent Health Strategic Plan and Provisions (service packages) and a one-day Adolescent Health Provisions Workshop completed the draft adolescent health strategic plan.
3. Results
Adolescent Health Situational Analysis (SitAn), National Adolescent Health Strategic Plan, are the two major outputs. (Fig 3)
3.1 Adolescent Health Situational Analysis
The adolescent health Needs Assessment and Landscape Analysis following the AA-HA! Guidance complements the Adolescent Health Situational Analysis (SitAn). The needs assessment identified conditions that have the greatest impact on adolescent health and development. The landscape analysis considered existing adolescent health programmes, policies, legislation, capacity and available resources. All of these juxtaposed against an understanding of local and global evidence-based interventions, i.e. gap analysis of what exists against what needs to be in place for adolescent health. The AH-SitAn is a compilation of AH indicators and data obtained from census, household surveys, academic journal articles, and other type of data, e.g. OpenEMIS, the Belize Health Information System (BHIS). The SitAn allowed an objective prioritization of issues affecting adolescents in Belize. Two national consultations with adolescents and service providers identified priority issues affecting adolescents’ health and wellbeing in Belize as the following: 1. Positive Health and Development; 2. Violence and Injury; 3. Sexual & Reproductive Health; and 4. Mental Health, Substance Use and Self Harm.
3.2 National Adolescent Health Strategic Plan
Based on the needs assessment, landscape analysis and priority setting with inputs from adolescents and stakeholders (national and district consultations), the AH-TWG defined fifteen key provisions for adolescents and the strategies for successful implementation of the plan (Fig 4). The provisions for adolescents are based on a human rights and life cycle approach. The provisions are not based on the local capacity of the state and service providers, rather on the rights and needs of adolescents to be fulfilled. The expected adolescent health outcomes reflected in key provisions will help them thrive and survive in a transformative environment in which they can realize their right to enjoy the highest attainable well-being.
The four strategies to achieve the vision and mission are institutional strengthening, service coverage and quality, monitoring and evaluation and advocacy and social mobilization. (Fig 5) Revisiting the plan every four years will ensure its continued relevance and implementation in a rapidly changing world. The vision, mission, adolescent health outcomes, the four strategies and a logical framework of the strategic plan were validated by the service providers and key stakeholders.
4. Highlights:
4.1 Adolescent participation at national and sub-national level
The approach gives a prominent voice to adolescents and ensures their effective participation in developing the national adolescent health strategic plan. Adolescents in Belize were given the opportunity to influence decisions during the development of the adolescent health strategic plan. In their own words they were able to match the priority listing of issues affecting them as done by service providers. Their involvement throughout the process allows decision-makers to tap into adolescents’ unique perspectives, knowledge and experiences, which brings a better understanding of their needs crafting the provisions for adolescents. Adolescents provided expertise through a range of distinctive adolescent participation approaches:
Adolescents in the AH-TWG: Adolescent representatives were included in the AH-TWG and were involved in each step of the design and implementation process. The process put adolescents in the driver’s seat.
Adolescents are given opportunities to identify key issues affecting them through national consultations: 55 adolescents participated in the national consultation, followed a methodology of step-by step-process. The Bronfenbrenner social ecological model (Fig 6), was used for the identification of issues affecting adolescents. This served as input for the prioritization of adolescent health issues. (Fig 7)
Adolescents themselves identified in order of importance the following issues: poverty, drug abuse, teen pregnancy, sexuality education, bullying, and mental health. Drawing on adolescents’ inputs and suggestions from service providers, the AH-TWG defined the four thematic areas to be addressed, based on their contribution to health and wellbeing of adolescents in Belize: 1. Positive Health and Development; 2. Violence, Accidents and Injury; 3. Sexual & Reproductive Health; and 4. Mental Health, Substance Use and Self Harm. (Fig 7)
Adolescent facilitated the national consultation: Trained by UNICEF, MOH and Department of Youth Services (DYS), adolescents facilitated the first national consultation. The reason for adolescents to facilitate the consultation session is that younger adolescents may not feel comfortable discussing potentially sensitive personal issues, such as sexual and reproductive health (SRH) and mental health, with adults.
