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

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

2. A wide range of players • Often with very different objectives • Operating in a variety of settings - Providing health services to adolescents/young people !

3. 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 limited…

4. Poor design & poor implementation leads to poor impact ! Uneven quality ! "…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.

5. Percentage of adolescents using youth centers & contacted by peer educators in the past year. Patchy coverage ! 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.

6. What are we doing to strengthen country-level action in reaching adolescents with the health services they need ?

7. National standards-driven initiatives to improve quality & expand coverage. Objective: To improve the quality & expand the coverage of an evidence-based package of health interventions in order to achieve clearly defined health outcomes.

8. What is our recommended approach to reaching adolescents with the health services they need ?

9. # 1. Using strategic entry points, to move the wider adolescent health agenda. Overall goal To improve the health & development of adolescents. HIV/AIDS 1. Prevention of too early pregnancy 2. Prevention of deaths in pregnancy & delivery Substance Use Mental Health Intentional & accidental injuries

10. # 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 ?

11. # 3 Identifying the groups in the adolescent population whom we need to reach. Adolescents are a diverse population group. Not all adolescents are equally vulnerable.

12. Alternative approaches to contraceptive information/services provision, Mexico 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.

13. # 4. Being clear about where & by whom health services are to be provided ? Private doctor Hospital Pharmacy NGO Traditional healer clinic clinic clinic

14. Working to make existing service-delivery points more "friendly" to adolescents. • Setting up new service-delivery points exclusively intended for adolescents. A focus on building on what already exists.

15. # 5. Setting out to do more than just make health services "friendly". Utilization Striving to ensure that the services that adolescents need are in fact being provided & are being provided in the right manner. Striving to ensure that adolescents are able & willing to obtain the health services they need. Provision

16. # 6. Using a quality framework for health-service provision to adolescents. Utilisation Provision Accessible Acceptable Equitable Appropriate Comprehensive Effective Efficient

17. A quality framework for health-service provision to adolescents. Utilisation Provision Accessible Acceptable Equitable Appropriate Comprehensive Effective Efficient

18. A quality framework for health-service provision to adolescents. Utilisation Provision Accessible Acceptable Equitable Appropriate Comprehensive Effective Efficient

19. A quality framework for health-service provision to adolescents. Utilisation Provision Accessible Acceptable Equitable Appropriate Comprehensive Effective Efficient

20. Clear definitions of 'required' quality of health service provision to adolescents. 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 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 Service providers: - are non judgemental & considerate in their dealings with adolescents - deliver the services in the right way

21. # 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.

22. Standards-driven quality improvement 1. