Committing to Comprehensive Sexuality Education for Young People in Eastern and Southern Africa

The Ministerial Commitment on Comprehensive Sexuality Education and Sexual and Reproductive Health Services for Adolescents and Young People in Eastern and Southern Africa (ESA), or the ESA Commitment, was affirmed December 7, 2013, by 21 countries located across this region during the 17th International Conference on AIDS and Sexually Transmitted Infections in Africa. The ESA Commitment speaks to the numerous practices and challenges of school age populations stemming from interplay among education, health, and contextual issues varying by country. Analysis of this policy is approached using methodology drawn from Bartlett and Vavrus (2014, 2017) and using a lens of policy borrowing, particularly focused on incorporating agency, process, impact, and timing (Steiner-Khamsi, 2000, 2010). This analysis seeks to understand the ESA Commitment and national curriculum subsequently implemented in Zambia by situating these actions among broader international, regional, and national discourse in the area of sexual and reproductive health and education for young people between 1994 and 2016. Through analysis considering its effectiveness in terms of implementation, scalability, and sustainability, its ability to enable progress towards improving the lives of young people, especially through increased knowledge of HIV/AIDS prevention, is examined and recommendations are presented. Education Policy Analysis Archives Vol. 26 No. 138 2


Introduction
The Ministerial Commitment on Comprehensive Sexuality Education and Sexual and Reproductive Health Services for Adolescents and Young People in Eastern and Southern Africa (ESA), or the ESA Commitment, was affirmed December 7, 2013, by 21 countries1 located across this region (United Nations Educational, Cultural and Scientific Organization [UNESCO], 2013).Comprehensive Sexuality Education (CSE) as an area had been previously investigated by UNESCO, UNAIDS, the United Nations Population Fund (UNFPA), the United Nations Children's Fund (UNICEF), and the World Health Organization (WHO) in 2009.These groups defined CSE as "an age-appropriate culturally relevant approach to teaching about sex and relationships by providing scientifically accurate, realistic, non-judgmental education" (UNESCO, 2009;UNESCO, 2014, p. 5).
The ESA Commitment marked an event in a timeline of numerous activities and discourse seeking to address the interplay among education, health, and contexts of young people through efforts at international, regional, and national levels.In 2011, dialogue began, guided by UNAIDS and with support of the German Ministry of Economic Cooperation and Development, Southern African Development Community (SADC), and East African Community (EAC), around the challenges and potential solutions for young people with regards to their sexual/reproductive health, education, and well-being (UNESCO, 2013).Further discussions were carried out by UNAIDS leaders and leaders from across ESA who gathered around these issues prior to the 17th International Conference on AIDS and Sexually Transmitted Infections in Africa (ICASA) in 2013 (UNESCO, 2013).These discussions culminated with the spectacle, to borrow from Kingdon (1984), of a signing ceremony as part of the conference (UNESCO, 2013).This event was particularly inspired by events at the 2008 International AIDS Conference, Mexico City, Mexico, where Latin American and Caribbean countries rallied around a declaration to implement CSE for 8to 12-year olds (AIDS 2008: Key Outcomes, n.d.;UNESCO, 2013).Agreement in Latin America and the Caribbean opened a policy window, drawing again from Kingdon (1984), paving the way for regional collaboration in the area of CSE (UNESCO, 2015a).
The ESA Commitment acknowledged the role education could play in affecting the health, including with respect to HIV, of young people.The document noted progress already made in implementing life-skills based HIV education and CSE.Gender issues, including inequality, violence, child marriage, and discrimination, were recognized as hindrances to overall achievement by girls and threats to their health and well-being, with gender and rights incorporation into CSE noted to strengthen the curriculum and its effects.The particular influence of faith, variable across communities, as well as influence of family and community members, in affecting actions and norms in this area were acknowledged.Inclusion of these stakeholders in the negotiating progress to come was recommended.The importance of offering CSE to both primary and secondary ages was stressed, as was the need for SADC and EAC to monitor progress regionally.Country level monitoring through tools such as the Education Management Information System (EMIS) and Higher Education Management System (HEMIS) and periodic surveys were also encouraged.
While the ESA Commitment signaled agreement on an overall agenda by Ministries of Education and Health of 21 countries and the potential for regional coordination among those present, the document acknowledged participating countries' diversity by advocating national approaches to implementing CSE.Broad targets were included for 2015 and 2020 (UNESCO, 2013(UNESCO, , 2015a)).A more detailed accountability framework was formulated and agreed to shortly thereafter based around 20 key indicators and targets distributed over 2015, 2017, and 2020(UNESCO, 2014)).Targets for 2015 began countries on a path to formulating CSE with knowledge increases expected to emerge in following years (UNESCO, 2014).Increasing the numbers of schools in various countries with CSE integrated into the curriculum was an additional goal, and the countries were expected to document strategies for CSE by 2017 (UNESCO, 2014).The targets moved gender concerns from the national education sector level to the institutional level between 2015 and 2020 (UNESCO, 2014).

