new zealand parliamentarians group on population and development submission

NZPPD Open Hearing Submission – Burnet Institute 1

NZ Parliamentarians’ Group on Population and Development Open Hearing: Adolescent Sexual and Reproductive Health and

Rights in the Pacific

11 June 2012

Submission

Burnet Institute on behalf of the

Women’s and Children’s Health Knowledge Hub

Submission prepared by: Dr Elissa Kennedy Principal for Maternal and Child Health Centre for International Health Burnet Institute


Table of Contents 1. Full contact details ............................................................................................. 2

2. Introduction....................................................................................................... 3

3. Executive summary ............................................................................................ 4

4. Recommendations and supporting information ................................................. 5

4.1 The need to address adolescent pregnancy...........................................................5 4.2 Effective approaches to address adolescent pregnancy in the Pacific .......6 4.2.1 Increase development assistance for adolescent SRH.......................................................... 6 4.2.2 Ensure adolescents are explicitly addressed in reproductive health and population policy. 7 4.2.3 Improve the availability and use of strategic information ................................................... 7 4.2.4 Support efforts to create an enabling environment............................................................. 8 4.2.5 Improve access to comprehensive SRH information, including prevention of pregnancy.... 8 4.2.6 Strengthen health systems to provide youth friendly health services .................................. 9

5. References ....................................................................................................... 11

1. Full contact details 1.1 Dr Elissa Kennedy

Principal for Maternal and Child Health Centre for International Health Burnet Institute 85 Commercial Rd, Melbourne, VIC, Australia 3004 Phone: +61 3 9282 2119 Fax: +61 3 9282 2144 Email: [email protected]


2. Introduction 2.1 The Burnet Institute, on behalf of the Women’s and Children’s Health Knowledge

Hub, welcomes the opportunity to make this submission to the NZ Parliamentarians’ Group on Population and Development Open Hearing on Adolescent Sexual and Reproductive Health and Rights in the Pacific.

2.2 The Burnet Institute is a leading Australian-‐based medical research and public health

institute seeking to achieve better health for poor and vulnerable communities through research, education and public health. Through the Centre for International Health (CIH) Burnet has full accreditation with AusAID as a health development non-‐government organisation (NGO). CIH’s health priorities include women’s and children’s heath (including adolescent health), HIV and sexual health, infectious diseases and health systems strengthening.

2.3 In addition to its office in Melbourne, CIH has a strong presence in Asia and the

Pacific with country offices in Papua New Guinea, Indonesia, Myanmar, Lao PDR and China (Beijing and Lhasa) and projects implemented through local partners in Sri Lanka, Timor-‐Leste and Vanuatu.

2.4 The Women’s and Children’s Health Knowledge Hub (WCH Hub) is an AusAID funded

partnership between the Burnet Institute, the Centre for International Child Health at the University of Melbourne and Menzies School of Health Research.

2.5 The WCH Hub draws on regional expertise to improve the effectiveness of aid for

women’s and children’s health, with an emphasis on contributing to equitable progress towards Millennium Development Goals 1, 4, and 5 – to reduce poverty, improve maternal and child health, and ensure universal access to reproductive health. One of the key thematic priorities of the WCH Hub is to ensure universal access to sexual and reproductive health for adolescents. This work has included research activities to identify current needs, barriers, effective approaches and knowledge gaps in the Pacific.

2.7 Burnet Institute is also a founding member of the Australian Sexual and Reproductive Health and Rights Consortium, a collaboration with Marie Stopes International Australia, CARE Australia, Plan Australia and International Women’s Development Agency. The Consortium seeks to ensure Australian non-‐government organisations are able to position reproductive health as a priority within the global health and development agenda.


3. Executive summary 3.1 A significant and growing proportion of the Pacific population is made up of

adolescents aged 10-‐19 years. Adolescents suffer a disproportionate burden of poor sexual and reproductive health (SRH), including high rates of early and unintended pregnancy, with significant health and socio-‐economic consequences for themselves, their families and communities. Addressing adolescent pregnancy and improving access to family planning information and services need to be prioritised (Recommendation 1).

3.2 Increased and long-‐term financial commitment for family planning in the Pacific is

needed, with funding specifically allocated to adolescent SRH. Greater funding for non-‐government and civil society organisations who provide the bulk of SRH information and services for adolescents in the Pacific is also required (Recommendation 2).

