“From birth, from almost from cradle to grave, girls have been seen as some sort of baggage,” said Shamsa Suleiman, Project Management Specialist for Gender and Youth at the U.S. Agency for International Development (USAID), Tanzania. Suleiman spoke at a recent Wilson Center event with USAID MOMENTUM Country and Global Leadership about balancing power dynamics to achieve equity for all women and children in maternal, child, and adolescent health, and family planning. Home should be a safe space, said Suleiman. But for many girls, it no longer is. To escape the poverty and pressures at home, including early marriage and other forms of gender-based violence, some girls leave, said Suleiman. “Girls are trying to escape the safe spaces.”

Reaching Zero-dose Children

Vaccination or immunization has been described as the most cost-effective and life-effective endeavor of the 20th century, said Dr. Dure Samin Akram, Honorary Chairperson and Founding Member of the Health Education Literacy Programme in Pakistan. Each year, vaccines save 2 to 3 million children from preventable diseases, yet there are great barriers to receiving vaccines in many parts of the world. Worldwide, there are close to 10 million zero-dose children  who have not received even one dose of a diphtheria-tetanus-pertussis-containing (DTP) vaccine and are deprived of protection against vaccine-preventable diseases. One-third of zero-dose children are concentrated in only six countries, and 8 percent of zero-dose children worldwide are concentrated in Pakistan, where Dr. Akram works. Most of these children live in “missed communities,” which she said could be rural settlements, conflict zones, urban slums, or other hard-to-reach areas. These communities face extreme poverty, lack access to health care, and suffer high mortality rates, said Dr. Akram.

During COVID-19 lockdowns, immunization rates fell due to lack of access to vaccination centers. Many children already miss their vaccines, because restrictions on the movement of women in Pakistan prevent their mothers from taking them to vaccine clinics, said Dr. Akram. To work around gender norms that prevent children from receiving vaccines, the government is opening vaccine clinics later in the day so men can accompany their wives to the clinics after work. The government is also increasing home vaccination programs to better serve communities. To reach zero-dose children and to reach missed communities, we have to partner with others who are doing similar work, such as community health workers, and have a sustained, enhanced, outreach program for immunization, said Dr. Akram. Collaboration between government and non-governmental and civil society organizations is key to progress, because these organizations work across levels and are often “the voice of the voiceless and the face of the faceless,” said Dr. Akram.

Access to Family Planning

In Sierra Leone, adolescents face extreme barriers to reproductive health care and family planning access. Over 80 percent of girls ages 15 to 19 have never used contraception and by age 19, 30 percent of girls will have given birth, said Marian Pleasant Kargbo, Family Planning 2030 Youth Focal Point in Sierra Leone. Often, adolescents lack knowledge about how to access health centers for contraception and care. They may also be burdened by lack of transportation and the high costs of contraception at these health facilities. Widespread misinformation about the use of contraceptives, including falsehoods that they cause cancer and infertility, said Kargbo, also pose a challenge.

A major problem within health systems in Sierra Leone is that youth are not included in designing, implementing, and evaluating the government health services, programs, and policies, said Kargbo. The government falsely believes that youth do not know what they want or what their needs are. A strategy and a process to include young people in planning and implementation are needed, she said. Young people are left out most of the time. “And I don’t think that should be the case,” she said. “If we are the ones going for the services, I think we need to be consulted in implementation and policies with regard to family planning and access to contraceptives.”

Gender-based Violence

Gender-based violence (GBV) affects 30 percent of women and girls ages 15 to 29. In Nigeria, no one has really given any serious thought to addressing gender-based violence, said Dr. Chris Ugboko, Director of the Gender, Adolescent, School Health, and Elderly Care Division at the Federal Ministry of Health in Nigeria. Traditionally, intimate partner violence has gone unrecognized because it is not viewed as a form of GBV, he said. Once a woman is married, she is seen as property, and laws in certain parts of Nigeria even permit violence against one’s wife, said Dr. Ugboko. This is particularly concerning due to high rates of child marriage in Nigeria, where 43 percent of girls are married before age 18. Female genital mutilation (FGM) is also very common in Nigeria where, according to Dr. Ugboko, 20 percent of women and girls ages 15 to 49 have undergone FGM.

Dr. Ugboko spoke of recent efforts to curb GBV, especially during the COVID-19 pandemic, which has exacerbated this violence. In 2015, the Violence Against Persons Prohibition Act was enacted in Nigeria so that people found guilty of committing GBV can be sentenced to life imprisonment. However, more people need to know about this law. “So the most important step one should take now, would be for our communities—local traditional communities—to be properly educated about the dangers of gender-based violence. Like I said, most of them do this without knowing it’s an offense, that it’s not allowed any longer in the modern world,” said Dr. Ugboko. We can no longer simply view women as victims and men as perpetrators of violence, said Suleiman. “We work very, very closely with men and boys, and we believe men and boys must be approached and recruited as partners in the process for social change.”

Read More:

• COVID-19 causes disruptions in routine immunizations with long-term consequences
• Fulfilling the unmet need for contraception will save women’s lives, infants’ lives, and money
• Pandemic reverses gains made in ending child marriage