Purpose and Significance
The purpose of this policy analysis is to understand the ESA Commitment and subsequent actions related to it in Zambia.This analysis is accomplished by using elements of Bartlett's andVavrus's (2014, 2017) construction of a case study, namely their consideration of vertical and transversal aspects for examination, while applying a lens of policy borrowing, specifically focused on agency, process, impact, and timing as drawn from Steiner-Khamsi (2000, 2010).
The ESA Commitment was chosen because it represents regional discussion and agreement on CSE for younger generations by a large and diverse group of countries.Impacts in this area are important to this region especially since it is home to 50% of all HIV infected individuals (UNAIDS, 2016b).Prior to the Commitment, investigations and definitions regarding CSE were provided by international level actors.While the ESA Commitment is a regional agreement, it acknowledges the need for country contextualization in order for successful implementation of actions impacting sexual and reproductive health and education of young people to occur.
Zambia is used as a case study for national contextualization of the Commitment for several reasons.First, the country was among those affirming it.Second, 46% of the country's population consists of individuals aged 14 or younger (Central Intelligence Agency [CIA], 2017; The Southern and Eastern Africa Consortium for Monitoring Educational Quality [SACMEQ], n.d.b).Its adolescent population faces HIV infection rates of one young male and two young females every hour, according to Maseko (2012).Adding to the urgency for introducing sexuality education to these young people, approximately one-third of this youth population only partially completes primary education (Education Policy Data Center, 2014).Zambia has actively pursued a number of avenues centered around CSE and HIV in schools throughout the 2010s, against the background of target measures for 2015, and eventually 2017 and 2020, as part of the Commitment's Accountability Framework (UNAIDS, 2016a).Notably aligning with the timing of affirmation of the ESA Commitment, Zambian curriculum, in classrooms by 2014, was revised to include integrated CSE and was built around certain themes (Life Skills, Population and Family Life Education, Reproductive Health and Sexuality, and HIV/AIDS) in a country considering gender-sensitive approaches in this area, as stated in its National Youth Policy (Ministry of Education, Science, Vocational Training, and Early Education, 2013;Republic of Zambia Ministry of Youth and Sport, 2015;UNAIDS, 2016a;UNESCO, 2015b).
This analysis is significant as it demonstrates how topics such as CSE, which have potential to positively impact health of a large segment of the population long-term, are borrowed and subsequently transformed from the abstract to the concrete by countries.Particularly for Zambia, this transformation is seen in the agency, process, impact, and timing associated with CSE.The case study approach and theoretical framework precipitate a number of policy implications and recommendations related to issues of capacity-building, monitoring and evaluation, and fidelity of definitions related to CSE.By incorporating these recommendations in the future, positive health impacts can be reinforced at the regional level and in Zambia through enhanced policy outcomes, scalability, and sustainability.Such actions have the potential to make a difference, especially for high rates of HIV/AIDS infection, as well as overall development.

Analytic Approach to the ESA Commitment
This section details how the case study was constructed and which theoretical framework was used in order to consider ESA Commitment implementation, scalability, and sustainability.

Case Study Construction
This work draws from Bartlett's andVavrus's (2014, 2017) case study construction, which applies vertical, transversal, and horizontal approaches.Vertical refers to noting events and actions across macro, meso, and micro levels, while transversal refers to the placement of policy historically across the vertical levels used (Bartlett & Vavrus, 2014, 2017).International, regional, and national (Zambia) levels are used here for the vertical aspect.The years 1994 to 2016 were chosen for the transversal aspect of this analysis as 1994 was the year connections were made between sexuality education and sexual/reproductive health services during the International Conference on Population and Development (UNESCO, UNFPA, & UNAIDS, 2016), and 2016 provides an opportunity to capture progress made by 2015 according to the ESA Accountability Framework.
While drawing from Bartlett andVavrus (2014, 2017), this case study diverts from their approach in two significant ways.First, this analysis does not employ a horizontal aspect to compare events across a particular location.Instead, it considers national level activities in Zambia.Second, it does not employ an ethnographic approach, as their work did.Existing documents and literature are used to situate the ESA Commitment and subsequent developments in the area of CSE for Zambia.Table 1 presents this evidence by type.As previously explained, the vertical aspect of this study examines international, regional, and national (Zambia) actions.Therefore, evidence from each of these levels was included when conducting an internet search for documents and literature pertaining to, among others, sexuality education, reproductive health, life-skills education, HIV/AIDS, and CSE.Also this case study is bounded transverally by looking between 1994 and 2016.Therefore, evidence included had to be published during this timeframe.The country profiles used are published through UNESCO, the UNFPA, and UNAIDS.These statistics were compiled and then approved during consultations with countries to produce the 2013 country reports.A multi-sectoral country reporting process yielded the data for the 2016 country reports.
Figure 1 provides a visualization of the timeline of events surrounding the ESA Commitment at international and regional levels as well as in Zambia.
Figure 1.Timeline of events and documents surrounding the ESA Commitment, including the international, regional, and Zambian contexts, 1994-2016.
Figure 1 also suggests a tool helping to scaffold evidence and discursive elements during the analysis.This is similar to Bartlett and Vavrus's (2014) own visualization of their methodology.This scaffolding tool is presented in Figure 2.  Bartlett and Vavrus (2014).

