1. Reaching adolescents through health services
October 2016
Reaching adolescents through health services
Dr V Chandra-Mouli
Training Course in Sexual and Reproductive Health Research
Geneva 2016

2. What do we mean by the term health services ?
The provision of a clinical service, which often includes the provision of information, advice & counselling aimed at preventing health problems, or detecting & treating them.
Here is a working definition.

3. Reaching adolescents through health services
1. Adolescent Friendly Health Services: What is the reality on the ground ? ?
Filename

4. Factors that make it difficult for adolescents to obtain the health services they need - 1
Not available
In many places, health services such as emergency contraception are just not available to anyone, either to adolescents or to adults. In many other places where these health services are in fact available, restrictive laws and policies may prevent them from being provided to some groups of adolescents (e.g. in many places, laws forbid the provision of contraceptives to unmarried adolescents). What this means is that although these services are - for all practical purposes - not available to adolescents.

5. (i.e. all right for some but not others)
Factors that make it difficult for adolescents to obtain the health services they need - 2
Not accessible
(i.e. not able)
Not acceptable
(i.e. not willing)
Not equitable
(i.e. all right for some but not others)
Even where health services are available, adolescents may not be unable to obtain them for a variety of reasons (e.g. health facilities may be located a long distance from where they live/study/work; or health services may be expensive and beyond their reach). What this means is that health services are not accessible to them.
Health services may be delivered in a way that adolescents do not want to obtain them, even if they can. One common reason for this is that they have to go to and wait in a place where they could be seen by people who they know. Other reasons are the fear that health workers will scold them, ask them difficult questions, and put them through unpleasant procedures; or that health workers will not maintain confidentiality. What this means is that the health services are not acceptable to them.
Finally, health services may be 'friendly' to some adolescents, such as those from well to do families, but may be decidedly 'unfriendly' to others, such as young people living and working on the streets. In other words, they may be available, accessible and acceptable but not necessarily equitable.
Not surprisingly, in many parts of the world, adolescents are reluctant to seek help from health facilities. If and when they do seek help, they are more often than not likely to leave discontented and unhappy with the way in which they are dealt with, and determined not to go back, if they can help it.

6. Initiatives are under way in many places to provide adolescents with health services
Hospitals
Public, private and NGO clinics
Pharmacies
Youth centres
Educational institutions
Work places
Shopping centres
Refugee camps
On the street
There is widespread recognition of the need to overcome the many barriers that hinder the provision and utilization of health services to adolescents, and to make it easier for adolescents to obtain the health services they need. Initiatives are being undertaken in many countries, to reach adolescents with the health services they need in a variety of settings (shown on this slide).

7. Initiatives are under way in many places to provide adolescents with health services
Hospitals
Public, private and NGO clinics
Pharmacies
Youth centres
Educational institutions
Work places
Shopping centres
Refugee camps
On the street
Attributes not clear
Short time frame
Low & patchy reach
In many cases, the adolescent friendly attributes of these initiatives is not clear.
Again, with some noteworthy exceptions, the many of these initiatives have a short time frame and have a low and patchy reach.

8. Reaching adolescents through health workers & health services
1. Adolescent Friendly Health Services: What is the reality on the ground ?
2. What is WHO doing to improve the quality and expand the coverage of health services to adolescents ? ?
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9. # 1. Using strategic entry points, to move the wider adolescent health agenda
Overall goal
To improve the health & development of adolescents.
HIV/AIDS
1. Prevention of too early pregnancy
2. Prevention of deaths in
pregnancy & delivery
In many countries, HIV and other reproductive health issues are recognised as important public health priorities. There are national HIV/AIDS and Reproductive Health programmes with human and financial resources in place.
In growing numbers of countries either one or both these programmes are recognising the importance of addressing adolescents. In some countries, we have used the HIV/AIDS programme as the entry point, and in others we have used the Reproductive Health programme as the entry point.
Whatever the entry point, we encourage countries to address HIV and other reproductive health issues in an integrated manner. We also encourage them to address other health issues of importance such as substance use and mental health, for which often there are no tangible programmatic entry points.
Substance Use
Mental Health
Intentional & accidental injuries

10. # 2. Being clear about the main purpose of delivering health services
1. What are the health outcomes we are aiming for.
2. What is the place of health service provision to adolescents within the overall strategy ?
3. What is the package of health services to be provided, to achieve the health outcomes we are aiming for ?
4. Where and by whom should these health services be provided ?
We strive hard to be clear about what health outcomes we are aiming for, and what health services need to be provided to achieve this.

