What is our understanding of the 'reality on the ground' ?

• A wide range of players• Often with very different objectives• Operating in a variety of settings - Providing health services to

adolescents/young people !

• A wide range of players• Often with very different objectives• Operating in a variety of settings - Providing health services to

adolescents/young people ! Often small scale & time lim

ited…

Poor design & poor implementation

leads to poor impact !

"…No effects on sexual on sexual or contraceptive-use behaviours or on use of public clinics was observed…"

Source: R J Magnani, L Gaffikin, E M Leao de Aquino, E E Seiber, M de C Chagas Almeida, V Lipovsek. Impact of an integrated adolescent reproductive health program in Brazil. Studies in Family Planning 2001; 32 (3): 230-243.

Uneven quality !

Percentage of adolescents using youth centers & contacted by peer educators

in the past year.

All boys

All girls

Boys 10-14

Boys 15-19

Girls 10-14

Girls 15-19

Youth centre 20.3 7.2 10.5 27.2 3.9 9.0

Peer education

26.5 15.1 18.3 32.3 12.7 16.5

Source: A. Erulkar, T Mekbib, N Simie, T Gulema. Differential use of adolescent reproductive health programs in Addis Ababa, Ethiopia. Journal of Adolescent Health. 2006, 38, 253-260.

Patchy coverage !

What are we doing to strengthen country-level action in reaching

adolescents with the health services they need ?

Objective:To improve the quality &

expand the coverage of an evidence-based package of health interventions in order to achieve clearly defined health outcomes.

National standards-driven initiatives to improve quality & expand coverage.

What is our recommended approach to reaching

adolescents with the health services they need ?

Overall goalTo improve the health & development of adolescents.

HIV/AIDS1. Prevention of too early pregnancy

2. Prevention of deaths in pregnancy & delivery

Substance UseMental Health

Intentional & accidental injuries

# 1. Using strategic entry points, to move the wider adolescent health agenda.

# 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 ?

• Adolescents are a diverse population group.

• Not all adolescents are equally vulnerable.

# 3 Identifying the groups in the adolescent population whom we need to reach.

Alternative approaches to contraceptive information/services provision, Mexico

0102030405060708090

100

CYP YouthCentre

CBD

MaleFemale

Townsend J W, Diaz de May E, Sepǘlveda Y, Santos de Garza Y, Rosenhouse S. Sex education and family planning services for young adults: alternative urban strategies in Mexico. Studies in Family Planning 1987; 18: 103-108.

clinic clinic clinic

Hospital

NGO

Private doctor Pharmacy

Traditional healer

# 4. Being clear about where & by whom health services are to be provided ?

• Working to make existing service-delivery points more "friendly" to adolescents.

A focus on building on what already exists.

• Setting up new service-delivery points exclusively intended for adolescents.

Striving to ensure that the services that adolescents need are in fact being provided & are being provided in the right manner.

Provision

UtilizationStriving to ensure that adolescents are able & willing to obtain the health services they need.

# 5. Setting out to do more than just make health services "friendly".

AccessibleAcceptableEquitable

Efficient

AppropriateComprehensiveEffective

ProvisionUtilisation

# 6. Using a quality frameworkfor health-service provision to adolescents.

AccessibleAcceptableEquitable

Efficient

AppropriateComprehensiveEffective

ProvisionUtilisation

A quality frameworkfor health-service provision to adolescents.

AccessibleAcceptableEquitable

Efficient

AppropriateComprehensiveEffective

ProvisionUtilisation

A quality frameworkfor health-service provision to adolescents.

AccessibleAcceptableEquitable

Efficient

AppropriateComprehensiveEffective

ProvisionUtilisation

A quality frameworkfor health-service provision to adolescents.

Community Advocates & facilitates preparedness & readiness actions

Facility is equipped, staffed & managed to provide skilled care for the pregnant woman & the new born

Provider provides skilled care for normal & complicated pr Community egnancies,

births & the postpartum period

Family Support pregnant woman’s plans during pregnancy, childbirth & the postpartum period.

Community

Facility

Provider

Adolescents

Service providers : -are non judgemental & considerate

in their dealings with adolescents -deliver the services in the right way

Clear definitions of 'required' quality of health service provision to adolescents.

Community members support the provision of health services to adolescents.

Adolescents -are aware of what services are

being provided -are (& feel) able & willing to

obtain the health services they need

Points of service delivery: -enable adolescents to obtain

the health services they need -are appealing to adolescents &

respectful of them -provide the health services that

adolescents need

# 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.

1. Standards set clear goals.They make explicit the definition of quality required Required

quality.

Standards-driven quality improvement

1. Standards set clear goals.They make explicit the definition of quality required Required

quality.

Standards-driven quality improvement

Actual quality.

Gap between required and actual quality.

2. Standards provide the basis for assessing the achievement of goals.They provide a clear reference against which quality can be assessed (& compared).

1. Standards set clear goals.They make explicit the definition of quality required Required

quality.

Standards-driven quality improvement

Actual quality.

Gap between required and actual 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.

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.

IMPROVE Q

UALITY

DEFINE QUALITY

MEASURE QUALITY

The Quality triangle. The Quality triangle.

Quality of Care

# 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 ?

1. By pressing for clarification on what proportion of the adolescents in a community need a specific health service.

2. By providing the basis for determining what proportion of them are in fact obtaining the health services they need.

1. Clarifying what proportion of adolescents in a community need a specific health service.

Expanding the coverage of health services.

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1. Clarifying what proportion of adolescents in a community need a specific health service.

Expanding the coverage of health services.

☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻☻ ☻ ☻ ☻ ☻

2. Determining what proportion of these adolescents are in fact obtaining the health services they need.

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1. Clarifying what proportion of adolescents in a community need a specific health service.

Expanding the coverage of health services.

☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻☻ ☻ ☻ ☻ ☻

2. Determining what proportion of these adolescents are in fact obtaining the health services they need.

☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻☻ ☻ ☻ ☻ ☻

# 9. Being clear about what it takes to translate ideas into reality.

" 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 Resarch & ExpandNet. From pilot projects to policies & programmes: Practical guidance for scaling up health service innovations (WHO, 2006).

National level•Providing directions•Providing methods & tools•Providing human & material support

District level•Acting as a bridge between the national level & the district.

•Playing a facilitating role in the district

•Supporting the service delivery points

•Supporting community action

Local level

Different but complementary actions at national, district & local levels.