A comparative human rights analysis of laws and policies for adolescent contraception in Uganda and Kenya

Background: Improving access to adolescent contraception information and services is essential to reduce unplanned adolescent pregnancies and maternal mortality in Uganda and Kenya, and attain the SDGs on health and gender equality. This research studies to what degree national laws and policies for adolescent contraception in Uganda and Kenya are consistent with WHO standards and human rights law. Methods: This is a comparative content analysis of law and policy documents in force between 2010 and 2018 governing adolescent (age 10–19 years) contraception. Between and within country differences were analysed using WHO’s guidelines “Ensuring human rights in the provision of contraceptive information and services”. Results: Of the 93 laws and policies screened, 26 documents were included (13 policies in Uganda, 13 policies in Kenya). Ugandan policies include a median of 1 WHO recommendation for adolescent contraception per policy (range 0–4) that most frequently concerns contraception accessibility. Ugandan policies have 6/9 WHO recommendations (14/24 sub-recommendations) and miss entirely WHO’s recommendations for adolescent contraception availability, quality, and accountability. On the other hand, most Kenyan policies consistently address multiple WHO recommendations (median 2 recommendations/policy, range 0–6), most frequently for contraception availability and accessibility for adolescents. Kenyan policies cover 8/9 WHO recommendations (16/24 sub-recommendations) except for accountability. Conclusions: The current policy landscapes for adolescent contraception in Uganda and Kenya include important references to human rights and evidence-based practice (in WHO’s recommendations); however, there is still room for improvement. Aligning national laws and policies with WHO’s recommendations on contraceptive information and services for adolescents may support interventions to improve health outcomes, provided these frameworks are effectively implemented. This article aims to assess to what degree national laws and policies for adolescent contraception (2010–2018) in Uganda and Kenya are consistent with the global standards in the WHO’s guidance. This study is a comparative content analysis of legislation and policy documents governing any aspect of adolescent contraception at the national level in Uganda and Kenya. As has been described in previous studies, we defined policy as principles or strategies for a plan of action designed to achieve a particular set of goals, including through guidelines, plans, and standards [22]. During the period 2010–2018 accelerated global efforts were undertaken to improve girls’ and women’s health, starting with the United Nations (UN) Secretary-General’s Commission on Life-Saving Commodities (UNCOLSC, 2010) for Women and Children was set up [23] and in 2015, the UN Global Strategy for Women’s and Children’s and Adolescents’ Health (UNGS WCAH, 2016–2030) was published [24]. A cut-off of 2018 was selected in order to catch the initial implementation of the UNGS WCAH. An online search (conducted in May 2019 and repeated in March 2021) identified relevant laws and policies that were in force between 2010 to 2018 through national government websites and legal databases (i.e. Uganda Legal Information Institute https://ulii.org/consol_leglist/consolidated_legislation, Kenya Law http://kenyalaw.org/kl/index.php?id=400, Kenyan Health Guidelines, Standards & Policies Portal http://guidelines.health.go.ke, Ugandan Ministry of Health Knowledge Management Portal http://library.health.go.ug, International Labour Organisation NATLEX), reference lists in relevant academic commentary and publications, a Google search using the search syntax “((adolescent OR sexual OR Reproductive) health) AND (law or policy OR policies) AND Uganda/Kenya”, and through crowdsourcing documents from our network. Documents were selected for inclusion in three stages (See flow diagram in Fig. 1). First, legal, strategic, and policy documents addressing subjects related to adolescent health, SRH, and/or contraception were collected for further screening (See Additional file 1 for a complete list of these documents). Second, we applied the following two inclusion criteria: (1) document is legal, strategic, or policy-related; and (2) the document was in force between 2010 and 2018. We determined whether the document was in force by the term stated explicitly in the document or in a superseding document, the status of the document on a government website, or, in the absence of other available information, by assuming that policy documents have a lifespan of 10 years. Documents were excluded if they did not meet the inclusion criteria or if no full text was available. Third, we scanned the full text to identify any explicit content related to the recommendations in WHO’s guidance document called “Ensuring human rights in the provision of contraceptive information and services” (‘WHO recommendations’). This resulted in a short list of documents that underwent content analysis (see Table ​Table1)1) [15]. Finally, local policy experts (DK, DKA, JO, TSG) verified whether the shortlist of documents was accurate, complete, and up-to-date, and suggested other documents for consideration. Experts were co-authors (DK, Executive Director of a Ugandan health policy NGO; JO, Kenyan academic expert in gender policy) and project advisors (DKA, TSG—both are health lawyers with track records representing Ugandan and Kenyan NGOs (respectively) with a strong focus on SRH and rights) who have extensively engaged with SRH policies in their respective countries. Flow diagram of the selection and inclusion of laws and policies in this study Ugandan and Kenyan laws and policies (in force between 2010 and 2018) included in content analysis A list of all documents reviewed for this study can be found in Additional file 1 AIDS acquired immunodeficiency syndrome, AYF adolescent- and youth-friendly, HIV  human immunodeficiency virus, SRH  sexual and reproductive health *In these cases the policy’s explicit timeframe had lapsed yet the Ministry of Health still listed the document as ‘current’ ^When not explicitly stated in the policy, we assume policies have a 10-year lifespan Three researchers (EW, CP, KP) were responsible for coding the documents and the data extraction. A pre-defined coding strategy and data extraction sheet was used, which was pre-tested by these researchers on legal and policy documents from South Africa. During analysis the included documents were screened for content relating to adolescents, and excerpts were classified by two independent researchers (a medical doctor (CP) and, a health scientist (EW) both trained in health policy, and a health scientist trained in law (KP)) using WHO’s nine recommendations and 24 sub-recommendations, which served as a coding matrix. See Table ​Table22 for an overview of these recommendations. Overview of the current Ugandan and Kenyan policy landscape for adolescent contraception according to the nine WHO recommendations 9.2 Recommended that evaluation and monitoring of all programmes to ensure the highest quality of services and respect for human rights must occur Recommend that, in settings where PBF occurs, a system of checks and balances should be in place, including assurance of non-coercion and protection of human rights. If PBF occurs, research should be conducted to evaluate its effectiveness and its impact on clients in terms of increasing availability AC  adolescent contraception, C  contraception in general, LARC  long-acting reversible contraception, PBS  performance-based financing Researchers used the coding matrix that scored the content based on references to: (1) adolescent contraception, or (2) contraception in general (not specifically related to adolescents). Discrepancies were deliberated until consensus was reached. The coding results were reviewed by two experts (DK, JO) with first-hand knowledge of the local policy context. Three researchers (KP, CP, EW) investigated between and within country trends. The between-country analysis examined the similarities and differences in the overall legal and policy frameworks that are currently in force. The within-country descriptive analysis examined the evolution in the adolescent-related content of relevant laws and policies in force in both countries between 2000 and 2018. A stakeholder validation meeting was held at the Ugandan Ministry of Health (MoH) on December 6th, 2019 to discuss the preliminary findings. Due to the Coronavirus pandemic a comparable stakeholder validation meeting in Kenya was not possible.