11. # 3 Identifying the groups in the adolescent population whom we need to reach
Adolescents are a diverse population group.
Not all adolescents are equally vulnerable.
We recognise that adolescents are a very diverse group.
We need to identify which segments in the adolescent population we need to make a particular effort to reach with health services and how best to reach them.

12. Hospital NGO clinic clinic clinic
# 4. Being clear about where & by whom health services are to be provided ?
Private
doctor
Pharmacy
Hospital
NGO
Traditional
healer
If we look at a typical town, there are different organisations that are (or could be) providing adolescents with the health services they need. These organisations are somewhat different in nature – in staffing and facilities. They are also likely to be reached by different groups of adolescents.
We strive to define the special contribution that each of these health service delivery points could make.
clinic
clinic
clinic

13. A focus on building on what already exists.
Working to make existing service-delivery points more "friendly" to adolescents.
Setting up new service-delivery points exclusively intended for adolescents.
Our focus is on working to make existing service-delivery points which provide health services to all segments of the population, more 'friendly' to adolescents, rather than on setting up new service-delivery points exclusively intended for adolescents.
A focus on building on what already exists.

14. # 5. Setting out to do more than just make health services "friendly"
Utilization
Striving to ensure that adolescents are able & willing to obtain the health services they need.
Provision
Striving to ensure that the services that adolescents need are in fact being provided & are being provided in the right manner.
We are working to make health-service provision more friendly, so that adolescents are more likely to be able and willing to obtain the health services they need. At the same time, we are working to ensure that the health services that adolescents need to stay healthy or to get back to good health are in fact being provided, and are being provided in the right manner.
In other words, we are working to improve health service provision, and to increase health service utilization.

15. Utilisation Provision # 6. Using a quality framework
for health-service provision to adolescents
Utilisation
Provision
Accessible
Acceptable
Equitable
Appropriate
Effective
Efficient
We use a 'quality of care' framework to guide our work on health service provision to adolescents.
Such a framework brings together these two complementary issues – provision and utilisation:
Providing adolescents with the health services they need.
Making it easier for adolescents to obtain the health services they need.
The dimensions of quality that relate to the utilization of health services by adolescents are accessibility, acceptability and equity.
Accessibility addresses whether adolescents are able to obtain the health services they need.
Acceptability addresses whether adolescents who are able to obtain the health services they need, are in fact willing to do so.
Equity addresses whether different population groups of adolescents (and especially marginalised ones) who need the services are in fact able to obtain them.
The dimensions of quality that relate to the provision of health services to adolescents are appropriateness, comprehensiveness and effectiveness:
Appropriateness addresses whether the health services that are being provided at the point of delivery are appropriate to the needs of the user. For instance, if the patient seeks help for the management of STI, and these services are not being provided, there is clear mismatch.
Comprehensiveness addresses whether all the health services provided address all the required aspects (including bio medical as well as psycho-social aspects). For instance, the patient with STI needs to be diagnosed and treated. In addition he/she will need advice and counselling support on partner notification and preventing re-infection.
Effectiveness addresses whether the health services provided bring about positive changes in health status.

16. A definition of adolescent friendly health services grounded in quality
Accessible - Adolescents are able to obtain health services.
Acceptable - Adolescents feel willing to obtain health services.
Equitable - All adolescents - including marginalized groups of adolescents - are able & feel willing to obtain health services.
Appropriate - The health services that adolescent users need are provided on the spot or through referral linkages.
Effective - The health services provided help well-adolescent users stay well, & ill-adolescent users get back to good health.
Our definition of adolescent friendly health services is grounded in the quality framework.

17. # 7. Using a standards-driven quality improvement approach
What is a standard ?
A standard is a statement of required quality.
How can standard-driven quality improvement contribute to our work ?
1. By setting clear goals for the quality of different aspects of the functioning of service-delivery points.
2. By providing the basis for assessing the achievement of these goals.
3. By providing the basis for identifying what needs to be done to achieve the goals.
We use a standards-driven quality improvement approach.

