Key informants’ perspectives on policy- and service-level challenges and opportunities for delivering adolescent and youth-friendly health services in public health facilities in a Nigerian setting

The high benefit-to-cost ratio of investing in adolescent and young people’s health and wellbeing is well recognized globally [1, 2]. Many low and middle income countries have taken this cue by investing substantially in initiatives and interventions to promote the health of adolescents and young people (AYP) [3]. This includes development of national standards for adolescent health services following the launch of World Health Organization’s (WHO) Global standards for quality of health-care services for adolescents [4]. Despite this, adolescent and youth-friendly healthcare services (AYFHS) are still widely unavailable at primary and secondary healthcare levels in a country like Nigeria [5, 6]. Most services provided at these facilities are focused on care for the general population [7]. This situation is also observable in many high, middle, and low-income countries [8]. Integrating care of adolescents into existing public health facilities requires deliberate efforts. According to Goicolea et al [9], an AYFHS that will be successful requires legitimacy, the self-confidence of the implementers in trying new things, a transformative process, and an integral approach to provision of services to adolescents while ensuring that contextual factors at the national, local, and institutional levels are adequately catered for.

Barriers to the provision of optimal health services to adolescents and young people include structural, sociocultural and individual barriers [10]. The structural barriers include laws and policies that limit access to services, non-availability of infrastructure, and service characteristics such as long waiting time, inconvenient hours, lack of commodities, cost of services, and lack of privacy and confidentiality. Closely associated to these are sociocultural factors that drive negative attitudes of health workers toward providing AYFHS, including restrictive norms and stigma concerning adolescents’ sexuality. The situation is further compounded by the low competency of health workers to provide optimal adolescent health services as well as a lack of synchronization of adolescents’ and young people’s wants with policy priorities [11, 12]. Individual barriers occur at the level of the adolescents including incorrect knowledge (including myths and misconceptions), limited self-efficacy and individual agency, and lack of access to correct information, among others [10]. In order to make significant progress in assuring optimum health for AYP, the key policy, programmatic and service-level stakeholders at both national and sub-national levels need to understand adolescent-specific issues [13]. This will enable them to run a system that has addressed values and morals that may conflict with providing care services to adolescents and young people [14], and be able to assure service recipients of confidentiality and privacy [8, 15].

To integrate AYFHS into the public health facilities in Nigeria, the national government developed the National guideline for integrating adolescent and youth-friendly services into Primary Health Facilities (PHC) in Nigeria in 2015 and the revised National Standard and Minimum Package for Adolescent Healthcare in 2018 [16]. The recommendation in the National Standard document for applying the national standards at the sub-national levels includes, the commitment of the state and local government administrative leadership, the commitment of the local government health management team to provide supportive supervision, and the existence of an organization (non-governmental or community-based) or health-related training institution involved in providing health education and counseling services to adolescents.

Recently, Ogun State in Southwest Nigeria launched the Ogun State Adolescents and Young People’s Sexual and Reproductive Health Strategic Framework (2018 – 2022) document [17]. The framework covers strategic priority areas—including pregnancy prevention and care, the prevention of sexually transmitted infections, and health promotion—and defines each stakeholder’s roles and responsibilities (Fig. 1). This strategic framework is the first of its kind among the States in Nigeria, and puts Ogun State in a position to provide leadership and example in programming for AYP at the state level. The role of the policy-level participants and healthcare worker are critical in supporting this framework. Policy-level stakeholders for adolescent health include government officials from health-related ministries, departments, and agencies, as well as others from local and international non-governmental organizations, and the academia. Their activities help to facilitate an environment that gives a premium to the health of AYP. In the same manner, healthcare workers, who work at the frontline, are indispensable in revamping a health system that has been traditionally unfriendly to adolescents and young people, particularly as it relates to sexual and reproductive health.

