Service delivery: poor or uneven quality
Global initiatives are urging countries to prioritize quality as a way of reinforcing human rights-based approaches to health.32 Yet evidence from both high and low income countries shows that services for adolescents are highly fragmented, poorly coordinated and uneven in quality.33-38 Pockets of excellent practice exist, but, overall, services need significant improvement39 40 and should be brought into conformity with existing guidelines.41
Services unacceptable. Adolescents often find mainstream primary care services unacceptable because of perceived lack of respect, privacy and confidentiality, fear of stigma, discrimination, and imposition of the moral values of health-care providers.42-45 For example, in Zambia HIV testing and counselling services are integrated into almost all health facilities in the country, but only 15% provide them in a manner acceptable to adolescents.46 While adolescents highly value privacy and confidentiality, many are not aware that their regular health-care provider should adhere to these principles; few identify their primary care provider as a source of confidential care.47 48
Quality USA Standards developmentMoving to standards. Recognizing the problems, many countries have moved towards a standards-driven approach to improve the quality of care for adolescents.49-55 With ministry of health leadership, more than 25 countries have adopted national quality standards, and some, including Malawi, the Republic of Moldova, South Africa, Tajikistan, the United Republic of Tanzania and Ukraine, have conducted surveys to measure the quality of the services being provided in order to inform action.56
WHO global standards for quality services for adolescents. The UHC concept implies that “sufficient level of quality” is defined and measured. To accelerate scaling up quality of care standards in countries, WHO has developed the Global Standards for Quality Health Care Services for Adolescents along with an implementation plan and monitoring tools.57
service provision services to adolescents ‘You’re Welcome’, the Department of Health’s quality criteria for young people friendly health servicesStandards are not enough. Having well-defined standards is not enough to improve quality. Standards must guide service delivery throughout mainstream primary and referral-level networks, not just in a few showcase facilities. A number of countries are systematically implementing standards, supported by facility certification systems in some cases, and have succeeded in scaling up quality fairly quickly.58-62
Republic of MoldovaService delivery: low coverage of services
Low coverage of services for adolescents is sometimes a consequence of poor quality. But it can also result from the way that services are organized. When attention goes to creating separate services for adolescents rather than investing in improving mainstream primary care services, they are likely to have limited coverage and sustainability.
In response to this challenge, Uruguay has recently shifted the focus from providing a limited number of dedicated multidisciplinary adolescent health points to making systemic changes in primary care services. These changes include building the capacity of primary care providers to care for adolescents; adjusting benefit packages to reflect the needs of adolescents; and providing regular check-ups that create opportunities for healthy adolescents to make contact with primary care physicians and specialists.63
Expanding opportunities for prevention and care. Use of health services in the past 12 months by 10–24 year olds is proposed as an indicator for monitoring adolescent health worldwide.64 To raise this indicator to a high level, it will be important to design service delivery models for prevention and care that adolescents will use. Many countries have, therefore, created opportunities for healthy adolescents to access preventive services through school health services and/or primary care.65-68 Of 29 European countries, 28 report some screening and preventive health programmes for adolescents.69
Improving primary Repeat Evaluation of Youth Friendly Clinics in Ukraine. Final report.Measuring coverage. Often, however, services are expanded but coverage is not measured. For example, many countries have adopted standards-driven processes to improve the quality of services for adolescents, but very few have measured or regularly monitored what proportion of the target population reports access to or use of these services.
In some countries, however, coverage has been measured. For example, in Chile it was possible to show more than a twofold increase between 2010 and 2012 in, coverage of adolescents with health check-ups of the registered population through primary care. In El Salvador implementation of the National Programme for Comprehensive Adolescent Health Care led to a 37% increase in nutritional assessments of the registered adolescent population between 2009 and 2012.
In addition to measuring the use of specific services by adolescents, it is also important to be able to assess the impact of the services on health outcomes.
Generating demand, fostering support. An important way to increase use of health services is to generate demand for the services among adolescents and to foster community support for adolescents’ use of services.70-72 Acceptance among community gatekeepers such as parents and religious leaders, who may question or oppose the provision of sexual and reproductive health services for adolescents, is very important. Strategies to generate demand and community support include linking school programmes with quality services, social marketing and franchising, and interventions to involve key community gatekeepers.73 74
Unfortunately, according to participants’ responses in the online consultation with primary care providers, linkages between the primary care practice and the community on adolescent health issues are not common. More than half of respondents were either not sure that meetings with local authorities, community health workers, school representatives or other community representatives are taking place to discuss adolescent health issues, or else they reported that such meetings happen once a year at most. Their most common contacts were with social workers. More than half of respondents indicated that their practice/centre meets with social workers on adolescent health issues at least every six months.
