Background
Methods
The problem: |
In many low and middle income countries, there was widespread recognition that adolescents were not obtaining health services, and that this led to missed opportunities to prevent health problems and respond to them when they occurred. |
Nongovernment organizations (NGOs) were the first to respond to this need by establishing stand-alone Adolescent Friendly Health Services (AFHS). There was no agreed upon definition of what AFHS meant, although many NGO efforts aimed to make health workers non-judgemental and empathic, make health facilities welcoming and to ensure confidentiality. |
Ministries of Health called for WHO guidance to draw upon experiences gained in small-scale and often time-limited nongovernmental projects to make government-run health workers and health facilities more responsive to adolescents. |
WHO’s response to the problem: |
Gathering and synthesizing evidence: |
1. WHO defined attributes of Adolescent Friendly Health Services based on implementation experience and research evidence and placed these attributes in a quality of care framework [5]: |
• Accessible: Adolescents are able to obtain the health services that are available |
• Acceptable: Adolescents are willing to obtain the health services that are available |
• Equitable: All adolescents, not just some groups of adolescents, are able to obtain the health services that are available |
• Appropriate: The right health services (i.e. the ones they need) are provided to them |
• Effective: The right health services are provided in the right way, and make a positive contribution to their health |
Taking evidence to action: |
Beginning in 2001, WHO worked with partners within and outside the United Nations system to support Ministries of Health to: |
1. Develop national quality standards using the five-step process outlined in WHO’s tool Making health services adolescent friendly: developing national quality standards for adolescent friendly health services [5]; |
2. Improve the quality of health service provision through complementary actions at the national, district/municipal and local levels as described in annex 2 of the above tool [5]; |
3. Assess the quality of health service provision using national adaptations of WHO’s toolkit: Quality assessment guidebook: A guide to assessing health services for adolescent clients [6]; |
4. Assess the coverage of health services using national adaptations of WHO’s tool kit: Coverage assessment guidebook: A guide assessing the coverage of quality health services for adolescents [7]; |
5. Share the findings of the quality and coverage assessments at the national level, and use them to address areas of weakness as part of the ongoing effort to improve the quality of health service provision to adolescents. |
Results
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The accessibility and acceptability dimensions of quality were highly adequately addressed in five of the eight countries and moderately adequately addressed in another three of them.
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The equity dimension of quality was highly addressed in one of the eight countries, moderately adequately addressed in one, not fully adequately addressed in three and absent in three.
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The appropriateness dimension of quality was highly adequately addressed in two of the eight countries, moderately adequately addressed in two, not fully adequately addressed in three and absent in one.
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The effectiveness dimension of quality was highly adequately addressed in five of the eight countries, moderately adequately addressed in two and not fully adequately addressed in one.Table 2 contains a detailed analysis of this.
Country | Accessibility | Acceptability | Equity | Appropriateness | Effectiveness |
---|---|---|---|---|---|
Bangladesh [10] | Highly adequate | Highly adequate | Highly adequate | Moderately adequately | Moderately adequate |
Standards 1, 2, | Standards 3, 4, 6 | Standard 5 | Standard 8 | Standard 9 | |
India [11] | Highly adequate | Moderately adequate | Not fully adequate | Highly adequate | Moderately adequate |
Standards 1, 5, 6 | Standard 3 | Standard 1 | Standards 1, 2 | Standard 2 | |
Indonesia [12] | Moderately adequate | Highly adequate | Absent | Not fully adequate | Highly adequate |
Standards 3, 4 | Standards 1, 2, 3, 4 | Standard 2 , | Standards 1, 2, 5 | ||
Malawi [13] | Moderately adequate | Moderately adequate | Absent | Not fully adequate | Highly adequate |
Standards 2, 3 | Standard 3, 4 | Standard 2 | Standards 1, 4, 5 | ||
Moldova [14] | Highly adequate | Moderately adequate | Moderately adequate | Absent | Not fully adequate |
Standards 1, 2, 4 | Standard 3 | Standard 6 | Standard 5 | ||
Mongolia [15] | Highly adequate | Highly adequate | Absent | Highly adequate | Highly adequate |
Standards 3, 4 | Standards 2, 3, 4 | Standards 1, 4 | Standards 1, 3 | ||