Theoretical Framework
This work uses a lens of policy borrowing to analyze the above evidence pertaining to the ESA Commitment, specifically incorporating considerations of agency as advocated by Steiner-Khamsi (2000, 2010).Agency emerges particularly through examination of a national context, in this case Zambia, as more local actors encounter the regionally agreed upon ESA Commitment and make choices for what CSE means for their contexts.Agency at the national level was actually built into the ESA Commitment itself as the "responsibility of the State to promote human development, including good quality education and health, as well as to implement effective strategies to educate and protect all children, adolescents, and young people" (p. 1) was noted.The Ministers of Education and Health began the document by also acknowledging their aims to make progress on behalf of young people empowered to impact their communities, countries, and region, pointing to the ripple effect of individual ministerial actions on countries.Each country represented was recognized to have its own unique "socio-cultural context" surrounding pursuit of the ESA Commitment (p. 2).
"Process, impact, and timing of policy borrowing" are also considered (Steiner-Khamsi, 2000, p. 5).A more analytical policy borrowing lens intersects well with the Bartlett andVavrus (2014, 2017) approach to case study, allowing "process" and "impact" (Steiner-Khamsi, 2000, p. 5) to emerge across and through the development and implementation of the ESA Commitment in Zambia.For investigation of time, the transversal aspect of the Bartlett andVavrus (2014, 2017) approach is particularly useful for greater analysis.Beyond its role here in the policy-making process, time is intertwined with a subject such as health and HIV prevention for young people because biology is often time-sensitive.Statistics, such as numbers of deaths from HIV and numbers of new infections, create their own sense of urgency and need to be considered to understand why policy is adopted when and how it is.

ESA Commitment Environs
The following section begins with a brief overview of eastern and southern Africa.The Zambian context is then presented, detailing demographic, administrative, cultural, and social aspects, especially those relevant to HIV/AIDS and sexuality.The section then presents an overview of stakeholder engagement, beginning prior to the Commitment and concluding with national level activities in Zambia.

Region
The ESA Commitment was signed by 21 countries across the region.Together these countries have a population of young people ages 10 to 24 numbering around 158 million and expected to reach 281 million by 2050 (UNESCO, UNDP, & UNAIDS, 2016).The HIV/AIDS epidemic has been devastating to the countries of eastern and southern Africa, and the region is home to 50% of all HIV infected persons (UNAIDS, 2016b).New infections have been especially prevalent among young women, accounting for 33% of new infections in 2015 (UNAIDS, 2016b).Pediatric infection rates did decline across the region between 2010 to 2015; however, this was in large part due to decreased mother-to-child transmission (UNAIDS, 2016b).
With the threat to adolescent girls and young women beginning five to seven years earlier than for boys and young men, early education for prevention is crucial (UNAIDS, n.d.).Examining why girls and women are especially hard hit, the UNAIDS Progress Gap Report for 2015 cited high levels of HIV/AIDS in this demographic overall, gender inequity and inequality, adherence to traditional ways of doing things, and poor educational opportunities alongside an "extremely high" amount of crime against women (UNAIDS, 2016b, p. 108).Many countries exhibit high rates of transactional sex and sex between couples very different in age (UNAIDS, 2016b).

Zambia
Since Zambia is the national context considered, demographic, administrative, cultural, social, and political contexts are presented in detail.

