When policy meets practice: enacting WHO global standards for adolescent reproductive health services in Uganda

Abstract

Background: Adolescent pregnancy remains a major public health concern in sub-Saharan Africa. In Uganda, about one in four girls becomes pregnant before age 19, a rate unchanged for more than a decade. Although national adolescent reproductive health policies broadly align with the World Health Organization Global Standards for Quality Health Care Services for Adolescents, important implementation gaps persist. This study examined how these standards are enacted in routine health facility and school settings. Methods: A qualitative study was conducted in eight public health facilities and eight secondary schools in south-western Uganda. Data were collected through structured observations and exit interviews with 80 adolescent girls aged 15-19 years and 20 accompanying caregivers. Health facility findings were organised using the eight World Health Organization Global Standards, while school observations were assessed against national school health and teenage pregnancy guidelines and interpreted alongside the World Health Organization framework. Data were analysed thematically in NVivo using Braun and Clarke’s framework, with Street-Level Bureaucracy theory informing interpretation of how standards were enacted in practice. Results: Implementation was partial and uneven across both settings. Some facilities provided respectful and confidential care, while others had stock-outs of essential commodities, reported out-of-pocket purchases, limited adolescent-friendly spaces, and judgemental or dismissive treatment, particularly toward unmarried adolescents. School-based reproductive health activities were largely abstinence-oriented and often donor-dependent, with weak curriculum integration, referral systems, monitoring, and evaluation. Community engagement and adolescent participation were limited in both settings. Several donor-supported activities became inactive after funding ended because they had not been absorbed into routine institutional systems. The findings indicated alignment in policy intent but weak embedding of adolescent-responsive components in routine institutional systems. Conclusion: Uganda’s adolescent reproductive health policy framework is broadly aligned with World Health Organization Global Standards, but implementation remains uneven because adolescent-responsive components are not sufficiently institutionalised within routine financing, supervision, school programming, data use, and accountability systems. Closing this gap requires embedding adolescent-responsive services in routine institutional systems and strengthening adolescent-specific supervision and accountability.