Tanzania [16] | Highly adequate | Highly adequate | Not fully adequate | Not fully adequate | Highly adequate |
Standards 1, 7 | Standards 3, 6 | Standard 2 | Standard 6 | Standards 2, 3, 4, 5, | |
Ukraine [17] | Moderately adequate | Highly adequate | Not fully adequate | Moderately adequate | Highly adequate |
Standards 3, 5, 9 | Standards 3, 4, 9 | Standard 5 | Standards 7, 8 | Standards 2, 6, 10 |
Country | What was the context in which quality was assessed? | Who did the quality assessment? | What were the objectives of the quality assessment? | What were the findings of the quality assessment on the acceptability dimension of quality (i.e. adolescents are willing to obtain the health services that are available)? |
---|---|---|---|---|
What methods were used in the quality assessment? | ||||
Bangladesh [18] | National quality assessment study | National research institution with support from WHO | Objectives: To assess compliance of the quality of health service provision with the 10 national standards and to determine if there were differences between intervention and comparison health facilities. | Performing well: Young People feel comfortable with the surroundings and procedures of Health Service Delivery Points 74% versus 66%. |
Need some improvement: The privacy and confidentiality of all young people who visit delivery points is maintained 63% versus 58% | ||||
Service providers are motivated to provide health services to young people in a youth friendly manner 66% versus 63%. | ||||
Methods: Quality assessment in 44 intervention and 44 comparison facilities | ||||
India (Haryana state) [19] | State level quality and coverage assessment study | Nongovernment organization with support from WHO | Objectives:To assess compliance with national standards and to determine if there were differences between intervention and comparison health facilities. | Performing well: Adolescents find the environment at health facilities conducive to seek services 86% versus 33% |
Service providers are sensitive to the needs of adolescents and are motivated to work with them 94% versus 59% | ||||
Methods: Quality assessment in 10 intervention and 10 comparison health facilities | ||||
Both samples consisted of 2 Primary Health Care centers and 8 Sub-centers. | ||||
Indonesia [20] | National level quality assessment survey | Ministry of Health with support from WHO | Objectives:To assess compliance with national quality standards. | Performing well: Adolescents are satisfied with the services 73%, health providers have positive attitudes about working with adolescents 73% |
Methods:Cross sectional study of 62 adolescent friendly Primary Health Centers | Need some improvement: Adolescent perceive that their confidentiality will be respected 42% | |||
Need considerable improvement: Adolescents feel comfortable about using the health services 38%; staff ae oriented on adolescent friendly health services 27%; services are provided outside regular hours 9%; adolescents are engaged in planning 10%; adolescents are engaged in monitoring 3%; mechanisms are in place to ensure privacy 18% | ||||
Malawi [21] | National level quality assessment study to assess readiness for accreditation | National youth council of Malawi and Ministry of Health, Malawi with the support of UNFPA | Objectives:To assess compliance with national quality standards. | Performing well: Privacy and respect for adolescents 83% |
Methods:Cross-sectional study involving 266 randomly sampled sites | Need some improvement: Involvement of young people 60%; availability of educational materials 50%; support staff oriented on youth friendly health services 51% | |||
Need considerable improvement: Recreational materials are available 37% | ||||
Moldova [22] | National level quality assessment study | National working group with support from WHO | Objective: To study the compliance of Youth Friendly Health Services with national quality standards. | Need some improvement: Service providers respect youth confidentiality and privacy 68% |
Methods: Assessment of 12 Youth Friendly Clinics | ||||
Mongolia [23] | National level quality assessment study | Consultant team engaged by Ministry of Health and supported by WHO | Objectives: To compare the quality of health facilities in intervention and comparison sites. | Performing well: Written confidentiality policy 86.3% versus 7.1%; providers respect adolescent opinions 82.1% versus 47.6% ; Information Education and Communication services provided 98% versus 75%,; receptionists are friendly 92.9% versus 82.9%, doctors are friendly 96.1% versus 86.5%; waiting area is comfortable and convenient 71.7% versus 18.8% |
Methods: Assessment of quality in 82 sites (51 intervention sites and 31 comparison sites), to determine which dimensions of quality and most important for client satisfaction. | ||||
