Lessons learned from youth-friendly sexual and reproductive health service programmes
Youth-friendly sexual and reproductive health services: a bilateral perspective
Von Susanne Amsler
Young people are an important and growing age group in many developing countries. While they have specific needs for information and services related to sexual and reproductive health, their access to health services adapted to their needs remains limited. As a bilateral actor, the Swiss Agency for Development and Cooperation (SDC) supports concrete programmes to promote youth-friendly sexual and reproductive health services and the advancement of young people’s rights and, as member of different multilateral bodies, it uses the lessons learned from the field to advance the global policy framework in this area.
Peer educators and young people celebrating the launch of one of the social media clubs in Zimbabwe (Photo: UNFPA)
The SCD’s health policy guides the agency’s overall work in global health. The policy is based on the Federal Council Dispatch on International Cooperation, which has been approved by the Swiss Parliament, and on Swiss health foreign policy, which has been approved by the Federal Council and aims to achieve coherence and effectiveness in the Swiss government’s approach in the health field. The overall objective of the SDC’s health policy is to improve the health conditions of the population, with a particular focus on vulnerable and poor groups. To achieve this, the SDC focuses its efforts on three priorities, one of which is specifically related to sexual and reproductive health and rights. On the basis of its health policy, the SDC supports several programmes in the area of sexual and reproductive health and the rights of young people, such as the Healthy Generation programme in Moldova and the Safeguard Young People programme in southern Africa (see boxes).
Based on these two programmes and additional literature, the following conclusions have been drawn and may be useful when designing Youth-friendly sexual and reproductive health services (YF-SRHS) programmes:
Get young people on board: Young people know best what they need. Therefore, programmes for young people should not just see young people as a target group but allow their meaningful participation at all stages of the programme. Participants should be selected in a way to represent the heterogeneity of young people and specific strategies should be applied to reach the poor and most vulnerable young people. Young people may also engage in service delivery, such as through peer education approaches.
Don't reinvent the wheel: While each context is different and a thorough context and needs analysis is crucial, research findings and generic guidelines and evidence for YF-SRHS exist and should be used. The process of creating or adapting guidelines is important and enhances key actors’ ownership of the programme. Nevertheless, previous lessons learned should also be taken into account. There is rarely the need to completely start from scratch.
Go beyond: Good results have been achieved by applying a comprehensive approach that embeds YF-SRHS as component of a wider programme that goes beyond just providing sexual and reproductive health services in a clinic. Some programmes have for example been supplemented with other health services requested by young people (e.g. in areas of mental health, nutrition), outreach activities, capacity building through pre- and in-service staff training, activities to change policies and laws, as well as activities that not only go beyond the health services but also beyond the health sector (e.g. collaboration with education sector).
Stronger together: From the beginning of a programme and long before starting to scale-up, the involvement of different key partners such as local and central authorities and relevant communities is crucial. It not only enhances ownership but also allows generating a common understanding of the issue as well as making the time to build trust and find ways to collaborate.
Get information out and youn people in: It’s clear that services that are not known or not accepted won’t be used. Experience has also shown that when outreach activities decrease, service utilisation decreases too. Programmes should therefore work on accessibility and acceptability and thus apply strategies to make the services known among young people, especially among the most vulnerable young people. They should also ensure that services are both physically and financially accessible and work to enhance acceptance not only by young people but also by their social surroundings (families, communities, authorities).
Be friendly: It’s crucially important yet often underestimated that the services as such should be youth friendly and that the attitude of all professionals involved in YF-SRHS also needs to be youth friendly. Therefore, training in behavior and attitude when working with young people should be provided to health professionals, social workers as well as to administration staff involved in YF-SRHS programmes.
Between you and me: Confidentiality, privacy and transparency are important elements when providing health services, but may be particularly important when dealing with young people. Service providers should inform at the very beginning about possible legal implications (e.g. in the case of the need for parental consent below a certain age or if service providers are obliged by law to pass on certain information).
Aim for quanitity and quality: Develop and test norms and standards (clinical, ethical, organisational, financial, etc.) to ensure the quality of services and feed them into technical and policy discussions. Programmes should aim for quality but also ensure that quality can be maintained when multiplying and scaling up services. Also, quality once reached will not automatically be maintained. Systems to assess the quality of services should therefore be put in place, and user feedback, including from mystery (“undercover”) clients, may be used systematically.
Show what it brings: Create a robust yet pragmatic monitoring and evaluation system that goes beyond merely counting the number of services provided, and may include broader public health information, user feedback and economic analysis. It should allow constant adaptation of and improvement to services. Furthermore, findings should be disseminated and used strategically for advocacy purposes and to inform policy discussions. There may be a need to present findings in different forms, depending on the target audience (e.g. scientists, practitioners, authorities, politicians, young people, the community).
Stay engaged: Public health changes can take time. Thus, realistic planning and the long-term commitment of all partners and particularly of funders are crucial elements for success.
Think systemically and do so systematically: Every programme should aim for systemic changes and be designed accordingly from the very beginning. Embedding YF-SRHS in the public health system will ultimately contribute to strengthening the health system and enhance the sustainability of the services provided, including in terms of funding, training of staff, data collection and analysis.
