My educational background

I am now working towards a Doctor in Philosophy Degree on sexuality education at the University of Ghent, Ghent, Belgium. I hope to complete this in early 2024.

I did my postgraduate training in public health with a focus on human nutrition at the London School of Hygiene and Tropical Medicine, London, England in 1989.

I did my undergraduate medical training at the Osmania Medical College, Hyderabad, India in 1980. I have learned, and continue to learn by doing and deliberate self-learning, on a range of issues.

My work experience

I joined WHO in early-1993 and worked on HIV prevention in WHO’s Global Programme on AIDS till the end of 1995. After a short stint in UNAIDS, I moved back to WHO in mid-1996.

Since then, my work has focused on adolescent health in different departmental configurations. Before joining WHO, I worked in Zambia, India and Zimbabwe for 12 years – providing primary care services (with a private Zambian company – Kitwe Medicare Center), preventing childhood malnutrition (with a Zambian NGO – Kitwe Nutrition Group), preventing HIV and responding to people with HIV (with another Zambian NGO – Copperbelt Health Education Project), providing NGOs with technical and financial support for HIV/AIDS related work (with an ‘NGO AIDS Cell’ set up in the All India Institute of Medical Sciences by the Norwegian Agency for Development Cooperation), and setting up a regional mentoring initiative – ‘School Without Walls’ (with the Canadian Public Health Association).

My achievements

During my 30 years in WHO, I led or contributed substantially to a number of the organization’s publications on different aspects of adolescent health including evidence reviews, policy and programmatic guidance, advocacy documents, training and self-learning materials and research/evaluation tools. I travelled to around 75 countries around the world, where I stimulated and supported research studies and evaluations, and contributed to strengthening policies and programmes, in different social, cultural and economic contexts. I contributed to global consultative processes, provided advice to a range of organizations, presented in scores of global, regional and national conferences, and authored/co-authored a large body of books, book chapters, newsletter articles and blog pieces and peer-reviewed journal articles.

I am especially proud of five things that I led with colleagues and collaborators:

We synthesized and disseminated data on the progress made in reducing the rates of child marriage, female genital mutilation, HIV infection and HIV-related mortality, and adolescent pregnancy and childbearing globally.