3.3 Adolescents do not automatically benefit from policies and programs aimed at the

general population. There is need for advocacy and support to ensure that adolescent pregnancy and access to family planning is explicitly addressed in national reproductive health and population policies and is integrated with other youth policies (Recommendation 3).

3.4 There is an urgent need for further research to better understand adolescents’

family planning knowledge, attitudes, practices, preferences and socio-‐cultural context to inform policies and programs. Advocacy and support are needed to build local research capacity, strengthen health information systems, and ensure adequate funding for program research and evaluation (Recommendation 4).

3.5 Advocacy and support are required for multi-‐sectoral approaches to create a

supportive environment for adolescent SRH. Consideration needs to be given to the legislative and policy environment (including age of marriage, gender-‐based violence, restrictions on contraceptive access and abortion); access to free and compulsory education for all adolescents and removal of policies that prevent pregnant adolescents and mothers completing education; and support for evaluation of programs that aim to address community attitudes and norms (Recommendation 5).

3.6 Adolescents require access to comprehensive SRH information, including

information about preventing early and unintended pregnancy. Advocacy and support are needed to facilitate the scale-‐up of evidence-‐based sexuality education in schools, peer education programs to reach out-‐of-‐school adolescents, and for further research into the potential of mass media and communication technologies (Recommendation 6).

3.7 Pacific governments should be supported to develop and implement guidelines for

youth-‐friendly health services. Non-‐government and civil society organisations currently providing a high standard of youth-‐friendly sexual and reproductive health services should continue to be engaged and supported (Recommendation 7).


4. Recommendations and supporting information

4.1 The need to address adolescent pregnancy 4.1.1 One in five people in the Pacific is an adolescent aged 10-‐19 years.1 These young

people are just beginning their sexual and reproductive lives. Recent data indicates that up to 65% of girls, and 72% of boys, aged 15-‐19 years have ever had sex, with a significant proportion reporting sexual debut before the age of 15.2-‐8 Many are ill-‐prepared for this transition, lacking adequate knowledge and access to comprehensive information and services. Subsequently adolescents suffer a disproportionate burden of poor sexual and reproductive health (SRH), including early and unintended pregnancy.

4.1.2 Adolescent fertility rates are high in many Pacific countries and have seen little decline in the past decade. Between 8 and 26% of girls aged 15-‐19 have already commenced childbearing.2-‐8 In Marshall Islands, births to adolescents account for 20% of all births. Adolescent pregnancy in the Pacific generally occurs outside of marriage and is often unintended.9 In Solomon Islands, Marshall Islands and Nauru more than half of all adolescent pregnancies are mistimed or unwanted.2, 5, 6

4.1.3 Adolescent pregnancy, intended or unintended, has significant implications for

maternal and child health: globally, conditions related to pregnancy and childbirth are the leading cause of death of girls aged 15-‐19 years, who are twice as likely to die as adult women. Babies born to adolescent mothers are twice as likely to die within the first month of life and suffer higher rates of perinatal morbidity.9-‐11

4.1.4 While there is paucity of data for the Pacific, globally between 2 and 4.4 million

adolescents resort to unsafe abortion every year, accounting for around 14% of all unsafe abortions. Adolescent girls are more likely to delay seeking abortion and post-‐abortion care, are more likely to resort to unskilled providers and unsafe methods and suffer higher rates of complication and mortality than adults.12, 13

4.1.5 Early pregnancy can have enormous socio-‐economic consequences. In the Pacific,

pregnant adolescents are often forced to leave school, contributing to a cycle of poverty, gender inequality and disadvantage that impacts on girls, their children and communities and hampers progress towards sustainable development.14,15, 16

4.1.6 The determinants of adolescent pregnancy are complex and relate to poor access to information and services, socio-‐cultural norms, gender inequality, early marriage, sexual violence and coerced sex, and low socio-‐economic status.11

4.1.7 In 2010, Burnet Institute, through the WCH Hub, conducted a qualitative study in

partnership with Wan Smolbag Theatre to explore the barriers to accessing SRH information and services experienced by adolescents in Vanuatu.17 The major barriers reported included:

• Socio-‐cultural norms and taboos regarding adolescent sexual behaviour; • Judgmental attitudes, poor communication skills and lack of confidentiality

among service providers; • Cost of transport and commodities; • Unreliable supply of commodities;


