CROSS-COUNTRY SYNTHESIS: ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS

The Exemplars in Adolescent Sexual and Reproductive Health and Rights (ASRHR) research examined successful strategies to reduce adolescent fertility and advance ASRHR by studying positive outlier countries that achieved sustained progress. This cross-country synthesis describes high-level insights from our research in five Exemplar countries: Cameroon, Ghana, Malawi, Nepal, and Rwanda. Results from India are expected and will be integrated in 2026. This synthesis highlights key thematic findings that can support decision-makers to allocate resources more effectively, craft evidence-based policies, and diagnose areas for further research.

KEY INSIGHTS

Across the Exemplar countries, sustained progress in ASRHR since 2000 was driven by aligning enabling environment reforms with targeted, adolescent-responsive actions.

Ending child marriage: Across Exemplar countries, reductions in child marriage were the largest contributor to explained declines in adolescent fertility in the decomposition analysis. Countries increased minimum legal ages of marriage and deployed coordinated national strategies to challenge entrenched gender norms, which delayed early pregnancy and improved maternal health outcomes, extended educational attainment, and contributed to poverty reduction.

Keeping girls in school: Countries improved access and retention by abolishing school fees and other financial barriers, creating flexible pathways for school reentry, and addressing norms that constrain girls’ learning. They also strengthened quality and equity through teacher development and targeted scholarships for girls and other marginalized groups. Education gains emerged as a primary contributor to explained adolescent fertility reductions in the decomposition analysis.

Delivering adolescent-responsive care: Exemplar countries elevated ASRHR to a national priority and operationalized it via youth-friendly health services (YFHS). In four of the five countries with results, introduction of policies that institutionalized YFHS coincided with or directly preceded periods that had the most rapid declines in adolescent fertility. Success hinged on training providers in adolescent-responsive care, integrating YFHS into routine services, and implementing demand-generation efforts to boost awareness and uptake.

Providing sexual and reproductive health education for informed decision-making: Cameroon, Malawi, Nepal, and Rwanda scaled comprehensive sexuality education through phased, context-sensitive approaches—starting with acceptable entry points, such as HIV/AIDS prevention, and broadening efforts to cover sexual and reproductive health more comprehensively. Effective models featured close collaboration between health and education sectors, harmonized educator guidelines, and peer-led support mechanisms. In all four countries, introduction or expansion of comprehensive sexuality education aligned with periods of accelerated decline in adolescent fertility.