• We showed that although progress has been slow and uneven, it has occurred. This has contributed to changing the discourse on adolescent sexual and reproductive health and rights (ASRHR) from: ‘This is difficult to do. This is nearly impossible to show results in.’ to ‘Yes, we are making progress but there is much more to do!’ Working with the Johns Hopkins Bloomberg School of Public Health and with research teams from countries in nearly 20 countries in WHO’s six regions, we conceived and executed the Global Early Adolescent Study, the first global study of gender socialization in adolescents. In addition to generating a huge and growing body of research outputs, the Study has had a huge influence on the field.
• The Study set out to (i) understand how social constructions of gender shape boys and girls as they grow, and how they inform health and wellbeing across the adolescent years, in different geographic, cultural and economic contexts; and (ii) to test whether and if so, how gender transformative interventions in early adolescence contribute to improving adolescent health and wellbeing.
• During its first phase, the Study team reviewed the available literature, developed a conceptual framework, and developed and tested tools to assess gender norms and attitudes in young adolescents in different contexts. In its second phase, it supported longitudinal studies with large numbers of adolescents, and combined this with intervention effectiveness studies – in some sites.
• The Study has generated a rich body of research findings. It has also contributed to raising the profile of young adolescents in the global health and development agendas, to increasing a focus on gathering and analysing data gaps in this age group, to integrating gender socialization in global normative tools on sexuality education, and to stimulating projects and programmes efforts in a large number of countries. We responded to the evolving needs of field on adolescent pregnancy and childbearing, over 25 years. We began by making a case for attention to and investment in this area. We then set out evidence-based guidance on what needed to be done to address this area. We then supported countries in developing national policies and strategies on preventing child marriage and improving access to and uptake of contraception by adolescents.
• Adolescent pregnancy and childbearing were placed on the global agenda by the International Conference on Population and Development (ICPD) in 1994. In the aftermath of the ICPD, we worked to make a case for attention to it.
• In 2000, the Millennium Development Goals (MDG) were announced. Goal 5 on reducing maternal mortality provided a new impetus for our work. In the 2000s, we pressed for attention to adolescent pregnancy (and to HIV in adolescents and young people as part of Goal 6). We developed tools to strengthen the abilities of health workers and health facilities to respond to adolescents effectively and with sensitively. We worked with United Nations partners to develop guidance on providing sexuality education in schools and elsewhere in communities. Despite concerted efforts, we struggled to find engagement because in the first decade of the MDG era, adolescent health was not really a priority.
• In the early 2010s, there was growing realization worldwide that adolescents were being left behind, and that this had implications not only for their health and wellbeing but for efforts to reduce maternal and childhood mortality. To respond to the call for authoritative guidance on what to do, we published guidelines on preventing early pregnancy and poor reproductive outcomes in adolescents in 2011. We also used the forum of the World Health Assembly to advocate for the application of the guidelines in a session on Early marriages, and adolescent and young pregnancies in 2012.
• In the last five years of the MDG era (i.e., 2011-2014), we worked with GirlsNotBrides and the newly established Joint UNICEF-UNFPA Programme to Accelerate an End to Child Marriage, to establish/strengthen national efforts to end child marriage, and with Family Planning 2020 to support countries in including adolescent contraception in their national commitments.
• The Sustainable Development Goals and the updated Global Strategy for Women’s, Children’s and Adolescents’ Health which were launched in 2015, placed adolescents at the center of the agenda. This has provided a solid basis for us to step up our efforts in the second half of the 2010s and the first half of the 2020s. We have published country profiles synthesizing available data, distilled evidence of what works and what does not, documented analytic case studies of ‘positive deviant’ countries that have demonstrated success in reducing levels of child marriage and of adolescent childbearing, stimulated and supported implementation research, built the capacity of researchers, policy makers and programmers from the global South, and set up an innovative mechanism to provide technical assistance to countries that is responsive to their needs, and is timely, effective, efficient, and contributes to strengthening national capacity. Over 30 years, we contributed first to defining adolescent friendly health services, and then – responding to developments in the field – to moving the focus from making individual clinics and centers adolescent friendly to making national health systems responsive to adolescents.
• We began by gathering experiences from around the world in making sexual and reproductive health services adolescent friendly i.e., in ways that responded both to their needs and to their preferences.
• We categorized these approaches and teased out the attributes of effective adolescent friendly clinics and centers. We then placed these attributes within a quality framework – with a focus both on provision and utilization.
• To promote standards-driven quality improvement, we developed tools for countries to set quality standards and criteria, to achieve them through complementary actions at the national, district and local levels, and to periodically assess progress.
• We supported countries in doing this, and documented their efforts and results. To tap into the momentum of wider efforts to strengthen health systems and to make them responsive to users, we matched the elements of adolescent friendliness with WHO’s health system building blocks.
• To promote the integration of these elements into health systems, we developed policy and programme guidance, and shared noteworthy country examples, thereby priming them for inclusion in the Universal Health Coverage agenda. We incrementally built a body of work on comprehensive sexuality education, that included building evidence; developing normative tools; advocating for action, building the understanding of decision makers; and their capacity in planning and implementing CSE as part of a multicomponent programme; and supporting countries develop and apply policies and strategies.
• Firstly, we carried out prospective research. One example is an implementation research study on the feasibility, acceptability, and effectiveness of delivering comprehensive sexuality education outside the school setting in four countries. Alongside this we carried out retrospective research to learn how countries have scaled up, sustained and enhanced school-based sexuality education and how they have built support and overcome resistance to it. One example is a set of two papers on scaling up school-based sexuality education in Nigeria – one of how scale up occurred, and the other on how support was built and resistance dealt with.
• Secondly, we contributed to the development of normative tools on CSE. One example is the International Technical Guidance on Sexuality Education, which was led by UNESCO and involved six UN agencies including WHO.
• Thirdly, we advocated for CSE in different fora. One illustrative example is a TEDx talk for general audiences. We have worked with partners within and outside the United Nations system to build support for and overcome resistance to CSE. An illustrative example is our contribution to ‘Friendship Retreats’ organized by the International Planned Parenthood Federation to engage with representatives of permanent missions to the United Nations of countries in New York and in Geneva, to build a shared understanding of CSE in a conducive atmosphere.
• Fourthly, we worked to build understanding and support of public health programme managers on the place of CSE in a multicomponent adolescent sexual and reproductive health programme through in-person and virtual courses. One example is the blended- learning certificate course that we have run for over a decade on adolescent sexual and reproductive health and rights with the Geneva Foundation for Medical Education and Research.
• Finally, we work with partners to support the integration of CSE in wider public health programmes as an integral part of a multicomponent strategy. One example is the work we did with FP 2030 (previously FP2020) to include CSE in the context of policy, programme, and budget commitments by countries on improving access to and uptake of adolescent contraception.

I am also proud about the way in which we have worked. Firstly, we built strong working relationships with individuals and organizations working on adolescent health from the global to the local levels, around the world. This includes colleagues in WHO and other United Nations agencies, government agencies and foundations supporting adolescent health work, global initiatives, academic institutions, government officials and nongovernment organizations. This has created many opportunities for working together and to sharing and learning. It has also contributed to our Department becoming the go-to place for advice and support on various aspects of ASRHR. Secondly, I proactively and unapologetically involved professionals living, studying and working in the global South. Finally, I am proud of the way in which we have meaningfully involved young people in our work. Our five-point approach has served as a model to others – setting up an open and transparent process to identify and engage young people, agreeing with them on their tasks, supporting them in successful accomplishing their tasks as best as they could, paying them for their work, and acknowledging/celebrating their achievements.