Demographic context.
The population of Zambia is among the fastest growing worldwide, due in part to high fertility rates, and 46.1% of Zambia's population is aged 14 or younger (CIA, 2017;SACMEQ, n.d.b).Thirty-four percent of youth attain only partial primary education (Education Policy Data Center, 2014).One consequence of poor educational attainment is higher incidence of early marriage for girls, especially if they are poor and living in rural areas (CIA, 2017).
Unfortunately, the demographics of HIV in Zambia reveal additional cause for concerns.Zambia ranked 16th worldwide in deaths of adults and children from HIV during 2014 (CIA, 2014).Looking more closely at HIV in relation to adolescent populations, one young male and two young females are infected by HIV every hour (Maseko, 2012).
Administrative context.The Ministry of Education oversees primary and secondary education, continuing education, and teacher training across the country, with Provincial and District offices operating locally (SACMEQ, n.d.a, n.d.b).At the school level, management boards provide oversight (SACMEQ, n.d.b).Schools in Zambia fall into one of three categories: government, or public; grant-aided, indicating receipt of government subsidies; and private, meaning that though autonomous they are subject to government regulations (Carmody, 2007).Religious involvement is present across the educational system.For example, the Catholic Church oversees approximately 15% of Zambian schools (grant-aided and private) (Carmody, 2007).Religious involvement is managed through denomination-based Education Departments, their respective Education Secretaries, and work through the Education Secretaries' Forum (Zambia Episcopal Conference, n.d.) Cultural context.Zambia is a multicultural country, with 70 different ethnicities (CIA, 2017).Most individuals are Protestant, though a fifth do identify as Catholic, but views rooted in tradition are frequently intertwined with those of religion (CIA, 2017;Warenius et al., 2006).Culture is indicated to impact sexuality, engagement in sexual practices, and contraception in Zambia.Views on what is acceptable with regards to adolescent sexuality often differ from one ethnicity to another (CIA, 2017).Premarital sex is not accepted across the country irrespective of religion, though it is still engaged in by young people (Warenius et al., 2006).
Social context.Warenius et al. (2006) report that the elderly traditionally imparted sex education to young people.Gradually, however, this responsibility was taken up by schools, churches, and non-governmental organizations, though frequently with varying messages (Warenius et al., 2006).Less than 40% of young people, and even fewer young females, in 2012 possessed thorough knowledge of HIV, despite presence of national HIV education efforts in schools for the previous 10 years (Maseko, 2012).
Sexual activity generally starts earlier for females than for males (United Nations Children's Fund, n.d.).Should pregnancy occur, more likely due to inability to obtain contraception, young females without the option of legal abortion, often choose risky illegal means (Ahlberg, Jylkӓs, & Krantz, 2001;Koster-Oyekan, 1998;Mmari & Magnani, 2003).Chatterji, Murray, London, and Anglewicsz reported in 2004 that 40% of males and 27% of females had obtained money, gifts, and/or favors in return for sex.Related to this is the practice of sex between younger females and older males, common across Sub-Saharan Africa, which puts them at an especially increased risk for HIV (UNICEF, n.d.).
Zambia ranked ninth in the region in 20152 on the basis of the Gender Development Index (GDI) statistics, calculated as the ratio of female to male Human Development Indices' values (United Nations Development Programme, n.d.).Though this represented an improvement since 2011, Zambian women continue to have poorer outcomes than other women across the region.
Political context.Politics impacting policy in Zambia's education system is marked by five particular periods.These include: the time until 1964 of colonial rule by Great Britain when Christian missionaries were heavily involved in education; the Kaunda period when few Zambians filled education roles; the Movement for Multi-Party Democracy which opened the education system up, including to private and community schools; a decade of decline; and, finally, renewed investment in education under the Patriotic Front as part of development efforts (Beyani, 2013;Mwizabi, 2014).

Stakeholder Engagement
Curriculum changes reflect work by a variety of political actors and stakeholders as the ESA Commitment, initiated by international groups for the regional level, trickled into national curriculum design and implementation for schools.This policy analysis is especially focused on four stages, starting with the initiation of dialogue leading to the ESA Commitment and ending with curriculum implementation in Zambian schools.

Initiation of dialogue leading to ESA Commitment. This stage involved United
Nations agencies, such as UNESCO and UNAIDS, in leadership roles over the two years prior to the Commitment (UNESCO, 2013).Support in this process came from the German Ministry for Economic Cooperation and Development, the EAC, and the SADC (UNESCO, 2013).
ESA Commitment process and affirmation.Leadership in this stage was provided by the UNAIDS Regional Support Team with support from the Technical Coordinating Group made up of UN partners, civil society groups, and bilateral entities (UNESCO, 2013).Leaders from countries across ESA steered this process, eventually following-up with regional civil society groups (UNESCO, 2013) Zambian curriculum implementation in schools.This policy analysis does not delve into what occurred as CSE curriculum was implemented in schools and classrooms.It is, however, instructive to consider those stakeholders expected to be involved at this stage as part of the analysis.This can help inform future research considerations.
A number of local level actors intersect with curriculum coming from the Ministry.These include, first and foremost, students and teachers, as they receive and deliver knowledge.School administrators oversee this process in their schools while managing and negotiating with teachers, students, parents, and school boards.Provincial, district, and local school boards must also negotiate between what comes from the national level and the feedback from those they oversee.Teacher training institutions and professional development trainers are involved with pre-service and inservice capacity-building for teachers.
Education Secretaries representing religious denominations act as conduits between their denominations and ministry officials (Zambia Episcopal Conference, n.d.).Community actors, especially religious leaders, and civil society organizations are also potentially involved in supporting or contesting CSE implementation in schools.Healthcare providers and support staff benefit from and share in discussions of CSE.

Policy Analysis
The policy analysis which follows considers its effectiveness in terms of implementation, scalability, and sustainability by focusing on agency, process, timing, and/or impact across vertical and transversal aspects.