Adolescents proposed services and programmes through the 2nd national consultation and 4 district consultations: To reflect different profiles at district level and get buy-in from adolescents and service providers at the sub-national level, UNICEF Belize provided both financial and technical support to Ministry of Health and DYS in engaging adolescents and service providers at sub-national level through four district consultations (Punta Gorda, Cayo, Orange Walk and Dangriga districts) with 178 adolescents and service providers. (Fig 8)
Adolescents were convened through the DYS for the national and district consultations. Adolescents from six districts, male and female, 10-14 and 15-19, in school and out of school, and representing the different ethnic groups participated in the first national consultation. This session facilitated by adolescents yielded adolescents meaningful participation. At district level, adolescents were given opportunity to speak on the issues affecting them and their comments as a mean to validate the draft thematic areas, key strategies, and identified priority programmes and services under each theme. (Fig 9)
4.2 Interagency collaboration
The development process is underpinned by a consultative and participatory process which actively engages key stakeholders and enabled a systematic collaborative effort to commit to strengthening adolescent health service delivery. The landscape analysis portrays the need for increased collaboration. The inter-agency collaboration is shown by sharing the responsibility of the development of the plan in collaboration with government and non-government service providers. Three-line ministries worked together namely the MOH, Ministry of Education, Youth, Sports and Culture (MOEYSC) and its DYS, and Ministry of Human Development, Social Transformation and Poverty Alleviation (MHD). Other key stakeholders were engaged in the design and planning stage. In January 2018, a stakeholder meeting introduced the AA-HA! Guidance to the stakeholders and identified organizations for establishment of an AH-TWG, including officials from MOH, and adolescent representatives. The AH-TWG supports implementation of the roadmap towards an Adolescent Health National Strategic Plan. The process of needs assessment and landscape analysis increased AH-TWG’ awareness and understanding of the extent of the issues affecting adolescent health.
4.3 Multi-sectoral collaboration
The health of adolescents is itself dependent on many factors reaching far beyond the health sector. Improving adolescent health hence, requires an understanding of the underlying determinants or drivers and threats to adolescent health. Strong multi-sectoral collaboration and broad adolescent engagement and community support for social and behavioural change is required. The focus of the strategic plan is on prevention and innovative strategies targeting adolescents that are largely not going to be seen in health facilities. In June 2017, Belize launched a national Children’s Agenda, which serves as a multi-sectoral framework for accountability for action for health, protection and development of children and adolescents. The adolescent health national strategic plan follows a similar framework.
Shared vision, mission, expected outcome and agreed provisions: The Strategic Plan provides a platform through which stakeholders agree on strategic directions and priorities for adolescents for the short and medium term. Adolescent Health Strategic Plan Development and Validation Workshop with service providers, identified multi-sector opportunities for collaboration and integration of the similar type of services into 15 provisions. Multi-sector collaboration was ensured through shared vision, mission, expected outcomes and agreed provisions for improving adolescent health. (Fig 4 & 5)
Life-course approach: Similar with the Belize Early Childhood Development (ECD) National Strategic Plan, the AH strategic plan is based on a right-based and life cycle approach with adolescents at the center and its designed is based on provisions for adolescents, therefore it requires strong collaboration among implementing agencies. (Fig 10) In January 2019, the three-day workshop on Validation of Adolescent Health Strategic Plan with implementing agencies identified how services can be delivered to adolescents.
Stakeholders are engaged throughout the process: Relevant stakeholders from multiple agencies participated in the entire development process: they reaffirmed their commitment towards improving adolescent health at the national and district consultations, workshops and meetings.