• Poor geographical access, particularly in rural areas; and • Lack of information and knowledge about their own SRH needs and

availability of services. 4.1.8 These barriers contribute to inadequate knowledge and low contraceptive use

among married and unmarried adolescents. Less than 20% of girls aged 15-‐19 and less than half of adolescent boys in the Pacific report having ever used a modern method of contraception (including condoms). Between 15 and 52% of married adolescent girls have an unmet need for family planning – meaning they would like to avoid pregnancy but aren’t currently using a method of contraception. Use of modern contraception is lower, and unmet need higher, among adolescent girls than adult women aged over 20.2-‐8

4.1.9 There are significant opportunities and incentives for investing in efforts to prevent

adolescent pregnancy. Pacific populations are dominated by a large and increasing youth bulge, whose SRH impacts not only on their own health and well-‐being but that of their families and communities. Delaying pregnancy contributes to better health outcomes for women and children, enables girls to complete education, may help to address rapid population growth, and has implications for sustainable socio-‐economic development.11, 15, 16 Adolescents are the future Pacific parents, workers and leaders -‐ investment in their SRH is crucial if Millennium Development Goal targets, and broader development goals, are to be realised.

4.1.10 Recognising the critical importance of addressing adolescent fertility and its

implications for sustainable development in the Pacific, NZPPD and other stakeholders must place greater strategic priority on the prevention of adolescent pregnancy and improving access to comprehensive family planning information and services for young people (Recommendation 1).

4.2 Effective approaches to address adolescent pregnancy in the Pacific

4.2.1 Increase development assistance for adolescent SRH (Recommendation 2)

4.2.1.1 Funding for reproductive health in the Pacific is currently inadequate. While there

has been a minimal increase in development assistance for reproductive health, funding for family planning has fallen in the past decade to less than US$ 1 million per year compared with US$ 31 million spent on HIV.18 An increased and long-‐term financial commitment for family planning is required, with funding specifically allocated to adolescent SRH to reflect current needs and priorities in the region.

4.2.1.2 In addition to supporting governments and multilateral agencies, greater funding is

needed for non-‐government and civil society organisations who currently provide a substantial proportion of SRH information and services for adolescents in the Pacific.


4.2.2 Ensure adolescents are explicitly addressed in reproductive health and population policy (Recommendation 3)

4.2.2.1 Adolescents suffer a disproportionate burden of poor SRH outcomes in the Pacific,

but are often overlooked and underserved in reproductive policy and programs. Adolescents do not automatically benefit from policies aimed at the general population.19, 20 They face unique barriers and have particular SRH needs requiring targeted responses that are comprehensive, evidence-‐informed and reflect international agreements on sexual and reproductive rights.21

4.2.2.2 NZPPD and other stakeholders are in a position to advocate for and support the

inclusion of adolescents in national reproductive health and population policies, ensuring that adolescent pregnancy and access to family planning is explicitly addressed and is integrated with other youth policies.

4.2.3 Improve the availability and use of strategic information (Recommendation 4)

4.2.3.1 Quality information is vital to support evidence-‐based policies and programs.

Currently, data for adolescent SRH in the Pacific are very limited. Routine health information systems often fail to adequately capture or report data for adolescents and lack adolescent-‐specific indicators that would help inform effective interventions.22

4.2.3.2 A review of Pacific DHS and MICS reports conducted by Burnet Institute in 2009

demonstrated that national-‐level surveys are frequently limited by the failure to report data disaggregated by age and marital status to demonstrate outcomes for unmarried adolescents, and failure to collect data for young adolescents (10-‐14 years).23 The inclusion of unmarried adolescents in the most recent Pacific DHS is encouraging, however many important indicators, including those relevant to family planning, are not reported for adolescents.

4.2.3.3 Further research is urgently needed to identify adolescents’ knowledge, sexual

behaviours, use of contraception, reasons for non-‐use and discontinuation, contraceptive preferences and socio-‐cultural and other barriers to better inform policy and programs. There is also a great need for data about sensitive but critical issues such as abortion. Support for rigorous evaluation of interventions and approaches in the Pacific is required to identify effective strategies for reducing early and unintended pregnancy.

4.2.3.4 Advocacy and support are required to strengthen health information systems,

ensure the inclusion of adolescents (married and unmarried) in national-‐level surveys, support efforts to enhance local research capacity and to increase financial commitment for Pacific-‐based research.