Implementation
In order to consider implementation of the ESA Commitment, three aspects of the policy are examined, with agency, process, timing, and impact emerging in terms of its effectiveness.First, the fidelity between the Commitment approach and its goal of a healthy, educated young population situated to impact the world is considered.The ESA Commitment as a moment in a longer history of curriculum focused on health, sexuality, and prevention is tracked across time, and outcomes are compared with these findings.Next, the target population impacted, reflecting work by Schneider and Ingram (1993), is placed into the greater timeline of events and discourse on health and sexuality education.Finally, incorporation of stakeholders and their interests is examined, especially regarding relationships and interactions between them and the contexts in which CSE is implemented.
Fidelity between the ESA Commitment approach and goal.There has been a variety of terms attached to CSE historically (UNESCO, 2016).For example, Zambian officials chose which themes to include in their CSE curriculum in 2014.This demonstrates a grappling with what needs to be accomplished and what fits under the umbrella of CSE.It is through this grappling, however, that actors have, and continue to, exert their own agency and incorporate their own views for what should be learned.These terms and this grappling process are evident in Figure 3 and detailed below.
In 1994, the connections between sexuality education as protective against HIV/AIDS were recognized (United Nations Population Fund, 2004).Sub-Saharan representatives agreed in 1999 to life-skills and HIV/AIDS education and curriculum in their work on regional Education for All priorities, notably without mention of issues surrounding sex and sexuality (UNESCO, 2000).HIV/AIDS is more often than not the focus looking over the years and is most likely representative of the urgency felt around this issue, demonstrating the effects of time as statistics indicate the disease's devastating effects on the health and well-being of young people.In 1994 reproductive health as an integral component of development was also acknowledged (United Nations Population Fund, 2004), and the ESA Commitment picked up this thread tying education to development through health.The Commitment presented CSE as a tool to positively affect outcomes for young people, and CSE curriculum and its integration into education were encouraged as part of it.
HIV/AIDS education including that integrated through life-skills work continued to be the focus for a number of years.SACMEQ continued to keep the focus on HIV/AIDS education, delivering the HIV/AIDS Knowledge Test in 2007 (SACMEQ, 2010).There was a very public adoption of CSE in Latin American and Caribbean countries with the declaration by countries from this region in 2008 (AIDS 2008: Key Outcomes, n.d.).Even in 2009, however, the term comprehensive sexuality education was only used twice3 in the main text of the two-volume International Technical Guidance on Sexuality Education, and this was in the Foreword by the UNAIDS Executive Director.The same year the ESA Commitment was affirmed, CSE curriculum was specifically mentioned as part of the framework for Zambia's education system (Ministry of Education, Science, Vocational Training, and Early Education, 2013).Nationally and regionally, CSE cemented its place with monitoring and evaluation targets using the term CSE.
Statistical reporting in published country profiles of those confirming the ESA Commitment supports what is demonstrated using the scaffolding tool above.Table 2 below exhibits how in country reporting of curriculum topics for 2013, CSE as a term was not reported, looking instead at various topics within the realm of CSE.Certain ones, like Life Skills, Gender Equality and Empowerment, HIV/AIDS, and Stigma and Discrimination, were covered more than others across the board.This picking and choosing demonstrates actor agency within national level decisionmaking.For 2015, accountability targets used the term CSE, though countries gave statistics based on life-skills based HIV/AIDS education and sexuality education (UNESCO et al., 2016).In some cases, no statistics were reported and description of curriculum was offered instead (UNESCO et al., 2016).This mismatch between target wording and measurement approaches is revisited in the Recommendations section of this analysis.Target population framing.In the Dakar Framework for Action in 2000 and then again in 2016, policy and discourse in this area targeted young people, who were framed as being on the cusp of positively contributing to development with health risks threatening their ability to do so (UNESCO, 2000;UNESCO et al., 2016).The International Technical Guidance on Sexuality Education in 2009 framed young people differently, less as future contributors to society and more as a group consuming and demanding to consume accurate, scientifically based information about health.The ESA Commitment in 2013 targeted "young people and adolescents" in its title (p. 1).Later the document speaks to the importance of beginning CSE in primary school.As shown in Table 2, in 2013 many primary school levels were addressing certain topics including life skills, HIV/AIDS/STIs, and stigma and discrimination.Framing young people as having the potential to shape their own future is echoed in the UNAIDS press release on CSE for Zambia in 2016, sitting somewhere between framing by other actors historically.
Looking across discursive evidence between 1994 and 2016, a notable shift emerges toward targeting CSE to younger ages both internationally, regionally, and in Zambia, and this is charted in Figure 4.This policy shift makes sense in terms of its timing.For the Zambian context, the timing aligns with introduction of the SACMEQ test results release in 2011.As of 2007, only 35% of Grade 6 students in Zambia had minimal knowledge of HIV/AIDS, producing a ranking of seventh out of 14 participating countries with data available (SACMEQ, 2011).Starting education earlier becomes necessary because students are tested in Grade 6, and a foundation must begin to form before then.The broadening of the target population with time also makes sense in terms of the realities of schooling, especially in places like eastern and southern Africa, where continuation into secondary education, especially for girls, is not always likely.In Zambia, 34% of youth attain only partial primary education (Education Policy Data Center, 2014).Particularly for the locations in eastern and southern Africa, it makes sense to begin this education in lower grades as the ESA Commitment includes the 2020 target measuring knowledge gains (UNESCO et al., 2016).Country profiles reflect this: with a turn of the page, the focus shifts from CSE provision to CSE knowledge for each country (UNESCO et al., 2016).

