The health of young people in Sri Lanka: conducive environment for road to adulthood – a desk review

Investing in young people is considered a high priority for developing a strong foundation for the future and it has higher benefit-cost ratios. Identifying the present environment in Sri Lanka for the health of young people is important for providing recommendations for the future. This desk review was carried out to review the current environment that is facilitating the health of young people in Sri Lanka. The documents relevant for understanding the current context of policies and strategies on the health of young people were studied. Databases including Google Scholar and PubMed, websites, and documents collected from the experts and key persons were searched. A narrative report with key recommendations was prepared by synthesis of the information extracted. According to the review, there are policies, laws guidelines, and programs in Sri Lanka that address youth health and support access for services and also provide an environment that is conducive for access. These are supported directly and indirectly to the access and provision of the health of youth. There are many positive aspects for youth in the areas of education and health, although there are certain challenges and gaps yet to be addressed. There are very few misleading legal frameworks that prevent youth from accessing sexual health services. Restructuring of school and higher education systems, focusing on a skill-based education system, is an investment that will have a direct effect on promoting the health status of youth. The establishment and strengthening of youth-friendly services will be of utmost importance to improve the status of Sri Lankan youth, addressing the health issues in youth will need inter-sectoral collaboration.


Introduction
Youth is the transition period of life from childhood to adulthood. The World Health Organization (WHO) and the United Nations define 'adolescents' as individuals in the 10-19 years age group and 'youth' as those in the 15-24 years age group. The term 'young people' covers the age range of 10-24 years [1]. Every child born has a right to a safe and healthy journey from adolescence to adulthood. Besides, a healthy, multitalented, and dynamic youth population is vital for the socio-economic development of the country. Investing in young people is a high priority to developing a strong foundation for the future.
Sri Lankan youth comprises one-fourth (4.7 million) of the total population of 21.4 million in Sri Lanka [2]. The country entered the process of globalization with the constitutional change to the open economy in 1977. Social determinants such as industrialization, urbanization, and the introduction of innovative information technology experienced over the last few decades significantly changed the behaviors of people, especially the youth in the country. As a result, the country had to address major challenges with this transition, such as unhealthy dietary practices, sedentary lifestyles, use of substances mainly tobacco, alcohol, and drugs, unsafe sexual practices, and engaging in violent activities of the youth population. Young people live in wide socio-cultural and economic contexts and share common challenges related to health, despite, many laws, policies, and guidelines being in place to promote health. This will lead them to face extra vulnerabilities and adopting unhealthy lifestyles in youth can lead to many health issues in later life.
Several health determinants influence the health status of persons including young people, and these

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MedNEXT Journal of Medical and Health Sciences include personal, social, economic, and environmental factors. It also includes income, education, physical environment, laws & policies, access and availability of health, and social support network. Investments in young people often produce a shorter time lag between costs and benefits compared to children, thereby having higher benefit-cost ratios [3]. Investing in young people brings out three main effects. These include reducing death and disability, promoting health and productivity across the life course, and providing the best possible start to life. Failing to invest in young people triggers substantial economic, social and political costs resulting from negative outcomes such as risky sexual behaviors, substance abuse, violence, and poor labor market entry. The overall losses to the society amount to several percent of the gross domestic product per year and that reaches into billions of dollars. Therefore, it is important to identify the existing environment and make recommendations to achieve the maximum investment for the future health of Sri Lankan youth. Thus, the objective of this paper aimed to review the current environment that is facilitating the health of young people in Sri Lanka.

Methods
The desk review was conducted to review the documents considered to be relevant, to understand how the policies and strategies have an impact on young people's health, in order to support a conducive environment to improve the health of young people. The relevant literature was searched through several databases (eg: Google Scholar, PubMed), websites, and documents relevant to health determinants retrieved from experts and key persons in the health and legal fields. More than 150 documents relevant to health investments for young person's health were identified and were categorized into different subcategories under the main subheading: reproductive and sexual wellbeing, non-communicable diseases, mental wellbeing, gender equity, substance abuse, and teenage pregnancy of Sri Lankan youth. It also identified the policy frameworks and investments in the fields of health, education, employment, social services, and other relevant fields related to youth. All relevant international conventions, policies, and laws relevant to youth in Sri Lanka were searched. Finally, all these findings were synthesized and a narrative report was given with key recommendations.