4.2.4 Support efforts to create an enabling environment (Recommendation 5)

4.2.4.1 The determinants of early and unintended pregnancy are multi-‐factorial, and

available evidence indicates that multiple, concurrent interventions are most likely to be effective, including multi-‐sectoral approaches to create a supportive environment. This includes increasing youth participation in policy and program development and support for youth development strategies to promote protective factors.24, 25

4.2.4.2 Consideration of the legal and policy environment and its impact on adolescents is

required. Legislation to prevent marriage before 18 years of age and address gender-‐based violence should be enacted and enforced. Legislation or policies that restrict adolescents’ access to a full range of SRH services, including restrictions on providing unmarried young people with contraception, or compulsory requirements for parental or spousal consent, should be addressed.26 Policymakers need to also consider the impact of highly restrictive abortion laws, which may disproportionately affect adolescents.12

4.2.4.3 In addition to ensuring free and compulsory education for all adolescents,26 harmful

school policies that prevent pregnant adolescents from continuing or returning to education should be removed and programs introduced to support adolescent mothers to complete education.

4.2.4.4 Socio-‐cultural factors are among the most significant barriers reported by young

people in Vanuatu. There is a need for evaluations of interventions that aim to overcome these barriers, including programs targeting parents and community leaders to address socio-‐cultural norms and attitudes.17

4.2.5 Improve access to comprehensive SRH information, including prevention of pregnancy (Recommendation 6)

4.2.5.1 There is a great need to increase adolescents’ access to comprehensive, age-‐

appropriate SRH information and education. Evidence suggests that such information provided from an early age can have life-‐long protective benefits.27 While the majority of married adolescents in the Pacific have heard of at least one modern method of contraception, limited data indicate that comprehensive knowledge about prevention of pregnancy is poor.28, 29 Research conducted by Burnet in Vanuatu identified that while prevention of pregnancy is important to adolescents, they currently receive little information about this compared with information about sexually transmitted infections and HIV.17 Compared with adults, adolescent boys and girls are less likely to have heard family planning messages in the media, and less than 25% of girls have discussed family planning with a health worker.2-‐8 Research conducted by Burnet has highlighted the need to reach boys as well as girls to promote shared responsibility for prevention of early and unintended pregnancy.17


4.2.5.2 Schools are an underutilised source of SRH information in the Pacific. There is

substantial global evidence demonstrating the positive effective of comprehensive school-‐based sexuality education on knowledge, attitudes, behaviours and, to some extent, SRH outcomes.30 Adolescents in Vanuatu reported that they would like to receive SRH through school, either as part of the standard curriculum or delivered by visiting peer educators or nurses.17 Evidence-‐based programs that build life skills and improve communication and decision-‐making, such the Family Life Education program, should be strengthened and scaled-‐up through-‐out the region.31

4.2.5.3 Adolescents in Vanuatu identified peer educators and health workers as preferred

sources of information because they were perceived to be well-‐trained, trustworthy and able to give correct information.17 Recent reviews have shown that youth peer education programs in developing countries can be effective in improving knowledge, and, to some extent, attitudes and behaviours and have the potential to reach large number of young people.32 33 Opportunities to expand peer education programs, particularly for out-‐of-‐school young people, should be sought and these approaches rigorously evaluated to identify impact.

4.2.5.4 Family planning information delivered through mass media can increase

contraceptive uptake, but messages need to be appropriately targeted and delivered to reach adolescents.26, 34 Adolescents in Vanuatu identified a range of preferred sources of information including print media, radio, television, community theatre and community workshops, but also noted that current mass media messages regarding family planning only target married couples.17 Further research is required to identify effective strategies, particularly the potential of social media and communication technologies.

4.2.6 Strengthen health systems to provide youth friendly health services

(Recommendation 7) 4.2.6.1 It is well recognised that adolescents face multiple barriers that limit their access to

mainstream health services, and indeed use of SRH health services by young people in the Pacific is low.35 Youth-‐friendly health services are those that are accessible, acceptable and appropriate for adolescents with limited research showing a promising impact on service utilisation.20, 24, 36

4.2.6.2 In 2010, Burnet Institute conducted a qualitative study of adolescents’ SRH service

delivery preferences in Vanuatu.17 The features of a youth-‐friendly health service that were identified included (from most important to least important):

• Friendly, non-‐judgmental health workers; • Reliable commodity supply; • Free (affordable) services and commodities; • Confidentiality; • Availability of male and female staff; • Convenient opening hours;


• Printed materials, television, peer educators and other activities provided in the waiting room;

• Privacy; and • Separate from adult services.