International
Gender-related issues and violations are connected to limiting girls and putting them at risk health-wise (UNESCO et al., 2016).Looking across documents from 1994 to 2016 (Figure 4) and curricular offerings for primary and secondary levels in 2013 (shown in Table 2) shows that gender, issues connected to gender, and gender-sensitivity were understood as important with respect to CSE.The shift is clearly toward gender-related issues on page two of each country profile (UNESCO et al., 2016).Taking a gender focus while making girls a target sub-population likely reflects the understanding that HIV, as explained by Boler and Aggleton (2005), is greatly affected by interactions between the sexes but also between women and girls or between men and boys.The gender focus brings interactions into focus and is, thereby, well-matched to positively impacting health of girls.
Table 2 shows how gender equality and empowerment were already being covered in Zambian classrooms in 2013.However, newly revised and integrated CSE curriculum was rolled out across all schools in 2014, alongside educational resources, designed to be gender-responsive (UNAIDS, 2016;UNESCO, 2015b).In 2016, a UNAIDS press release on CSE in Zambia noted the way in which the benefits of CSE were extended through the gender focus to positively affect human rights and encourage non-violence.Data pertaining to both were being measured and reported in the country profile of Zambia and other ESA countries through statistics on the prevalence of gender-based violence and percent of women married before 15 (UNESCO et al., 2016).
Stakeholders and their interests.Considering stakeholder interests is stressed as crucial throughout the ESA Commitment.Their importance, particularly in the realm of sexuality education and HIV/AIDS, has been stressed for more than 20 years, looking across the evidence.Reasons for the emphasis highlight one way agency is exerted particularly for this area of policy.Looking for common themes, the evidence points to three different bases motivating this agency: socio-cultural contexts, religious beliefs, and institutional mission.
The Programme of Action in 1994 encouraged curriculum updates aligning with social and cultural contexts and "stakeholder involvement" ( UN Population Fund, 2004, p. 100).This seemed to imply paying attention to those choosing to actively engage on the topic, whereas the ESA Commitment encouraged policymakers to seek out stakeholders to engage them around the Commitment.This was encouraged, despite the possibility for pushback, acknowledged with recognition of the variety of faith-based views stakeholders may have.
Sexuality, HIV/AIDS/STIs, pregnancy, curriculum, and training are important issues in the area of CSE; however, they bridge spheres of both education and health.The ESA Commitment was affirmed by Ministers of both Education and Health, and the document encourages further ministerial involvement, advocating inclusion of Ministries of Gender and Youth, for example.While inclusion of these makes logical sense, institutional mission is often siloed, posing a challenge for such collaborative work (Boler & Aggleton, 2005).For example, Boler and Aggleton (2005) explain how HIV/AIDS rarely sits in the domain of any ministry other than health.This siloing can have additional ramifications for funding, so that education ministries miss out on funds tied to HIV/AIDS, making them unwilling to take on HIV/AIDS-related projects.

Scalability
Scalability is considered next across vertical and transversal aspects.Agency emerges as integral here.The ESA Commitment recognizes that while it serves as a "common agenda," it is ultimately enacted through "national responses" (p.5).In line with this, all countries, including Zambia, agreed to be held accountable to targets dependent on their ability to see growth at the country-level.
Even with its existence, curriculum cannot educate without effective delivery by teachers (UNESCO, 2015a).With so many teachers requiring training on what has been newer curriculum in many places, alongside the potential for CSE to conflict with teachers' personal values and general lack of participatory teaching skills, actually implementing CSE in the classroom has met challenges (UNESCO, 2015a).These have been addressed through provision of pre-service and in-service training (UNESCO, 2015a); however, this requires training capacity to be already in place.By 2014, Zambia addressed preparation of primary school teachers for delivering CSE during pre-service training (UNESCO, 2015b).Those already in the classroom were also trained (UNESCO, 2015b).In 2014, 12,852 teachers were trained with almost twice as many ready by close of 2015 (UNESCO, 2015b).
Zambia also offered designation as a "Champion School" as an inducement (McDonnell & Elmore, 1987), potentially augmenting the scale of CSE in Zambia.These schools offered additional resources for CSE to their students including peer education (UNESCO, 2015b).The Deputy Minister of Education of Zambia regarded this difference between schools as an important way to identify what works as CSE scaling continues (UNESCO, 2015b).
Another potential challenge to bringing CSE to scale is the decentralized school systems seen across the region, including in Zambia (Ministry of Education, Science, Vocational, and Early Education, 2013).While the Ministry of Education, Science, Vocational, and Early Education in Zambia must ensure schools are aligned with curriculum and policy regulations are in place, schools do have the flexibility to determine their own subject topics and learning outcomes (Ministry of Education, Science, Vocational, and Early Education, 2013).With such a culturally diverse country where religion and tradition occupy such an important place, space exists for CSE to be shaped as stakeholders, for example from religiously affiliated schools, see fit.This poses a challenge to bringing the ESA Commitment to scale.Future research in this area could help clarify what is needed in regards to this challenge.