Adolescents on what stops them from using health services: Lack of financial resources and lack of access to good treatment.
male, 18-19, Morocco
Adolescents on what can be done to improve health services: Make access to psychiatric services easier because in my opinion, it is vital to see a psychiatrist when you are an adolescent.
female, 18-19, France
My mum would have to know, and I am not comfortable with that.
female, 12-14, United Kingdom
Education of adolescents is important - they don't know the services available to them.
female, general practitioner, Australia
I may not be able to improve my sexual life (as I want to be a girl) because I live in a small town with a population of approximately 25,000, and there are no experts on this subject.
trans, 12-14, Argentina
Adolescents on what can be done to improve health services: Educate more doctors and reinforce their competences, construct more sanitary infrastructures and equip them with modern healthcare materials.
male, 18-19, Burundi
Long distance from the health center, lack of information on available health services and lack of money to pay for health services like STI's treatment.
female,18-19, Uganda
If I want to go to the gynecologist for any given reason, I can't go because it would show up in insurance. I can't get birth control pills, for example, because it would show up on insurance, and there's no free clinics nearby.
female, 18-19, United States of America
The cost. Also the hours and availability. Calling only to find out you can have an appointment in six months, it’s discouraging.
female, 18-19, Switzerland
They usually scold me when I go to clinics, saying that I am too young to have sex or ask for condoms.
male, 15-17, Mexico
Health risks are so high that services don’t have enough resources. Also the doctors are difficult to access. There are few doctors for many illnesses.
male, 18-19, Burundi
Adolescents on what stops them from using health services: In my country, the high levels of disorganization, the lack of resources. The lack of time, as there are big lines for getting medical attention that start forming extremely early in the morning.
male, 18-19, Peru
The demand for services at community health centers is far too high, which quickly becomes exasperating, and the services are terrible. The government spends more money on guns for the army than on the well-being of its population.
male, 15-17, Guatemala
Linking organizational and delivery of care to payment might raise the profile and lead to better care being offered. QOF drives care in the UK to a large extent and if youth health is absent from the QOF be default it is off the radar.
female, general practitioner, United Kingdom
Community people are conservative minded; services in the health centre are not sufficient.
male, community health worker, Bangladesh
Adolescents on what stops them from using health services: Negative and judgmental attitudes of health care providers, long waiting periods, lack of trust in diagnosis (especially for elective counselling i.e.: pill pushers due to pharmaceutical company endorsement), expensive.
female, 18-19, Romania
Adolescents are not able to pay for themselves and have to be dependent on parents for consultations.
female, adolescent physician, India
Improve public education and the way in which health is taught. Improve public hospitals. To have a kind of place of care or assistance where youth can go without involving parents.
female, 15-17, Mexico
The only problem I really want to see anyone about is, ironically, my anxiety. I intend to seek therapy after leaving home as it's meant to be extremely good. That being said, I am surprised that the NHS doesn't offer general health check-ups - nobody has ever checked to see if I am suffering from symptoms unless I bring it up myself.
male, 15-17, United Kingdom
Adolescents on what stops them from using health services: Fear, distance, not being aware that they are available in your region, language barriers.
female, 15-17, Switzerland
In order to have to see specialists, I would need my parents' approval. However, asking them to see a nutritionist or counselor would make them worry.
female, 15-17, United States of America
There is a lack of information about how to reach health services. For example, I just recently found out that my school has a nurse - two years after getting there!
female, 18-19, Peru
I am an adolescent clinical nurse specialist and work exclusively with adolescents. However I do not have the time or resources to see them all. System problems stop me from seeing all patients.
female, nurse, United Kingdom
I use free healthcare services offered by the government. So nothing gets in the way of me using those services even if they’re not necessarily the best, I am just happy it’s an option because I don’t have the means to pay at a clinic.
female, 18-19, Mauritius
Adolescents on what can be done to improve health services: Greater flexibility and efficiency during emergencies and routine appointments, of any kind in public hospitals. Better equipment, medications in schools, more efficiency when distributing medications in hospitals, and also warmth and patience with patients.
female, 18-19, Mexico
Adolescents on what can be done to improve health services: To be allowed access to health services without being judged.
female, 18-19, Mexico
Adolescents on what stops them from using health services: Time, because there are too many people in health clinics and few doctors, meaning the waiting times are long, and I honestly don’t have the time to wait.
female, 18-19, Mexico
Delays in public services, like at the hospital; often they attend to your needs but it’s already too late, and they can be very rude, which is psychologically damaging.
female, 18-19, Mexico
Adolescents on what can be done to improve health services: That there be more places that offer free services as it is very necessary.
female, 18-19, Mexico
I am scared of the gynecologist, I know I have to go one day, but the idea terrifies me.
female, 18-19, France
Adopt a system of universal healthcare, because if society possess both systems, the private system will have the tendency to look at patients as though they were clients.
male, 15-17, Canada