Results and Discussion
The desk review revealed a number of policies, laws, strategies, and programs in Sri Lanka which are supportive towards overseeing health promotion of young people and address the issues of youth in Sri Lanka in relevance to health, which ensures an environment that is supportive and conducive for health promotion. In addition to that, opportunities and a conducive environment were facilitated by allocating money for health and education which were directly related to the health of young people. The Sustainable Development Goal targets have made significant achievements. This includes reduction of poverty and unemployment and improvement of gender equity and health among youth during the recent past.
Globally, the average national percentage of total government expenditure devoted to education was 3.66% in 2019, and the latest available Sri Lankan figure for 2018 was lower than that (2.1%) [4]. In 2018, the health expenditure in Sri Lanka amounted to approximately 3.76 percent of the country's gross domestic product (GDP) [5]. Universal accessibility and participation in primary education are impressive and the primary education enrolment rate was 100% during the year 2019 [6]. The education system provides equal opportunities for both girls and boys. Limited resources available in Sri Lankan universities restrict enrolment of all eligible youth for university education. Even the private university education system cannot meet the demand. It is also evident that the undergraduate public education system is not properly oriented to the present demands in the job market in some fields.
Although there are vocational training opportunities established for the school-leaving youth to some extent, in 2013, 25% of youth who underwent vocational training in 2012 were unemployed. A study carried out in Sri Lanka revealed that being a youth with vocational training made them about 10.54% more likely to be unemployed than youth without vocational training [7]. In Sri Lanka, 4.1% of the population lived below the national poverty line in 2016 [8]. Although the overall unemployment rate was 4%, youth (ages 15-24) unemployment rate was 17.3% in the year 2012 [9]. The estimated youth unemployment rate was 20.79% in 2019 [10], while the study by Weerasiri and Samaraweera (2021) [7] showed that 16.8% of male and 30% of female youth were unemployed in Sri Lanka. Sri Lanka achieved 0.782 high ranks on the Human Development Index and was placed 72 out of 189 countries in the year 2019 [11]. Education plays a key role in lowering morbidity and mortality from diseases and reducing the unemployment rate. Sri Lanka shows contrasting data when compared to the other South-East Asian countries as the only country to offer free healthcare and education. Drastic reduction of maternal mortality in Sri Lanka after the establishment of a free education system in the country in 1945, coupled with the improvement of female child education, has been

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MedNEXT Journal of Medical and Health Sciences well-documented. The comprehensive healthcare in the public sector functions through a vast network of healthcare institutions and a network for services in preventive and curative aspects which reaches the grassroots. The preventive health services are provided mainly through the public health sector and are organized through the Medical Officer of Health offices with a catchment area of 60,000-100,000 people at the grassroots level [12]. Medical Officers of Health provide a range of services relevant to communicable and non-communicable diseases. The network of hospitals in the health sector comprises Teaching Hospitals, Provincial General Hospitals, District General Hospitals, Base Hospitals, Divisional Hospitals, and Primary Medical Care Units, and it has very limited youth-specific services except for youth clinics which are not functioning island-wide. The services available are also mainly for sexual and reproductive health including counseling. In the private sector, there are three main groups of providers: hospitals, clinics, and diagnostic services. Ninety percent of in-patient care is delivered within the public sector [13]. Out-patient care is delivered more equally between the public and private health sectors. The public sector does not provide youth-specific services except for a handful of clinics that are limited to the capital city. The concept of Adolescent and Youth Friendly Health Service was introduced in Sri Lanka in 2005. However, despite around fifty Adolescent and Youth Friendly Health Service centers being established by late 2008, there were only nine functioning centers by 2015. The reasons for closure or failure were identified as lack of demand due to unawareness and poor quality of services [14].