4.2.6.3 These findings suggest that much can be done to make existing services, including

government services, more youth-‐friendly – even where it is not feasible to provide stand-‐alone youth clinics. These approaches require increased investment from government and other stakeholders, and engagement with young people and communities, and should include:

• Training for health workers (SRH needs and rights of young people, confidentiality and communication and counselling skills);

• Strengthening commodity supply of condoms and contraceptives, particularly in rural areas;

• Providing affordable services and commodities – including free contraceptives;

• Ensuring all facilities have a confidentiality and privacy policy; and • Providing a separate waiting area or separate opening hours for young

people 4.2.6.4 SRH services should be integrated with other general health services for young

people and other youth activities (such as youth centres) where possible to reduce stigma and increase accessibility.20 Consideration should also be given to the appropriateness and feasibility of providing SRH services and contraception in school clinics.

4.2.6.5 Pacific governments should be supported to develop and implement country-‐

specific guidelines for youth-‐friendly health services based on local research. 4.2.6.6 Increased support is needed for non-‐government and civil society organisations who

currently provide high quality stand-‐alone youth-‐friendly health services in the Pacific37 and may be better able to reach young people, particularly marginalised adolescents. Innovative models of service-‐delivery models and outreach services to reach most-‐at-‐risk adolescents should also be explored.


5. References 1. SPC. Youth population -‐ PICT. Secretariat of the Pacific Community. AHD Section. 2010. 2. National Statistics Office (SISO), SPC, Macro International: Solomon Islands 2006-‐2007

Demographic and Health Survey. Noumea: SPC; 2009. 3. Ministry of Health (Samoa), Bureau of Statistics (Samoa), and ICF Macro: Samoa

Demographic and Health Survey 2009. Apia, Samoa: Ministry of Health, Samoa: 2010. 4. Central Statistics Division (TCSD), SPC and Macro International Inc: Tuvalu Demographic and

Health Survey. 2007. 5. Nauru Bureau of Statistics, SPC and Macro International Inc: Nauru 2007 Demographic and

Health Survey. 2007. 6. Economic Policy, Planning and Statistics Office (EPPSO), SPC and Macro International Inc:

Republic of the Marshall Islands Demographic and Health Survey 2007. 2007. 7. National Statistical Office Papua New Guinea: Papua New Guinea Demographic and Health

Survey 2006: National Report. Port Moresby: National Statistical Office Papua New Guinea; 2009.

8. Kiribati National Statistics Office (KNSO) and SPC. 2009. Kiribati Demographic and Health Survey. Secretariat of the Pacific Community (SPC), Noumea; 2010.

9. WHO: Adolescent pregnancy: unmet needs and undone deeds. World Health Organisation. Geneva: 2006.

10. Patton GC, Coffey C, Sawyer SM, Viner RM, Haller DM, Bose K, et al. Global patterns of mortality in young people: a systematic analysis of population health data. The Lancet. 2009;374(9693):881-‐92.

11. WHO. Position paper on mainstreaming adolescent pregnancy in efforts to make pregnancy safer. Department of Making Pregnancy Safer. World Health Organisation. Geneva: 2010.

12. Olukoya AA, Kaya A, Ferguson BJ, AbouZahr C. Unsafe abortion in adolescents. Int J Gynaecol Obstet. 2001 Nov;75(2):137-‐47.

13. Shah I, Ahman E. Age patterns of unsafe abortion in developing country regions. Reprod Health Matters. 2004 Nov;12(24 Suppl):9-‐17.

14. UNFPA: Briefing notes for Pacific Parliamentarians on population, development and reproductive health issues. UNFPA Office for the Pacific. Suva: 2007.

15. Greene M, Merrick T: Poverty Reduction: Does Reproductive Health Matter? In World Bank Human Development Network, ed. Health, Nutrition and Population Discussion Papers. The World Bank. Washington DC: 2005.

16. World Bank: Development and the Next Generation, World Development Report. International Bank for Reconstruction and Development. Washington, DC: 2007.

17. Kennedy E, Gray N et al. Identifying the sexual and reproductive health informaiton and service delivery preferences of adolescents in Vanuatu. Burnet Institute, on behalf of Compass: the Women's and Children's Health Knowledge Hub. Melbourne, Australia; 2010.

