SRHM – Adolescent sexual and reproductive health and universal health coverage: a comparative policy and legal analysis of Ethiopia, Malawi and Zambia

by Godfrey Kangaude, Ernestina Coast, Tamara Fetters

Sexual & Reproductive Health Matters 30 Oct 2020;28(2)  DOI: 10.1080/26410397.2020.1832291


Universal Health Coverage (UHC) forces governments to consider not only how services will be provided – but which services – and to whom, when, where, how and at what cost. This paper considers the implications for achieving UHC through the lens of abortion-related care for adolescents. Our comparative study design includes three countries purposively selected to represent varying levels of restriction on access to abortion: Ethiopia (abortion is legal and services implemented); Zambia (legal, complex services with numerous barriers to implementation and provision of information); Malawi (legally highly restricted). Our policy and legal analyses are supplemented by comparative vignettes based on interviews (n = 330) in 2018/2019 with adolescents aged 10–19 who have sought abortion-related care in each country. We focus on an under-considered but critical legal framing for adolescents – the age of consent. We compare legal and political commitments to advancing adolescent sexual and reproductive health and rights, including abortion-related care. Ethiopia appears to approach UHC for safe abortion care, and the legal provision for under 18-year-olds appears to be critical. In Malawi, the most restrictive legal environment for abortion, little progress appears to have been made towards UHC for adolescents. In Zambia, despite longstanding legal provision for safe abortion on a wide range of grounds, the limited services combined with low levels of knowledge of the law mean that the combined rights and technical agenda of UHC have not yet been realised. Our comparative analyses showing how policies and laws are framed have critical implications for equity and justice.

All three countries have young population age structures with more than 40% of the population aged below 15 years and less than half of sexually active unmarried women aged 20–24 currently using modern contraceptives. Malawi is the poorest of the three countries and has the highest poverty ratio.

All three countries are normatively conservative with respect to sexual practices of unmarried adolescents, reflected in the reluctance of parents and health providers to support adolescent contraceptive use. In addition to limited services, adolescent use is constrained in all three countries by concerns including confidentiality, provider biases, and low levels of knowledge.