In the 2013 National Youth Health survey, 80% of youth were aware of nearby free general health services, but the knowledge on available sexual and reproductive health and mental health services were poor at 55% and 59%, respectively. It further revealed that the reason for poor accessibility to the services is the cost as indicated by 38% of youth, and out of the 50% mentioned that cost was covered by their parents [11]. These factors in particular hinder youth accessibility to health services. Relationships between youth and the field health workers facilitate reducing adverse health outcomes like teenage pregnancies. The demographic and health survey (DHS) 2016 revealed that 82.1% and 78.4% of ever-married women in the age of 15-19 years and 20-24 years who were not using contraception, did not discuss family planning either with fieldworkers or at a health facility during the past 12 months [15].
According to the Constitution of Sri Lanka (1978), equal fundamental human rights should be available for all. Further, all persons are considered to be equal before the law and equal protection of the law should be given to all, without discriminating anyone based on their race, religion, language, caste, sex, political opinion, place of birth, etc. Thus, the constitution in Sri Lanka provides access to everyone including young people for all services irrespective of their status and it identified that education is a right of young people. Sri Lanka has signed many international conventions which promote the health of people including young people and these international instruments provide a means to access health services and education for all without being discriminated against. Some of these international human rights instruments are the Convention on the Elimination of All In addition to that, several country policies and guidelines support directly and indirectly the access and provision of the health of youth. The Health Policy and Health Master Plan provide free of charge, accessible, efficient, cost-effective safe, and effective healthcare services to all without any discrimination. Sri Lanka was able to develop a National Youth policy in the year 2014, with the vision of 'developing young people to enable their active participation in national development for a just and equitable society [23]. This was complemented by the present governmental policies in "Sawbhagayaye Dakma" of Vistas of Prosperity and Splendour, 2019 [24]. It also ensures access to youth-friendly services [24]. The interventions in the policy have focused on reviewing and improving school health programs and expanding and strengthening physical, mental, sexual, and reproductive health education in schools. This policy has also pointed out how important continuation of these services as appropriate is to the higher education sector, which includes universities and technical and vocational training institutes [24].
The National Policy and Strategy on Health of Young Persons were developed by the Ministry of Health to promote and identify young people's health [25]. The commitment of the government to provide life skillsbased and age-appropriate education in a culturally acceptable framework that is gender-sensitive is ensured through this policy, and so is providing youthfriendly health services. The promotion of safe and responsible behavior among young people is also a The "Population and reproductive health policy" was produced in 1998 by the Ministry of Health. It focuses on population and reproductive health issues that are considered crucial, including safe motherhood, subfertility, induced abortions, reproductive tract infections, and sexually transmitted diseases. To overcome these issues, interventions like comprehensive family planning information, education, communication, and services through government, NGOs, and private sectors, have been mentioned in the policy. The policy provides an opportunity for ensuring the reduction of morbidity and mortality of health issues especially among specific segments of the population and enrich the health of young people. The health issues include STDs and HIV/AIDs. It intended to accomplish a better quality of life for its population by providing quality reproductive health information and services as well as achieving gender equality, providing healthcare and social support for the elderly, promoting economic benefits of migration and urbanization while controlling their social and health ill effects and reaching a stable population size in the long run. There were eight goals in the policy and strategies were listed [26].
In 2012, the Ministry of Health published the National Policy on Maternal and child health (No 1760/32). It comprehensively addresses the wellbeing of the mother and the child and also of the family. The need for providing the highest possible levels of health to all women, children, and families has been identified in the policy, to be achieved through providing comprehensive, sustainable, equitable, and quality maternal and child health services including family planning [27].
