Multisectoral Programming for Adolescent Health and Well-being in Sub-Saharan Africa-Insights From a Symposium Hosted by UNICEF and the Bill & Melinda Gates Foundation.

Recognizing that the physical, mental, and social well-being of adolescents is influenced by interrelated social, environmental, and economic factors, there is growing consensus globally on the need for programming that works across sectors to achieve broad and sustained adolescent health and well-being outcomes [[1], [2], [3]]. In May 2019, the United Nations Children's Fund (UNICEF) and the Bill & Melinda Gates Foundation (BMGF) convened a symposium on intentional multisectoral programming to advance adolescent health and well-being in sub-Saharan Africa, where adolescents aged 10–19 years comprise 23% of the population [4]. Participants included representatives from BMGF, 13 UNICEF country offices, UNICEF West and Central Africa and East and Southern Africa regional offices, UNICEF headquarters, other UN agencies and development partners, government representatives, and youth leaders from five African countries. Here, we present findings from this symposium.

Despite a recognition that multisectoral collaboration can contribute broadly to increased access to and more efficient use of resources, enhanced accountability and a sense of collective ownership, knowledge- and responsibility-sharing, and programs that efficiently leverage unique capacities [5], the evidence regarding the impact of multisectoral programming on adolescent health and well-being outcomes is quite limited. In a recent British Medical Journal (BMJ) series on multisectoral collaboration in maternal, child, and adolescent health, for example, only two of the 12 case studies focused on adolescent health [6].

While multisectoral collaboration has the potential to be both effective and cost-effective, it can be more complex to implement than sectoral approaches. Its challenges (which are not exclusive to adolescent health and well-being) may include a lack of political will; changes in political leadership; insufficient resources; poor management, coordination, and communication; and an inability or failure to identify benefits across sectors [7,8]. Imbalances of power, divergent institutional cultures, and conflicting interests between sectors may lead to difficulties, including in agreeing on monitoring mechanisms and data sharing. Assessing and attributing the unique contribution of each sector—often needed for donor reporting—is also a challenge [9].

Participants of the symposium illuminated shared challenges from their own programmatic experience. These included a lack of accountability or governance in multisectoral response, insufficient support for scaling and sustaining multisectoral programs, difficulties in identifying the right platforms to deliver multisectoral programs, and an inability to reach the most disadvantaged young people, as well as to ensuring the meaningful engagement of young people. These challenges were further complicated by a lack of global consensus on definitions of multisectoral action, as well as complexities faced by governments in applying international standards for adolescent health and well-being to their respective contexts.

Despite these challenges, however, there is good reason to believe in the potential for success. Previous studies of women's and children's health, family planning, nutrition and HIV have found improved quality of care, increased service use, and, in some cases, increased cost-effectiveness and better health outcomes resulting from multisectoral programming [6,10]. This evidence, as well as logic, suggests that approaches that engage different sectors and stakeholders collectively are likely better able to tackle the varied determinants of adolescent health and well-being through leveraging different expertise, knowledge, skills, and resources. [11].

Several programs in sub-Saharan Africa, including Geração Biz in Mozambique, [12] the Adolescent Girls Initiative in Kenya (AGI-K), and the Zomba cash transfer study in Malawi [13], for example, are well-evaluated multisectoral adolescent-focused programs that offer helpful lessons for those seeking to design and implement similar programs. The successes of these programs can be attributed, in part, to strategies for successful multisectoral collaboration, including a shared understanding of interests of diverse stakeholders and open communication [6].

But findings from these and other studies also suggest that multisectoral interventions will not be successful unless they address the context-specific gender and social norms that underlie the drivers of harmful health outcomes for both adolescent girls and boys. Several new multisectoral initiatives aimed at understanding and improving adolescent health and well-being, including with a gender lens, are currently underway. These include efforts such as the UNICEF and UNFPA (UN Population Fund) Global Programme to Accelerate Action to End Child Marriage, the UNICEF and World Health Organization (WHO) Helping Adolescents Thrive Initiative, UNICEF's Human Papillomavirus Virus (HPV) + Project, and the UNICEF-AstraZeneca Global Program for Youth-led Prevention of Non-communicable Diseases. They also include BMGF-supported projects, such as Act with Her, implemented by Pathfinder International; Inspiring Married Adolescent Girls to Imagine New Empowered Futures (IMAGINE) and Abdiboru, both implemented by CARE; and the President's Emergency Plan for AIDS Relief (PEPFAR) DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) program, for which BMGF is supporting the evaluation.

The UNICEF-BMGF symposium recommended learning and action in several areas. First, focused research is needed on which service packages work best for which populations of adolescents, and on how diverse financing mechanisms can better facilitate multisectoral approaches to advance adolescent health and well-being. Second, more intentional efforts to build capacity for multisectoral leadership, as well as to manage power dynamics and achieve buy-in across sectors, were deemed fundamental to strengthening accountability for action. Finally, underpinning all efforts to improve quality of care, program effectiveness, and equity is a need to meaningfully engage adolescents and youth, including those who are difficult to reach. This requires the involvement of young people in the design, implementation, monitoring, and evaluation of programs and policies that impact them, which itself may demand innovative ways to ensure such engagement, including through targeted capacity building. (See this UNICEF video for an example of how young people want to engage.)

Looking forward, UNICEF and BMGF seek to leverage their comparative advantage for promoting multisectoral work that will benefit large numbers of adolescents around the world. Specifically, BMGF is supporting the generation of evidence around multisectoral programming, and UNICEF is looking to use its influence at the country level to scale up such programming in sustainable ways. Together, the two entities are working to advance measurement of adolescent health and well-being, cutting across the health, education and social protection sectors.

Improving adolescent health and well-being outcomes through multisectoral programming requires action beyond that which any single organization or institution can achieve. BMGF and UNICEF thus encourage others, including their own partners, to work across sectors, to generate and use evidence to inform effective multisectoral programming, and to foster and sustain true and meaningful partnerships with adolescents and youth.