Need some improvement: Toilets are of good quality 53.2% versus 42.9%,youth participation present 45.5% versus 27.1%, confidentiality policy is posted 48% versus 0%; clients are satisfied with services 45% versus 33% | ||||
Need considerable improvement: Long waiting time (15.4% versus 10.2%), written policy on patient consent 13.7% versus 0% | ||||
Tanzania [24] | National level quality assessment | Nongovernment Organization on behalf of the Ministry of Health | Objectives: To assess compliance with national quality standards. | Performing well: Service Delivery Points ensure privacy and confidentiality78%; clean and appealing 72% |
Methods: Cross-sectional survey involving 90 health facilities randomly chosen. Nine districts of mainland Tanzania were involved, covering all 8 Ministry of Health and Social Welfare zones. | ||||
Ukraine [25] | National level quality assessment study | Academic institution with the support of the Ministry of Health and UNICEF. | Objectives: To compare progress made in compliance with national standards, with the findings of a previous assessment. | Performing well: Friendly behaviour from registration staff 90%; mentioned similar treatment by physicians and psychologists 95%; clients reported specialists were not distracted by external interruptions 97 |
Repeat Evaluation report | Methods: Repeat assessment in 23 Health Centres |
Country | Context in which health service utilization by adolescents was measured | Who did the measurement? | Methods used in the measurement | Results of the measurement of service utilization by adolescents |
---|---|---|---|---|
Bangladesh [18] | National quality and coverage assessment | A research institution with support from WHO | Household coverage survey | Though 49 % of the youth in the intervention areas and 54 % in the comparison areas reported visiting a health service provider in the period six months prior to the survey, this difference was not significant |
India [19] | State level quality and coverage assessment study | Nongovernment organization with support from WHO | Household coverage survey carried out in the catchment area of health facilities - 10 village clusters around 10 intervention sub-centres and 10 village clusters around 10 comparison sub-centres | For government-run health facilities, the utilization of health services in the intervention health facilities was higher than that in than the comparison facilities. |
Indonesia [20] | Managers and staff of 62 health facilities surveyed reported that service-utilization by adolescents was increasing but there was no data to back up their impressions. (20) | |||
Data on health service utilization was not available from the Ministry of Health. Data from a project in Aceh province, Indonesia showed both improvements in quality and increases in service/utilization [26]. | ||||
Malawi [21] | District level project on improving access to sexual and reproductive health services for adolescent girls | Joint United Nations programme on adolescent girls in conjunction with the Ministry of Health at the national and Chikwawa district level | Assessment of service statistics | In 2011, there were 12 visits by girls aged 10–14 years and 330 visits by girls aged 15–19 years. In 2012 there were 163 visits by girls aged 10–14 years and 512 visits by girls aged 15–19 years. |
Moldova [22] | External review of a project to scale up adolescent friendly health services nationwide | Independent team of consultants engaged by the Swiss Development Cooperation Agency with support from the Ministry of Health | Household coverage survey and assessment of service statistics | In 2009 - 5 % young people reported using youth friendly health services (30 % boys and 70 % girls). In 2012, 12 % (38.7 % boys and 61.3 girls) did so. |
Mongolia [23] | Nationwide survey of quality and coverage of health service provision for adolescents | Consultant team engaged by Ministry of Health and supported by WHO | Assessment of service statistics from 82 health facilities complemented by a school based coverage survey | The number of boys aged 14 – 18 who used services increased from 15,575 in 2008) to 30,741 in 2010. The number of girls aged 14 – 18 years who used services increased from 29,852 in 2008 to 57,236 in 2010. Similarly, the number of boys aged 18–24 s who used services increased from 6,914 in 2008 to 17,381 in 2010. And the number of girls aged 18 –24 who used services increased from 13,876 in 2008 to 32,072 in 2010. |
Tanzania [24] | Data on health service utilization was not available from the Ministry of Health. Data from a multisite project in the country showed both improvements in quality and increases in service/utilization [27]. | |||
Ukraine [25] | National level quality assessment study - repeat evaluation | Academic institution with the support of the Ministry of Health and UNICEF | Analysis of service statistics | Data emanating from evaluations carried out in 2008, 2009 and 2010, show a steady trend in the increase in service utilization both for the younger and the older age groups of adolescents. |