The National HIV/AIDs policy was developed with the objectives to prevent HIV and other sexually transmitted infections in Sri Lankans to improve the quality of life of people infected and/or affected by HIV/AIDS through minimizing stigma and discrimination and to provide quality care and support. These strategies emphasize how important safe and responsible behavior among youth and the general population is [28]. The National HIV/AIDs policy was further supported by the National strategic plan of HIV prevention 2018-2022, under the section which promotes youth interventions for preventing HIV infection [29]. This was further supported by the National Policy on HIV and AIDS in the World of Work in Sri Lanka. Around 7.6 million men and women comprise the workforce in Sri Lanka in the formal and informal sectors and these numbers are represented by the number of youth [30].
Although the Sri Lankan legal framework indicates the legal age of marriage as 18 years, any person can agree to sexual intercourse once they are 16 years or above [22]. This leads to an unsafe period of two years from 16 years to 18 years. Sri Lanka, due to its cultural norms and values, accepts only sexual relations among married couples. This results in sexual and reproductive health services only being meant for married people, thus creating a barrier in accessing services for youth between 16 to18 years. Despite having a comprehensive reproductive health education policy in the country in the school set up for a long time, as for sexual health, it doesn't adhere to the international standards. Teaching about condoms is considered taboo in the school set up except in the Advanced Level Biology stream. It is also identified that there is a lack of skill-based reproductive and sexual health due to a lack of skills among teachers to tackle sensitive areas due to cultural barriers. This was further revealed in the 2014 National Human Development Report 2014: Youth and Development, which showed that 59% of youth got reproductive health knowledge from schools, and almost half of them were willing to get the knowledge from school.
Abortions are a criminal offense under the Sri Lankan penal code except for therapeutic reasons. Therefore, the majority of female youth are exposed to unqualified private facilities where youth are put into life-threatening situations. Socio-cultural reasons and legal age of marriage direct them to illegal abortions. Sri Lanka National Human Development Report 2014: Youth and Development, further revealed that half of the youth didn't know about contraception. Out of those who were aware of contraceptive methods, 73% knew about condoms, which indicated the vulnerability of youth for HIV/STI infection. Sexual education in the school is taught only for the bioscience stream students, and none of the students from the other streams get the knowledge on sexual education at school. This evidence showed that youth are vulnerable to sexual and reproductive challenges [9].
The total fertility rate (TFR) for Sri Lanka  . These data indicate that urgent investment is necessary. It is important to pay special attention to the population groups and areas with high teenage pregnancies, and plan interventions addressing the root causes specific to them. Investments in the provision of contraceptives yield social and economic returns and reduce maternal and infant mortality. Demographic and Health Survey 2016 revealed that the contraceptive prevalence rate among women aged 15-49 years was 65% in Sri Lanka and was the highest level in the region. But it was only 43% for the currently married 15-19 years age group, and the value was equal to the lowest level in the region [15]. This indicates that the country needs to pay attention to improving the situation of young married women.
There are very few misleading legal frameworks that prevent youth from accessing sexual health services. Two laws in the Sri Lankan penal code (Vagrants Ordinance and sexual activity between persons of the same sex -article 365 & 365A) hinder access to sexual and reproductive health services for the high-risk youth [33]. This was evident by the increase of HIV among young MSMs (Men who have Sex with Men) and commercial sex workers during the last few years [34]. Further, Sri Lanka does not provide specific protection of human rights under anti-discrimination laws for Lesbian, Gay, Bisexual and transgender, including youth.
Gender stereotypes also interfere with the judgment of health workers, families, and teachers concerning the sexual, reproductive and mental health among youth whose sexual orientation remains uncertain, and this ends up in early school dropout. These transgender youth tend to engage in illegal activities for day-to-day living and end up in prisons where discrimination, sexual coercion, exploitation, and abuse are more common for transgender people. Educated youth are empowered in decision-making. Sri Lanka National Human Development Report 2014: Youth and Development showed that 75.1 % and 80.2 % of Sri Lankan youth respectively, had taken their life decisions on education and employment on their own. But almost half of the youth were influenced by their parents on their marriage indicating the need for further interventions.