My awards

In 2022-23, I received three awards, which speak to my contribution to the field of ASRHR – the USA’s Society for Adolescent Medicine and Health’s Lifetime Achievement Award, the Rotary International Award for Outstanding Humanitarian Service for outstanding leadership, scholarship and service in adolescent sexual and reproductive health, and the World Association of Sexual Health Gold Medal.

My reading of the global adolescent health situation

Thirty years ago, adolescent health was not on the priority agendas of national governments in most countries. Nongovernment organizations were active in learning about adolescents’ lives and providing them with whatever services they could to respond to their needs. Today, the situation is very different. National governments in most countries have identified some aspects of adolescent health as priorities, and have put in place policies and strategies to address them, which are increased more grounded on data and evidence than they were. Almost everywhere, ASRHR figures high in the list of adolescent health priorities. Over the last three decades, the discourse in the field has evolved from asking Why do we need to address adolescents ? through: What do we need to do to address adolescents ? to: How do we do what needs to be done to address adolescents, in our social, cultural, and economic context ?

There is much more funding available for ASRHR today than ever before. On the one hand, coalitions of funding bodies – government bodies, foundations, and funds – provide funds to prevent child marriage, prevent female genital mutilation, prevent HIV infection and HIV related illness and death, prevent cervical cancer through Human Papilloma Vaccination, and prevent adolescent pregnancy and childbearing. Interventions such as comprehensive sexuality education, contraceptive service provision and safe abortion care provision are increasingly well funded. On the other hand, only a small number of countries have invested in the resources needed to translate their policies and strategies into large scale and sustained programmes. Most countries are heavily reliant on United Nations agencies, governmental development agencies, and foundations for support. These agencies almost always come to the table with the priority issues they want to address, programmes or programme components they want to support, and even the geographic areas they want to operate in.

With some notable exception, ASRHR programmes tend to be weak because of one or more of the following reasons – lukewarm commitment because of other competing priorities, discomfort with addressing the sensitive aspects of ASRHR, weak capacity within governments leading to weak governance and management, no systematic effort to engage civil society bodies and groups, and reluctance to tap into the expertise of nongovernment organizations with expertise in this area, and lack of any real accountability for the execution or the results of programmes.

My vision for country-level action on adolescent health

As a result of the combined effect of snowballing social movements and improved governance, I want to see adolescents in all the world’s countries, get the support they need from their families and communities to grow and develop in good health (using WHO’s broad definition of health as not merely the absence of disease and infirmity but the presence of physical, mental and social wellbeing) and to get back to good health if they fall ill or are injured.

In terms of strong social movements, I want to see civil society bodies and groups pressing for investment and action to ensure that adolescents have the opportunities to study, to play, to work and to contribute to their families and communities, and to have second chances if they ‘stumble and fall’. I want to see civil society bodies and groups acknowledging adolescents as sexual beings, and supporting efforts to provide them with the knowledge, skills, medical tools and the legal and social support they need to prepare them and to support them to have healthy and satisfying sexual and reproductive lives.

In terms of good governance, I want to see strong government-led action in countries, fully involving other key stakeholders – civil society bodies and groups including adolescents themselves, the commercial sector, and academic institutions. I want to see policies, strategies and plans that are grounded in sound evidence, and respond to local realities. I want to see adequate investment, and effective implementation and monitoring with a focus on quality and equity. I want to see careful documentation and evaluation to draw out lessons learned, and periodic reviews of progress that celebrate strengths identify weaknesses, and examine how to build on strengths and address gaps and weaknesses. I want to see individuals and institutions held accountable for their actions, through functional accountability mechanisms that involve adolescents.

My mission

After a successful 30-year career in the World Health Organization, I continue to work on Adolescent Sexual and Reproductive Health and Rights with a wide range of organizations, but not for any of them.

My mission is to contribute to the public discourse on ASRHR, and through that to shape the practice of individuals and institutions working to improve ASRHR from the global, through the national, to the local level.

My five lines of work

• I keep track of developments in the field (through journal articles, reports, social media posts, and meetings)
• I contribute to generating epidemiologic data, research and programmatic evidence
• I distill and actively communicate my learnings and their implications
• I provide advice on request
• I teach

Here is a list of issues that I am working on

• What progress is being made in key areas of ASRHR, where and in which groups of adolescents ?
• Which groups of adolescents are being left behind on areas of ARSHR in which progress is being made (e.g., in reducing child marriage), why, and what can be done about it ?
• How to build pro-social and gender-equitable attitudes and norms in very young adolescents, growing up in contexts with deeply engrained gender inequality and/or with low levels of social capital ?
• How to ensure that clinical management and public health practices are tailored to meet the special needs of adolescents within the context of population-wide programmes ?
• How to integrate adolescent friendly health service elements into national health systems ?
• How to build support and overcome resistance to comprehensive sexuality education ?
• How to scale up proven ASRHR interventions with quality and equity ?
• How to go improve and sustain improvements in the performance of managers, health service providers and teachers ?
• How to strengthen planning, implementation, monitoring and reporting at the district level, tailored to local realities and capacities ?
• How to improve the fidelity and quality of implementation of proven interventions ?