With the launch of a strategic framework for adolescent reproductive health in Ogun State, the four mechanisms of Goicolea et al [9] for successful AYFHS are taking shape, starting with legitimacy through to ownership, grounded self-confidence in trying new things, the transformative process, and an integral approach to adolescents. In the wake of Ogun State’s implementation of its new framework, it is vital to study and understand some of the contextual factors that are likely to promote or prevent successful ASRH policy adoption and uptake. This research assesses key informants’ perspectives on policy and service-level challenges and opportunities for delivering AYFHS in public health facilities. Findings from this research will help to guide policymakers and program designers in addressing the factors associated with the provision of adolescent health services in the study area and beyond.

Among the 17 key informants interviewed, five were State-level Ministry of Health officials, and five were LGA-level health officials (Table 1). There were two participants who were staff of NGOs operating within the state, two lay members of the ASRH TWG, and two youth representatives. Eight of the participants were males, while nine were females.

The large population of AYP in many developing countries like Nigeria make them to be important targets for health interventions. Supporting their transition into healthy adulthood must continue to be a policy priority. According to an adolescent health and development situation analysis conducted by the Nigeria Federal Ministry of Health in 2018 [11], “Most States have appointed adolescent health and development (AHD) desk officers in the ministries of health but with no program direction, plan and budget, there is very little that they can do. Except Lagos state”. The implementation of a strategic framework for adolescent health in Ogun State is changing this narrative. The other States in the country need to take the cue to develop their strategy. However, the promoters in the various states must seek favourable policy windows to ensure successful uptake of the adolescent health-oriented policies just as was done in Ogun State.

Findings from this study indicate that health workers continue to have a negative attitude towards adolescent and young people’s sexual and reproductive health. Mchome et al [25] similarly showed healthcare workers having paternalistic/maternalistic attitudes while lacking knowledge about ASRH services. This discourages young people from using services such as condoms and family planning methods. Some of the challenges that need to be addressed include knowledge of health workers about existing adolescent health policies, competency regarding counseling and interpersonal communication, conflicting personal feelings, cultural and religious values, and beliefs concerning ASRH [14, 25, 26]. Approaches to reducing the negative attitude of health workers to sexual and reproductive health issues of AYP lie in training and retraining of health workers. These should include updating pre-service curriculum, in-service training of all cadres of health workers, and retraining from time to time, on contemporary adolescent sexual and reproductive health issues. This competency-based education in adolescent-responsive health-care is what the World Health Organization (WHO) supports through its “Core competencies in adolescent health and development for primary care providers” document [27]. The document also includes a tool to assess the adolescent health and development component in pre-service education of health-care providers. Given the cultural context within which ASRH exists in many lower income countries, desensitization to ASRH issues among health workers may also be needed to make them less judgmental, and more accepting and understanding of AYP and their peculiarities. Institutionalizing adolescent responsive elements into existing contraceptive services has been successful at a high impact level by making the services responsive to the needs and preferences of adolescents and young people [28].

The findings that there is some level of inclusion of AYP living with disabilities in ASTH programming is welcome and extremely important. The 2018 Nigeria Demographic and Health Survey [29] indicates that up to 7% of household members older than five have some difficulty in at least one functional domain while at least 1% cannot function independently or have a lot of difficulty in doing so. Persons with disabilities suffer from the inability to access basic services, including health care, along with discrimination and stigmatization mostly because of absent, weak, or inadequately executed inclusive policies [30]. This is likely to be even more acute among AYP living with disabilities. It was reported in this study that it was challenging to locate some of these vulnerable people in order to include them in interventions. However, the ongoing efforts must continue. Adolescent health policy implementation must be further strengthened to provide the enabling atmosphere for the protection of these more vulnerable AYP [31]. Such efforts must also include involving young people, including those living with disabilities, in the design, implementation, and evaluation of the AYP SRH programs [32].