Non-communicable diseases (NCDs) rapidly increased over the recent past in Sri Lanka, accounting for 65% of annual deaths [35], similar to other developing countries. Out of many other causes, demographic transition, industrialization, globalization, and changing behaviors such as smoking, use of alcohol, unhealthy diet and the sedentary lifestyles of people are the leading factors behind this evolution. It has been identified that the changing lifestyle of people is highly cost-effective in addressing this issue.
A life-course approach to health promotion is an important intervention, which leads young people to reach older age in a healthy platform. Initiating from the exclusive breastfeeding strategy, promoting a healthy school environment facilitates this healthy platform. The Ministry of Health of Sri Lanka had taken many steps by encouraging other stakeholders to adopt multi-sectoral national policies and plans over the last few years to reduce the NCD-related risk factors. Several studies including the Sri Lanka National Human Development Report 2014: Youth and Development showed that youth skip homemade meals and consume unhealthy food influenced by media advertisements. Although Sri Lanka has already taken important steps to reduce the NCD burden, these interventions should be strengthened, monitored, and evaluated further. Youth Friendly 'Content Marketing' communication interventions should be implemented through social media targeting youth. The STEP survey which was carried out island-wide in 2014-2015 revealed the prevalence of key NCD risk factors in Sri Lanka, which were high rates of tobacco and alcohol use, inadequate physical activity, unhealthy dietary behaviors, and low levels of health screening [35].
The country has insufficient capacity to cater to mental health services. Offending youth who stay for 3 years in the prison does not have a specialized mental health promotion package combined with courses for vocational training. These challenges could be addressed by strengthening the existing framework of mental health services. Human capacity development, psychiatric modalities, rehabilitation activities, and community-based health promotion services should be increased to meet these challenges. In 2020, a total of 3074 people have committed suicide in Sri Lanka. Out of them, 130 males and 84 females were in the 17-20 years age group, while 209 males and 86 females were in the 21-25 years age group [36]. According to the World Health Organization, the global suicide rate for 2019 was 9.2 per 100,000 people, while for the South-East Asia region, it was 10.1. The rate for Sri Lanka was

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MedNEXT Journal of Medical and Health Sciences higher than both the global and the South-East Asian region figures, with a suicide rate of 14.0. For males, the value was even more alarming at a rate of 22.3, while for the females it was 6.2 which was much lower. A study in Sri Lanka revealed that the age-specific suicide rates for females of 10-19 years and 20-29 years were 11.98 and 13.98 respectively, per 100,000 population in 2011. As for their male counterparts, the values were respectively 11.90 and 31.85 for the 10-19-year-olds and 20-29-year-olds [37]. The high incidence of homicides, self-inflicted injuries, and suicides are some of the major causes of death among youth. High levels of psychosocial stress could be linked to high rates of suicide and self-harm. The rise of mental health problems in Sri Lanka is a big problem and only 20% are getting treatment due to a lack of knowledge and stigma for accessing health care. Society excludes youth with mental disabilities, from societal life and this leads to denied opportunities to participate in decision-making that affects life decisions including marriage and having children. Further, this will restrict access to care, social integration, and recovery from the illnesses.
Substance abuse is a significant factor that affects all individuals and social systems. Irrespective of age, it impairs mental abilities and the physical skills of youth and enhances the long-run risk of developing cancers, lung diseases, ulcers, heart disease, and liver diseases. Further, this contributes to accidents, suicides, violence, sexual abuse, and poverty among youth. Peer pressure and stress can also result in substance abuse in youth, evidenced by the first use of a cigarette, or use of alcohol taking place during adolescence due to pressure from peers. Some youth continue to use them from then onwards. The STEPS survey carried out in 2015 shows the magnitude of the tobacco problem, where it is mentioned that nearly 45.7% of males of 15-69 years consume tobacco in either smoke or smokeless [35]. The Global Youth Tobacco Survey (GYTS), a crosssectional, nationally representative school-based survey of students of ages 13 to 15 years, recorded the prevalence of current use of any form of tobacco to be 3.7%, with 1.7% being current tobacco smokers and 2.4% being smokeless tobacco users in Sri Lanka [38].