18. OECD Statistics. Query Wizard for International Development. Organisation for Economic Co-‐operation and Development. Available at http://stats.oecd.org/qwids/#?x=2&y=6&f=3:51,4:1,1:1,5:3,7:1&q=3:51+4:1+1:1+5:3+7:1+2:262,240,241,242,243,244,245,246,249,248,247,250,251,231+6:2002,2003,2004,2005,2006,2007,2008,2009 Accessed 16 April 2012.

19. UNICEF. Adolescence and age of opportunite. State of the World's Children. United Nations Children's Fund, New York; 2011.

20. Tylee A, Haller DM, Graham T, Churchill R, Sanci LA. Youth-‐friendly primary-‐care services: how are we doing and what more needs to be done? Lancet. 2007 May 5;369(9572):1565-‐73.

21. Kennedy E, Gray N, Azzopardi P, Creati M. Adolescent fertility and family planning in East Asia and the Pacific: a review of DHS reports. Reproductive Health 2011;8:11.


22. Ekeroma A. Building audit and research capacity in the Pacific Islands in the area of reproductive healthcare. Auckland: Pacific Women's Health Research and Development Unit, Middlemore Hospital, 2007.

23. Gray N, Azzopardi P, Kennedy E, Creati M, Willersdorf E. Improving adolescent reproductive health in Asia and the Pacific: do we have the data? A review of DHS and MICS surveys in nine countries. Asia-‐Pacific Journal of Public Health. 2011 Jul 13 [Epub ahead of print].

24. Speizer IS, Magnani RJ, Colvin CE. The effectiveness of adolescent reproductive health interventions in developing countries: a review of the evidence. J Adol Health 2003; 33: 324–48.

25. Oringanje C, Meremikwu MM, Eko H, Esu E, Meremikwu A, Ehiri JE. Interventions for preventing unintended pregnancies among adolescents. Cochrane Database Syst Rev. 2009(4):CD005215.

26. Bearinger LH, Sieving RE, Ferguson J, Sharma V. Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention, and potential. Lancet. 2007 Apr 7;369(9568):1220-‐31.

27. Blum R, Mmari K. Risk and protective factors affecting adolescent reproductive health in developing countries. World Health Organisation. Geneva, 2004.

28. UNFPA. Adolescent sexual and reproductive health situation analysis for Solomon Islands. A review of literature and projects 1995-‐2005. UNFPA Office for the Pacific, Suva, Fiji; 2006.

29. UNFPA. Adolescent sexual and reproductive health situation analysis for Vanuatu. A review of literature and projects 1995-‐2005. UNFPA Office for the Pacific, Suva, Fiji; 2006.

30. Kirby D, Laris BA, Rolleri L. Impact of sex and HIV education programs on sexual behaviors of youth in developing and developed countries: FHI youth research working paper no 2. North Carolina: Family Health International, 2006: 1–56. .

31. SPC Assessment report of adolescent sexuality education (or Family Life Education) in ten PICTs. AHD Section, Secretariat of the Pacific Community: June 28, 2010.

32. Maticka-‐Tyndale E. Evidence of youth peer education success. In Adamchak S. Youth Peer Education in Reproductive Health and HIV/AIDS. Youth Issues Paper 7. Arlington, VA: Family Health International (FHI)/YouthNet, 2006. .

33. Kim CR and Free C. Recent evaluation of the peer-‐led approach in adolescent sexual health education: a systematic review. International Family Planning Perspectives2008; 34(2).

34. Wakefield MA, Loken B, Hornik RC, Use of mass media campaigns to change health behaviour. The Lancet. 376(9748):1261–71 (2010). doi:10.1016/S0140-‐6736(10)60809-‐4.

35. SPC. Pacific adolescent health and development partnerships expanded. AHD Section, Secretariat of the Pacific Community, Suva, Fiji; 2011. Available at http://www.spc.int/en/component/content/article/216-‐about-‐spc-‐news/824-‐pacific-‐adolescent-‐health-‐and-‐development-‐partnerships-‐expanded.html.

36. WHO. Adolescent friendly health services. An agenda for change. Department of Child and Adolescent Health and Development. World Health Organisation, Geneva; 2002.

37. SPC. Youth friendly service clinic assessment in 5 Pacific Island countries. AHD Section, Secretariat for the Pacific Community, Suva, Fiji.

new zealand parliamentarians group on population and development submission

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