Peers on the Safeguard Young People programme in Malawi. Photo: UNFPA Malawi)
The Safeguard Young People programme in southern Africa
Southern Africa is characterised by the large proportion of young people in society, which in some countries makes up over two thirds of the population. At the same time, young people are particularly vulnerable to sexually transmitted infections including HIV/AIDS, which is clearly shown in the high burden of infectious diseases among adolescents in the region - 75% of global HIV infection among young people occurs in Southern Africa. The situation is influenced and exacerbated by the limited offer of youth-friendly health programmes and services, inadequate health and education systems and legal frameworks. The Safeguard Young People programme was initiated in 2013 by UNFPA, in partnership with the Southern African Development Community (SADC), eight SADC member states, other UN agencies, donors and different national and international NGOs. The programme is largely based on experiences from previous programmes in the region and thus applies a comprehensive approach, including addressing knowledge gaps, promoting behaviour change, capacity building of health care and other key staff, service delivery, changes in policy and legal frameworks. Currently, systematic reviews of existing health services as well as policies and laws are under way, which is expected to provide a basis for the development of regional standards for youth-friendly health services. The programme has started only recently but the commitment of the SADC and the eight member countries where the programme is being piloted is a promising start. Challenges ahead are certainly the relatively weak health systems and legal restrictions in some countries such as the age of consent for young people to decide themselves about services without the need for consent from parents or tutors. The SDC is committed to supporting the development and implementation of this ambitious programme.
Shaping the global policy framework to advance young people’s sexual and reproductive health and rights
In addition to support for specific programmes, the SDC is also active at the global level in the area of sexual and reproductive health and rights, and represents Switzerland in a number of different UN organisations (UNFPA, UNAIDS, Human Reproduction Programme - HRP), UN commissions (CPD), the Global Fund (GFATM) and the civil society based International Planned Parenthood Federation (IPPF). SDC support is not only financial but in most cases involves substantial contributions to policy discussions, negotiations and decision making, which are also based on the experiences gained by various programmes in the field.
It is important however to bear in mind that although the findings of research and programmes play an important role. They are not the only factor in guiding global, regional and national policy discussions and decisions. Other elements such as knowledge (e.g. of formal or informal processes, previous discussions), networks and partnerships with various actors (e.g. governments, CSOs, academia), timing and tactics in bringing forward proposals (e.g. considering other priorities, previous agreements) or the broader political context have a considerable influence on the evolvement of global policy frameworks.
Switzerland’s role in international organisations may vary from one organisation to another and can range from being a member state with a single vote (UNFPA, HRP), being part of a constituency composed of several member states (UNAIDS, GFATM) or having a consultative voice (IPPF). In addition, Switzerland may take on temporary roles, such as assuming the chair of a board or acting as a facilitator in a negotiation process. For example, Switzerland facilitated the 2012 Commission on Population and Development which focused on youth and adolescents that year. This role involved several months of preparation that included numerous consultations and discussions with member states, the preparation of a draft resolution and informal negotiations. The Commission on Population and Development (CPD) 2012 finally ended with a resolution that led to the introduction of some new language in the area of sexual and reproductive health and rights for youth and adolescents, and underlined the importance of the full and effective participation of young people and youth-led organisations. (CPD Resolution 2012/1, pdf) In comparison with a chair’s summary (document presented in case member states can’t agree on a resolution), a resolution requests members states to act and implement the decisions, it asks for official monitoring and thus holds member states accountable. Consequently, the SDC strives to build on the global decision when supporting programmes in the field and thus to advance the SRHR agenda at national level.
As a bilateral actor, Switzerland aims to link the programmatic experience with the policy discussions at national, regional and global levels in order to promote and advance needs-based sexual and reproductive health and rights for young people.
Neovita-Centrul de Sanatate Prietenos Tinerilor Neovita - Foto by Neovita
The Healthy Generation programme in Moldova
In 2002, one of the first youth-friendly clinics in Moldova was opened by the local NGO Neovita. This happened at a time when young people (10-24 years old) made up a quarter of the Moldovan population. However, only 5% of Moldovan youth had access to youth-friendly health services despite the fact that health problems in this age group were on the rise, including HIV, sexually transmitted infections, early pregnancy as well as mental health problems. Acknowledging this need, further youth-friendly health services have been created under the Healthy Generation Programme, which is led by the NGO Health for Youth and primarily supported by the Moldovan Ministry of Health, UNICEF and the SDC. To ensure quality services, norms and standards have been developed and adapted that have informed national guidelines. In the course of the programme, the services have gradually been included into public clinics and since 2008 have been partially financed by the national health insurance scheme. Both developments are an important step forward in terms of sustainability. An important element in the programme is the application of a combined approach that includes, but is not limited, to service provision. Thus, areas such as building up and strengthening human and financial resources, the collection and analysis of strategic data to inform national policies and support for other sectors such as education are part of the comprehensive approach. Furthermore, the programme ensures the active participation of young people, be it in the planning of the programme or during the implementation where young people act as peer educators or are engaged in delivering services. Meanwhile, the national scaling up of the youth friendly health services is under way and young people are visiting the services, which is a great success. A recent external evaluation has clearly shown the relevance and efficiency of the programme and has also identified areas for improvement, such as the need to intensify efforts to reach the most vulnerable and to ensure maintaining the quality of services when scaling up. The SDC continues to support the programmes and the implementation of the aforementioned recommendations.
Susanne Amsler, Advisor on Sexual and Reproductive Health and Rights, Swiss Agency for Development and Cooperation (SDC), Swiss Federal Department of Foreign Affairs (FDFA).