The National Authority for Tobacco Act (NATA) 2006 is an important activity going on par with the Framework Convention of Tobacco Control (FCTC) [39,40], implemented in the country since 2006, prohibiting the sale of any tobacco or alcohol products to persons under twenty-one years of age. According to the National Size Estimation of Most at Risk Populations for HIV in Sri Lanka, the estimated average number of drug users in Sri Lanka was 12,618 on a usual day [41] and a fair number out of them belonged to the 15-24 years age group. Sometimes the lack of guidance, employment, and educational opportunities, push young people towards coping mechanisms that include smoking and substance abuse. Despite the various initiatives that had been implemented in the recent past for the prevention of youth using drugs, these rehabilitation programs have not yet produced fruitful results.
Young people with special needs face challenges and their knowledge on health, accessing of healthcare services & health communication is minimum, and no sign language interpreters are there at the hospital setup except at the court level judicial system. At present, Sri Lankan youth are contributing more to national development compared to the regional countries, aided by national strategies. However, certain areas need improvements including health. Further, several challenges have emerged highlighting the urgent need for such improvements including public health challenges. Though many services related to health and social services are made accessible and available to youth, services are not friendly due to cultural norms and societal attitudes of some communities. Overcoming these challenges will need the provision of services in a youth-friendly manner, including recourses for preventing teenage pregnancy, contraception, HIV/STI prevention, testing, counseling, treatment, and care. The need for age-appropriate comprehensive sexual education in school setup is highly important to overcome these negative cultural norms.
Accelerated progress and further reforms in education are required to accommodate the current needs of the country, to generate a healthy youth population. The focus should be on the skill-based education system, which is aligned with the needs of the labor market, such as enhancing computer literacy. Recently, Sri Lanka succeeded in overcoming human development challenges typical of a low-income country, and now it is time to excel in its service delivery systems in education, health, and other areas typical of a middle-income country. Free youth-friendly health services should be expanded to meet the demand of youth, and awareness of services should be enhanced. Comprehensive sexual education is recommended in addition to this.

Conclusion
Through this review, it was revealed that there are many supportive policies, laws, plans, guidelines, strategies, and programs in Sri Lanka overseeing the structure of the health of young people in the country and ensuring a supportive and conducive environment for youth to access for sexual health services. Youth in

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MedNEXT Journal of Medical and Health Sciences Sri Lanka are enjoying many achievements in the areas of education, health, and policies through investments in different fields, although there are certain challenges and gaps yet to be addressed. Investment for restructuring of school and higher education systems has a direct effect on promoting the health status of youth. The majority of health issues are not isolated events and cannot be intervened alone without the larger social context. Therefore, they should be addressed within the existing framework by giving special emphasis in a youth-friendly manner.
Further investment is required to improve knowledge, self-esteem, and life skills to ensure healthy development. Advocating the gatekeepers at the family, school, community, and service provider levels is necessary for this. Investment for an urgent change of attitudes among existing staff for youth-oriented, mental, reproductive, and sexual health services would provide a conducive environment for youth to improve accessibility to their needs and overcome a majority of their health issues within the existing legal framework. However, still, there are certain areas to be reformed, and the need for amendments to the legislation was observed.
The existing youth-oriented policies can resolve a majority of health problems and the need is for urgent reforms with a strong regular monitoring system rather than developing more and more policies. The government needs to impose an integrated and coordinated approach for the improvement of health and well-being for young people. These approaches should be targeted beyond the prevention and treatment of diseases and should focus on conditions and enabling environments in youth-friendly services necessary for young people to lead healthy lives free from coercion, discrimination, violence, and stigma.

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MedNEXT Journal of Medical and Health Sciences