Sustainability
Sustainability, in terms of long-term effectiveness and usefulness, is examined next across vertical and transversal aspects, with agency and process emerging as integral.
A detailed accountability framework was formulated shortly following affirmation of the ESA Commitment, based around 20 key indicators and targets distributed over years 2015, 2017, and 2020(UNESCO, 2014)).The ESA Commitment included a binding accountability clause (UNESCO, 2014).This clause acts as a type of mandate, according to policy instrument categories defined by McDonnell and Elmore (1987), and helps to maintain compliance.Monitoring and evaluation in alignment with the accountability framework and subsequent publication of results in publicly available country profiles followed.This encouraged country follow-through with increasing knowledge, spread of curriculum into more schools, employment of multi-sector collaboration, and expansion of responsibility to the institutional, not just ministerial, level (UNESCO et al., 2016).
Accountability at upper levels encourages progress towards sustainability as well.Regional and country level monitoring through tools such as the EMIS and HEMIS was suggested in the Commitment as were periodic surveys.The regional groups SADC and EAC serve as an example of McDonnell and Elmore's (1987) systems change, as these organizations were tasked with the additional responsibility of monitoring.Similarly in Zambia, National and Provincial Standards Monitors evaluate the quality and actual implementation of CSE across schools there (UNESCO, 2015b).The Deputy Minister of Education of Zambia highlighted "building ownership" through evidence as "essential" to the implementation process (UNESCO, 2015b, p. 9).Without continuation of these approaches, it is difficult to imagine sustainability in this area.

Limitations
As explained in the approach to this policy analysis, a horizontal aspect is not included in this study and an ethnographic approach was not used.Consequently, a comparison across different school sites in Zambia is not offered and what teachers themselves are presenting in terms of CSE is not presented.This is certainly an important future step for research in this area, especially in a country like Zambia with its differing school types, religiously affiliated schools with representation by their own Education Secretaries, and so many different ethnicities.Deepening understanding of approaches within classrooms and schools will further inform capacity-building and curriculum development.A number of policy implications and recommendations emerge, however, through the approach applied in this study.These are presented in the section that follows.

