Background

Government-led efforts are underway in a number of low and middle income countries (LMIC) to make health service provision adolescent friendly. This paper examines whether in fact these efforts make health services adolescent friendly and result in increased use of health services by adolescents.

In 2001, based on a review of the available evidence and on the experiences of organizations from around the world, WHO called for countries to undertake efforts to make health services adolescent friendly: ‘All adolescents should be able to access promotive, preventive and curative health services relevant to their stage of maturation and life circumstances’ (consensus statement 2) [1]. WHO’s call noted that ‘for a variety of reasons, adolescents in many places are unable to obtain the health services they need’ (consensus statement 3) and outlined promising approaches that could be used to overcome these barriers and increase health service utilization by adolescents (consensus statement 6).

In 2007, WHO’s recommendation was reiterated in a paper published in The Lancet. Based on an updated review of the literature the authors concluded: ‘Enough is known that a priority for the future is to ensure that each country, state and locality has a policy and support to encourage provision of innovative and well-assessed youth-friendly health services’ [2].

In international conferences and in other fora, government-run clinics and hospitals are described as being unwelcoming to adolescents, and health workers in government-run health facilities are perceived to be judgemental and unfriendly, and to lack the clinical and interpersonal competencies needed to provide health services to adolescents effectively and with sensitivity [3]. And researchers and implementers question whether government-run health facilities and health workers can be made adolescent friendly at all [4].

To respond to these questions and concerns, we set out to answer the following three questions:

  1. 1.

    What did LMIC governments set out to do, to improve the quality – including the friendliness – of health service provision to adolescents? (Here and henceforth in this paper, quality includes friendliness.)

  2. 2.

    Did their efforts lead to improvements of quality of health service provision to adolescents?

  3. 3.

    Did these improvements in quality lead to increased health service-utilization by adolescents?

Methods

Beginning in 2001, WHO worked with partners within and outside the United Nations system to support Ministries of Health in LMIC standardize, assess and improve the quality/expand the coverage of health service provision to adolescents in primary-level government-run health facilities in nearly 25 countries in Asia, Africa, Central and Eastern Europe and the Western Pacific (Table 1).

Table 1 WHO-supported efforts in LMIC to standardize, assess and improve the quality of health service provision to adolescents in primary-level government-run health facilities
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We reviewed published and unpublished documents - normative guidance and reports emanating from these LMIC and selected eight in which we had information to answer the questions we set out to answer - Bangladesh, India, Indonesia, Malawi, Moldova, Mongolia, Tanzania and Ukraine.

To answer the first question, we analysed national quality standards and accompanying criteria for adolescent friendly health services developed by each of these countries against WHO’s dimensions of quality adolescent friendly health services. Depending on whether the quality dimensions had been named in the standard statements, and depending on how adequately they were addressed in the accompanying criteria, we placed the countries in four categories – highly adequate, moderately adequate, not-fully adequate and absent. To answer the second question, we analysed findings from the assessments of the quality of health service provision carried out under the auspices of the Ministries of Health of these countries. Depending on compliance with the required standard of quality, we placed them in three categories: ≥ 70 % compliance = performing well; 40– 69 % = need some improvement and ≤39 % = need considerable improvement. To answer the third question, we analysed findings on the uptake of health services by adolescents (10–19 years) and youth (20–24 years) from health facility-based service statistics and from community-based coverage studies.

Results

  1. 1.

    What did LMIC governments set out to do, to improve the quality of health service provision to adolescents?

    Our analysis of national standards and criteria showed that governments of the eight countries set out to improve the accessibility, acceptability and effectiveness dimensions of quality with reasonable adequacy. However, they addressed the appropriateness and equity dimensions less adequately. Selected details are provided below:

    • 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.

    • 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.

    • 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.

    • 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.

    Table 2 Analysis of how adequately the WHO dimensions of quality are addressed in the national standards for quality health service provision for adolescents of selected countries
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  2. 2.

    Did the efforts of LMIC governments lead to improvements in the quality of health service provision to adolescents?

    Our analysis of the assessments of the quality of health service provision in the eight countries showed that while the assessments were carried out in different contexts and by different organizations, they all used the same combination of approaches - interviews with health facility managers, health service providers, support staff and adolescent patients/clients, and observation of health service delivery points. Further, while there were variations in the levels of improvement of the different dimensions of quality in the eight countries, efforts to improve quality of health service provision, led to observable and measurable improvements. Selected details are provided below:

    Accessibility: Accessibility was assessed in all eight countries. Various criteria of this dimension were rated as performing well in five countries, needing some improvement, in five countries and needing considerable improvement in four countries.