18. Standards-driven quality improvement
1. Standards set clear goals.
They make explicit the definition of quality required.
Required quality.
2. Standards provide the basis for assessing whether goals have been achieved.
They provide a clear reference against which quality can be assessed/compared.
Gap between required and actual quality.
3. Standards provide the basis for
identifying what needs to be done to achieve the goals.
They provide an entry point for identifying why the goals were not achieved, and what actions need to be taken for the goals to be achieved.
Standards-driven quality improvement has three key strengths.
Firstly, they set clear goals for different aspects of a service-delivery point's operations.
For example, a standard statement could specify what medicines (e.g. antibiotics) and supplies (needles and syringes, cotton swabs and spirit to clean inject sites) need to be in place in a service-delivery point. It could also specify the quantity of each of these medicines and supplies that need to be in place.
Secondly, they provide the basis for assessing the achievement of goals.
In relation to the example, the standard statement provides a basis to assess whether in a particular service-delivery point, the specified medicines and supplies are in place, and whether the specified quantities of these medicines and supplies are in place.
Thirdly, they provide an entry point for identifying the why the goals were not achieved.
Based on this they can help point to what needs to be done, by when and by whom for the goals to be achieved.
In relation to the example, if antibiotics to treat childhood pneumonia are out of stock, the main reasons for this and actions to solve the problem and to prevent it from occurring again need to be identified. These actions may need to be taken at the point service-delivery, or they may need to be taken at other levels - at the district level or even at the national level. Once these actions are put in place, the situation must be reviewed periodically to determine whether the problem recurs.
Actual quality.

19. Standards communicate a clear vision
Adolescents knowledgeable, able & willing to obtain the health services they need.
Service providers non judgemental & considerate in their dealings with adolescents; & deliver the required services in the right way.
Health service delivery points welcoming & appealing to adolescents; & provide the health services that adolescents need.
Community members aware of the health service needs of different groups of adolescents, & support their provision.
Standards communicate a clear vision of what the 'required quality' to be.

20. # 8. Working to expand the coverage of health services, alongside efforts to improve quality
What is coverage ?
The proportion of a given population that is able to/willing to/has in fact obtained the health services that they need.
Why is a focus on coverage relevant to our work ?
By pressing for clarification on what proportion of the adolescents in a community need a specific health service.
By providing the basis for determining what proportion of them are in fact obtaining the health services they need.
Alongside our efforts to improve quality, we are working to expand the coverage of health services.

21. Expanding the coverage of health services
☻ ☻ ☻ ☻ ☻
1. Clarifying what proportion of adolescents in a community need a specific health service.
2. Determining what proportion of these adolescents are in fact obtaining the health services they need.
☻ ☻ ☻ ☻ ☻
The first step in assessing the coverage of health services is assessing the proportion of adolescents in a community who require a particular health service.
For example, in this community 10 of the 25 adolescents between (40%) are sexually active and require contraceptive services.
The next step is determining what proportion of adolescents who require a particular health service are in fact able to obtain it. In this example of only 6 of the 10 adolescents who are sexually active are obtaining the contraceptive services they need.
Once this is done, questions can be asked as to why these adolescents were not obtaining the contraceptive services they needed, and what could be done to ensure that they are do so.

22. # 9. Using a systematic approach to scaling up
" Scaling up: Deliberate efforts to increase the impact of health service innovations successfully tested in pilot or experimental projects so as to benefit more people ".
Source: WHO, Reproductive Health Research & ExpandNet. From pilot projects to policies & programmes: Practical guidance for scaling up health service innovations (WHO, 2006).
We recognise that spontaneous diffusion of innovations from innovative projects and programmes to others in possible. However, successful scaling up almost always requires purposeful action, and needs to be deliberate and guided.

23. Systematic process National level District level Health facility level
Do a situation analysis or a programme review
.Orient district leaders
Develop a health sector strategy within a multi-sectoral strategy
Orient health facility staff
Orient district health management teams
Do a self-assessment of quality to identify areas where quality is low
. Develop a plan to improve quality
Develop national quality standards
Do a district level mapping exercise
.Disseminate approved national standards (to sub-national levels)
Develop a district scale up plan
This is the systematic approach we support in countries, with complementary actions at the national, district (or other sub national level) and local levels.
Develop/adapt generic materials
Orient health facility managers
Develop national scale up plan

24. Systematic process - Grounded in national policies & strategies
National level
District level
Health facility level
Do a situation analysis or a programme review
.Orient district leaders
Develop a health sector strategy within a multi-sectoral strategy
Orient health facility staff
Orient district health management teams
Do a self-assessment of quality to identify areas where quality is low
. Develop a plan to improve quality
Develop national quality standards
- Grounded in national policies & strategies
- A clear vision articulated & championed by the highest level of the Ministry of Health
- Housed in at least one national programme & integrated in its plan & budget
Do a district level mapping exercise
.Disseminate approved national standards (to sub-national levels)
Develop a district scale up plan
Our objectives at the national level are listed on this slide.
Develop/adapt generic materials
Orient health facility managers
Develop national scale up plan