It is a critical finding that the coordination of activities of donors/partners working in the adolescent health space is insufficient. This pattern of lack of donor/partner coordination is also demonstrated in the study by Makinde et al. [33] where between 2010 and 2016, there were ten different donor-funded health facilities listing efforts within the country, indicating duplication of efforts. The increased number of donors focusing on one area has led to duplication of efforts, and concentration of intervention [33, 34]. The best approach to managing donor activities perhaps is to design a coordination mechanism [35]. Also, without coordination, competition among donors may shift their focus away from the business of providing aid to a fight for market recognition [36]. This is one of the reasons a technical working group at the state level is always necessary, which will be tasked with creating a platform for all stakeholders to interact. Coordinating activities can include mapping of all partners, their areas of activities (including geographical location), and compulsory registration of all interventions being carried out by any partner. The mapping will also help to avoid program concentration in a few places and/or overlap of efforts.

Another gap we found in this study is the missed opportunity to strengthen policy implementation with research. Activities for ASRH in the State didn’t seem to involve academic institutes within the state. A likely reason for non-involvement of academic institutes in ASRH within the state is because many programs are supported by partners who usually have their compliments of researchers/consultants, often from outside the location of intervention. This is partly demonstrated by the eligible participant in this study who declined participations because of organizational policies. The challenge in this setup is that local research capacity is not retained within the state to meet future needs after the funded program has ended. To bridge such gaps, the academic institutes must also be proactive in seeking a ‘seat at the table’. Researchers in Ebonyi State, Nigeria started the Health Policy Advisory Committee (HPAC), as a health policy advisory committee to facilitate knowledge translation through capacity building, mentorship, and stakeholder policy dialogues [37]. This effort was reported to have promoted cooperation between policy-makers and researchers. This lays credence to the argument of Hawkes et al. [38] that evidence-informed policy can be sustainable when institutional capacity and proper management of the political environment occurs. There is an opportunity in Ogun State to institute a viable research-based policy implementation process if these recommendations are followed.

There seems to be a political will for promoting the health of adolescents in the Ogun State that stakeholders can leverage on. Presence of political will is a window of opportunity to leverage funding for adolescent health services through the internal funding called the Basic Health Care Provisions Fund (BHCPF). The BHCPF is a statutory allocation of not less than 1% (revised to 2% following revision of the law in 2022) of the Consolidated Revenue Fund (CRF) – that is, the total Federal Revenue before it is shared with all tiers of government [39]. It is to be used to provide a basic package of services in primary health care facilities through the National Health Insurance Scheme (NHIS), the National Primary Health Care Development Agency (NPHCDA), and the Federal Ministry of Health. Its contribution of 25% in counterpart-funding towards specified primary health care (PHC) projects could be very useful in improving health services for young people. Policy stakeholders should use advocacy and communication to make a case for funding adolescent health through this internal fund.

Sustainability is always a challenge when programs are externally funded by donors. The World Health Organization defines sustainability as the ability of a project to continue to function effectively, with high treatment coverage, and integrated into available health care services, with community ownership, and community and governmental funding using resources mobilized by the community and government [40]. Often, lack of funding is the most critical threat to sustainability. Policy stakeholders must be innovative and creative in addressing these funding challenges. In addition to the BHCPF already identified, there may be local funders interested in promoting these services. We recommend that policymakers within the state should actively seek out funders, for instance, manufacturers of menstrual sanitary products. Some of these factories are located within Ogun State, and are easily accessible [41].

One of the recommendations provided by a participant in this study was the need for increased focus on other aspects of adolescent and young people’s health including their mental health, and substance use, among others. Looking into the future, SRH of adolescents should be used as a springboard for mainstreaming other aspects of adolescent health. Taking an integrated approach to the health of adolescents and young people can enable such a procedure [42]. While this integrated approach is enshrined in the Ogun State adolescent reproductive health strategic framework, its implementation was less evident.

This study provided the context of the implementation of the strategic framework for adolescent reproductive health in a Nigerian setting from the perspectives of policy- and service-level stakeholders. The findings indicate the need for continued implementation of adolescent-responsive contraceptive services, increasing the reach of programs to adolescents living with disabilities, stronger coordination among partners, and leveraging new sources of funding. Opportunities for improving program delivery identified include ensuring research-based policy implementation and seeking program sustainability through tapping into internal funding such as the Basic Health Care Provisions Funds (BHCPF).