4.4 Centrality of data and the use of evidence to guide priority setting
Data disaggregation for adolescents aged 10-14 and 15-19: The needs assessment ensured the national strategic plan is built on available data as well as reported data. Comprehensive assessment of available data resulted in a situational analysis (SitAn) of adolescent boys and girls, highlighting specific health priorities for each district, based on the disaggregated data by geographic locations.
Adolescent health fact sheets to facilitate discussions: Existing data on key indicators were disaggregated by age group 10-14 and 15-19 and district and other characteristics. The disaggregated data were summarized in 8 adolescent health fact sheets, and used in the strategic analysis and planning process sessions.
Adolescent Health Matrix for programme data entry and analysis: An adolescent health matrix based on the AA-HA! Guidance was developed and used for data entry and supported documentation of the process, assumptions and justifications for the strategic planning process.
Use of technology to collect data from adolescents: A U-Report poll and a Facebook survey enabled wider consultations with adolescents throughout the country. Three rapid online polls collected data via Facebook in November 2017. Each poll received between 20 and 28 responses on the priority issues to improve health and wellbeing of adolescents in Belize. In July 2018, a U-Report poll collected data on the issues affecting adolescents and the approach that works for adolescents to get engaged.
5. Next Steps:
5.1 Adolescent Health Operational Plan (2019-2022)
The Adolescent Health National Strategic Plan will be implemented in three phases over a period of 12 years. (Fig 11). The operational plan will be developed every four years: 2019-2022, 2023-2026 and 2027-2030. the proposed inputs and outputs of each operational plan will be costed. The interventions will be targeted by age group and by territory based on data available. One of the responsibility of the AH-TWG is the development of a project portfolio for successful implementation of the AH Operational Plan. Each Operational Plan is expected to have its respective M&E plan for tracking progress and planned evaluations. This will be a multi-sector collaboration effort to be completed every four years to ensure its relevance and implementation in a rapidly changing world.
5.2 An Investment Case for Adolescent Health
The three-line ministries (MOH-MHD-MOEYSC) have the responsibility to translate government policy goals into budget allocations for improving adolescent health. UNICEF and the Ministry of Health held a Webinar with the Futures Institute (Now “Avenir Health”) in January 2019. The OneHealth Tool was introduced and will be used to estimate resource needs for the implementation of the priority package of interventions and associated programme costs.
6. Limitations and Lessons learned:
Adaptation of the AA-HA! Guidance: The value of the AA-HA! guidance was the sensitization of the stakeholders involved in the needs assessment and landscape analysis to comprehend the extent of the concept of adolescent health, the situation and gaps in adolescent health in Belize. It helped the team to walk the walk of adolescents, contributing to greater commitment to adolescent health.
Adolescent participation: There are unforeseen factors which may affect the number of participants to planned consultations. For example, conflict with the school schedules, lack of support from administrative staff at a few schools, competing school-based activities and clash with major public holidays. When inviting students, the MOEYSC should lead it.
Use of data: Prevalence data on issues affecting adolescent health is not readily available. The health data in the majority of cases represents the situation of those with access to services, whilst we work towards achieving the provisions for adolescents, prevalence data is key for decision making. Prevalence data on mental health is absent hence the magnitude and severity of mental health issues among adolescents is unknown.
Multi-sectoral collaboration: Addressing the adolescent health needs in the form of provisions, allows for long term planning, it keeps the adolescent at the center of the strategic plan and fosters strong collaboration among implementing partners. It is based on the rights of adolescents. The dedication and commitment of the AH-TWG in being present and effectively contributing to the implementation of the designed process.
Ownership within the government: UNICEF together with UNFPA and PAHO have actively contributed to ensure the Ministry of Health has the ownership for the development of the AH national strategic plan. This led to many results: 1) the development process was moving forward smoothly because it was led and owned by the Ministry of Health; 2) Formal outreach by the Ministry of Health to other ministries and other stakeholders ensured the multi-sectoral nature of the extended working group and that the contents and priorities of the strategy will be multi-sectoral.