25. Systematic process National level District level Health facility level
Do a situation analysis or a programme review
.Orient district leaders
Develop a health sector strategy within a multi-sectoral strategy
Orient health facility staff
Orient district health management teams
Do a self-assessment of quality to identify areas where quality is low
. Develop a plan to improve quality
Develop national quality standards
- District public health leaders supported to lead planning, implementation & monitoring.
Do a district level mapping exercise
.Disseminate approved national standards (to sub-national levels)
Develop a district scale up plan
Our objectives at the district level are listed on this slide.
Develop/adapt generic materials
Orient health facility managers
Develop national scale up plan

26. Systematic process National level District level Health facility level
Do a situation analysis or a programme review
.Orient district leaders
Develop a health sector strategy within a multi-sectoral strategy
Orient health facility staff
Orient district health management teams
Do a self-assessment of quality to identify areas where quality is low
. Develop a plan to improve quality
Develop national quality standards
- Empowered & supported to drive the quality improvement process
Do a district level mapping exercise
.Disseminate approved national standards (to sub-national levels)
Develop a district scale up plan
Our objectives at the local level are listed on this slide.
Develop/adapt generic materials
Orient health facility managers
Develop national scale up plan

27. Both top down & bottom up
To make their contributions, people need clear guidance on what to do, as well as the space to adapt & innovate.
National level
A) Develop national policies and ensure their application
B) Provide guidance on actions by district public health management staff
C) Provide guidance on actions by health facility managers and other health facility staff
D) Develop/ adapt guidelines, operational procedures and training materials for health facility staff
E) Manage human resources
F) Develop /adapt informational materials for adolescents and community members
District level
A) Act as a bridge between the national level and health facilities
B) Support health facility managers to:
(i) assess quality of service provision & to use these finding to address areas of weakness;
(ii) carry out actions in the health facility and in the community
C) Play a facilitating role within the district
Health facility level
As part of a scaling up strategy, there are clear roles – different and complementary ones - to be played at the national and district levels, in order to ensure that service providers in each health service delivery point to do what they need to do.
The debate about top down versus bottom up approaches is a needless one. Both approaches are needed and can reinforce each other.
A) Work with the district authorities to ensure that the health facility has the resources needed to deliver health services
B) Support health facility staff to perform effectively
C) Ensure that health facility is adolescent friendly
D) Manage outreach activities to generate community support & demand
E) Monitor the health facility's performance internally as well as periodically in conjunction with officials from national & district level (externally)
F) Use the findings of internal and external assessments of quality to address gaps and areas of weakness

28. Collaborative learning
" People engaged in collaborative learning capitalize on one another’s resources and skills - asking one another for information, evaluating one another’s ideas, monitoring one another’s work etc."
- MM Chiu, 2000
District Health
Management team
We strongly believe in supporting people to learn from each other's experiences.
We support this by bringing them together periodically for collaborative learning.
Collaborative learning is a situation in which two or more people learn or attempt to learn something together.
Unlike individual learning, people engaged in collaborative learning capitalize on one another’s resources and skills (asking one another for information, evaluating one another’s ideas, monitoring one another’s work, etc.).

29. Two key trade-offs in scaling up
Trade-off between extending coverage & maintaining quality
Trade off between efficiency & equity (i.e. it may be more efficient to expand access to 'easy to reach' groups, but it is not equitable)
Source: L J Mangham, K Hanson. Scaling up in international health: What are the key issues. Health Policy & Planning 2010; 25;
While working to scale up health service provision, we need to be constantly aware of the two key trade offs listed on this slide.

30. # 10. Using measurement to find out what is happening on the ground & to shape efforts
Implementation
Have activities been implemented as planned ?
Quality
Have these activities led to improvements in quality of health service provision ?
Utilization
Has the improvement in quality led to improved health service utilization by adolescents ?
Coverage
What proportion of adolescents in a community need a specific health service ?
Of them, what proportion are obtaining the health service & what proportion are not ?
Cost
What is the additional cost of making health services adolescent friendly ?
Finally, we strongly believe that measurement has an important role to play in finding out what is happening on the ground and helping to shape our efforts.