Policy Implications and Recommendations
The ESA Commitment represents an important regional step in connecting education to development through health with a number of policy implications.Coinciding with the timing of its affirmation, CSE curriculum was made part of the Zambian education system framework.The ESA Commitment highlighted the importance of CSE for the primary grades.This, reinforced by the SACMEQ HIV/AIDS Knowledge Test with results available for students as young as Grade 6, encouraged curriculum implementation in the lower grades.For Zambian boys and girls, earlier implication of CSE in curriculum means the 34% of youth only partially completing primary grades is reached (Education Policy Data Center, 2014).Also in the country, where HIV infections are especially prevalent for young women and threats to them begin five to seven years before boys (UNAIDS, 2016b, n.d.), these policy implications are very likely to be life-saving.Women and girls are similarly impacted by collection and publication of data pertaining to gender as part of monitoring and evaluation in connection with the Commitment, as such publicity creates motivation and public pressures to address these targets.
For the future, issues of capacity-building, monitoring and evaluation, and, ultimately, fidelity of definition emerge, based on the policy analysis centered around implementation, scalability, and sustainability.This section next presents recommendations pertaining to these areas to maximize effectiveness of the ESA Commitment for the region and Zambia.
First, capacity-building issues are considered.It is not evident whether regular capacitybuilding is in place for individual members of regional groups, like SADC and EAC, and national ones, like the National and Provincial Standards Monitors in Zambia, so that they can stay up-todate on the latest research in the area of CSE to strengthen their monitoring and evaluation skills.Since accountability is a key component of sustainability, the level of knowledge of those monitoring countries and schools is important.
Potential ways of improving monitoring and evaluation are evident.In Zambia, the National and Provincial Standards Monitors should provide data disaggregated by school type (public, private, and grant-aided).This would help the country's ministries and provincial, district, and school boards ensure that all students have the benefit of truly comprehensive sexuality education to live healthy and productive lives.Should some schools be limiting topics covered, it is even more important for school officials and administrators to partner with civil society organizations and community members to supplement CSE and the resources available.
Fidelity of definition, beginning with indicators and looking more broadly, offers an important area in which to make improvements.Together, life-skills based HIV education and sexuality education serve as a proxy for 2015 Targets 1 and 2 which look at curriculum and teacher training in CSE.This is problematic for a number of reasons.First, not all countries are able to respond positively to whether or not they have CSE curriculum and teacher training in place when the measure is so narrowly focused only on the topic of life-skills based HIV education and sexuality education, and it is not clear why these two particular themes were the only ones chosen.To an extent, the ways of reporting results represent a step back from the more complete data provided in 2013 just as the ESA Commitment was affirmed.
Secondly, if life-skills based approaches are the proxies, the indication is that these are the favored approaches.This is problematic because, as Boler and Aggleton (2005) explain, life-skills are closely tied to a of individualism, with each person needing to have the ability and the opportunity to assess how he/she is at risk and make personal choices accordingly.Choice is a luxury not available universally.More collectivist societies are frequently seen across Africa, which challenges individualistic life-skills based approaches.It is, therefore, recommended that the measure of curriculum and teacher training in CSE move away from life-skills as a proxy.
This change may mean that ESA countries need to, at a regional level, consider in more detail what should be included for a CSE approach that moves participating countries closer towards their goal for young people.Comprehensive Sexuality Education is defined as "an age-appropriate culturally relevant [emphasis added] approach to teaching about sex and relationships by providing scientifically accurate, realistic, non-judgmental education" (UNESCO, 2009;UNESCO, 2014, p. 5).The ESA Commitment should go a step further to define and delineate what its participating Ministers of Education and Health agree to be a culturally relevant education in this area for this region.This definition should be subsequently operationalized and incorporated to revisions of targets and their indicators for countries.
In conclusion, the advantage of working through the regional level is that, though the ESA Commitment itself is non-binding, it is normalizing.This means it has the power to transform and influence thinking on what CSE means for the region.This presents an avenue to circumvent problems arising from the situation potentially existing in, for example Zambia, where the decentralized education system means schools have the agency to choose subjects covered and learning outcomes within the overall national curriculum framework (Ministry of Education, Science, Vocational Training, and Early Education, 2013).By doing so, the health and long-term well-being of young people may be positively affected for maximum impact in eastern and southern Africa.
The white paper consulted includes a summary of discussions of the UK Working Group on Education and HIV/AIDS(Boler & Aggleton, 2005), while the policy briefs are published by the Southern and Eastern Africa Consortium for Monitoring Educational Quality (SACMEQ).The PowerPoint presentation from 2015 was prepared by a UNESCO representative as part of a multiday expert meeting presented to StopAidsNow.org,now part of Aidsfonds, an operational umbrella NGO based in the Netherlands (StopAIDSNOW.org,n.d.a, n.d.b).The International Technical Guidance on Sexuality Education was written by UNESCO, UNFPA, WHO, UNICEF, UNAIDS, and experts worldwide.The book Comprehensive Sexuality Education in Teacher Training in Eastern and Southern Africa was published by UNESCO and includes statistics submitted by countries.Zambian ministerial documents include one by the Ministry of Education, Science, Vocational Training, and Early Education in 2013 and another by the Ministry of Youth and Sport.The one-page case study was based on a presentation to the World Economic Forum in May 2015 by the Deputy Minister of Education of Zambia, and the media release came from the UNAIDS press center.

Figure 2 .
Figure 2. Scaffolding tool for analyzing evidence and discursive elements pertaining to the ESA Commitment, drawing fromBartlett and Vavrus (2014).

Figure 3 .
Figure 3. Timeline of the terms found around curriculum and discussions of knowledge pertaining to health and prevention, 1994-2016.Note.SE = sexuality education; RH = reproductive health; CSE = Comprehensive Sexuality Education

Figure 4 .
Figure 4. Shifting target populations and address of gender in the area of CSE, 1994-2016.

curriculum response to the ESA Commitment.
. Ministers of Health and Education from the 21 countries affirmed the ESA Commitment during ICASA.Returning home from ICASA, the Zambian response relied on a number of stakeholders for the national level work stemming from the Commitment.The Ministry of Education, Science, Vocational Training, and Early Education published new curriculum (Ministry of Education, Science, Vocational Training, and Early Education, 2013), presumably collaborating with the Ministry of Health for topics connected with CSE.Both National and Provincial Monitors were designated to track quality and delivery in the schools (UNESCO, 2015a).Youth involvement in evaluation was encouraged (Republic of Zambia Ministry of Youth and Sport, 2015), though it was not evident if this actually occurred.

Table 2
Topical Coverage in Core Curriculum and CSE Curriculum Framework Implementation for Countries Affirming ESA Commitment, 2013