    Acceptability: Acceptability was also assessed in all eight countries. The criterion ‘health facilities have a welcoming and friendly ambience’ was rated as performing well by seven countries; Moldova rated it as needing some improvement. Six countries assessed privacy and five assessed confidentiality. On privacy, three of the six performed well, two of the six needed some improvement, and one needed considerable improvement. On confidentiality, one of the five performed well, while the other four needed some improvement.

    Appropriateness: Only four countries measured appropriateness. On the provision of a specified package of services, one was rated as performing well, and two as needing some improvement. For the fourth country (Indonesia), some interventions within the specified service package were assessed as performing well or needing some improvement while the functioning of the referral system was rated as requiring considerable improvement.

    Equity: The equitable provision of health services was assessed in only two countries. It was rated as needing some improvement in both.

    Effectiveness: The various criteria of this dimension were also assessed in all eight countries. Regarding the training of health service providers, five of the eight countries were assessed with one of them rated as needing some improvement and the other four as needing considerable improvement. On data management and use, only three countries were assessed with one of them rated as needing some improvement and the other two as needing considerable improvement.

    Table 3 contains an analysis of the acceptability dimension of quality in all eight countries. (Details of the assessment of other dimensions are available on request).

    Table 3 Analysis of the context in which the quality of health service provision to adolescents was assessed, who assessed it, what the objectives of the assessment were, how the assessment was done, and findings of the assessment
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  3. 3.

    Did the improvements in the quality of health facilities lead to increased health service-utilization by adolescents?

    We gathered and analysed reports from all eight countries. In two countries health facility based service statistics were available at two time periods (Malawi and Mongolia) and 3 time periods (Ukraine). In Mongolia, health facility based service statistics were available from intervention and comparison sites, from a cross-sectional survey. In Bangladesh, India and Tanzania, community-based coverage studies compared self-reported service use in health facilities in intervention and comparison areas. In Moldova, community-based coverage studies were carried out at two time-periods but without comparison facilities. In Indonesia, no utilisation data were available from health facilities or through community-based coverage studies, but a Ministry of Health supported project in Aceh province showed improvements in quality and increased health service utilisation. Health service utilization was lower in intervention health facilities than in comparison health facilities in Bangladesh, through the difference was not statistically significant. In the other seven countries improvements in service quality were associated with increases in service utilization. Table 4 contains an analysis of this.

    Table 4 Analysis of the context in which the health service utilization by adolescents was measured, who measured it, how the measurement was done, and what the findings of the measurement were
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Discussion

Our analysis of normative guidance documents from eight LMIC from different parts of the world shows that the governments of these countries have set clear expectations for the quality of health service provision to adolescents at the primary care level. Our analysis of the quality of health service provision in these countries showed measurable improvements, although these were uneven. Our analysis of health facility-based service statistics and community-based coverage studies shows that improvements in the quality of health service provision are accompanied by improvements in service utilization by adolescents.

Our results clearly show that the quality of health service provision to adolescents in government-run health facilities and their utilization can be improved in different social, economic and cultural contexts. A limitation of our study is that, while we analysed what governments set out to do to improve the quality of health service provision, we were not able to assess what they actually did. Thus, we cannot comment on what actually occurred to bring about these improvements.

Other authors have shown that the quality of health service provision to adolescents by government-run health facilities in LMIC and service utilization by adolescents can be improved. But these improvements have been brought about in the context of operations research or well-funded and tightly-managed projects [8, 9]. Our findings show that such improvements are possible even in the context of routine programming e.g. in India, Tanzania and Ukraine.

A strength of this study is that we assembled data from published reports of quality assessment, and of service utilization and coverage assessment in different contexts by different organizations, including academic institutions, nongovernment organizations and consultant teams. While the attributes assessed and the methods used were broadly similar across assessments, another strength, the level of rigor varied greatly. Given this, a meta/analysis was not possible. While this is an important limitation, it is also reflective of the reality of programmatic monitoring and evaluation activities for AFHS programmes in LMICs.

Conclusions

With support, governments in LMIC have defined quality standards for health service provision to adolescents and the actions needed to achieve them. Actions to achieve these standards have led to increases in the quality and in the utilization of government-run health services by adolescents in very different contexts. This study provides a sound basis for decision makers in national and international institutions to invest in efforts to expand the reach of good quality health services to world’s adolescents.