This post is part two of two in our family planning feature this week
Building on the emphasis at the PMNCH Partners’ Forum this week of extending care to adolescents, identifying strategies that work for increasing access of contraception to adolescents is both critical and timely. This week the article Scale Up of Adolescent-Friendly Contraceptive Services: Lessons from a 5 Country Comparative Analysisco-authored by Pathfinder, UNFPA, and Expandnet on this topic was published. This paper assesses adolescent-friendly contraceptive services (AFCS) in five countries: Ethiopia, Ghana, Mozambique, and Tanzania.
Gaps in Adolescent SRH Services
Addressing the sexual and reproductive health (SRH) needs of adolescents is critical especially for 10-19 year old girls since their limited power due to age and gender inequality put them at increased risk of unintended pregnancy and sexually transmitted infections (STIs). In fact, in South Central and Southeast Asia and sub-Saharan Africa, 68% of sexually active adolescent girls have an unmet need for contraception. Adolescents bear the burden of poor SRH due to barriers to appropriate services, which include contraceptive services. The World Health Organization (WHO) defines adolescent-friendly contraceptive services (AFCS) as those that are equitable, accessible, acceptable, appropriate, and effective (which includes the provision of a wide range of methods). AFCS can greatly mitigate the barriers adolescents currently face in accessing contraception.
Cross-cutting aspects of scale-up and delivery
As the authors in this paper assessed the AFCS programs in the five countries listed above, major themes emerged. First, the five programs all included key characteristics:
- Privacy and confidentiality;
- Use of trained, nonjudgmental providers;
- Availability of a full range of methods;
- Free or subsidized services; and
- Adolescent involvement in design, implementation, and quality improvement of services.
In addition, scale-up and sustainability was increased by creating public-private partnerships; establishing a variety of service access points (pharmacies in Vietnam, workplace satellite clinics in Ghana, and community-based distribution in Ghana, Tanzania, Ethiopia, and Mozambique); and generating demand for AFCS through peer educators, youth groups, community workshops, social marketing, and mass media.
Overall the key categories of lessons learned are as follows:
- Government Commitment: Successful scale-up requires clear national, regional/ provincial, and district government commitment, policy and agreement to the extent of scale-up of AFCS at the onset of the program.
- Synergistic Scale-up: Both institutionalizing and then expanding services were key strategies for successful sustainable scale-up of AFCS.
- After supportive policy was created, it was critical to roll-out AFCS as soon as possible and facilitate institutionalization through dissemination of technical expertise, tools, and curricula. As services were expanded, more adolescents accessed services which created momentum for adolescents and civil society to hold governments responsible for maintaining fully adolescent health policies.
- Adolescent involvement: Given their age, adolescents often have less political visibility, so in order to actively engage youths, extra steps need to be taken .Adolescents were trained as peer-educators and in this role they generated demand for AFCS by bridging connections between the community and health facilities, providing information and nonclinical contraceptive methods to their peers, and by making peer referrals to clinical services.
- Using Pilot Sites: In order to envision and implement successful AFCS, adolescents and health providers found observing pilot sites of successful, quality AFCS created learning opportunities and reinforcement of training. In addition, these pilot sites were critical for fostering good will and political commitment from district- and regional-decision makers.
- Analysis and investments in health service delivery: Before planning for implementation and scale-up of AFCS, it is critical to analyze the strengths and weaknesses of the current health delivery system. Identifying strengths and weaknesses will impact how scale-up is planned and should expedite investments to mitigate gaps in basic service delivery. These aspects of health systems strengthening should occur before AFCS is implemented.
- Key weaknesses identified in health systems were: low-quality contraceptive services for all ages, unavailability of some methods of contraception due to poor supply chains and untrained health providers, weak supervision systems, and lack of age-disaggregated data for informing quality management decisions.
- Factors Affecting Sustainability:
- Degree of expansion;
- Extent of institutionalization;
- Inclusion of AFCS into relevant budget lines;
- Integration of AFCS into pre-service curricula, lessening the need of on-going trainings given the high rate of staff turnover; and
- Level of adolescent engagement.
- Monitoring & Evaluation Data: Before implementation and scale-up of AFCS is started, it is key to engage with key stakeholders to ensure revised national HMIS that will support age-disaggregated data and sufficient monitoring & evaluation of programs so that quality improvement is implemented. In addition, the experience of all five countries demonstrated that collecting and routinely examining service quality data is critical to ensuring quality expansion of services.
As this is a brief overview of the article, we encourage you to read the full open-access article if you are involved in implementing AFCS in your country.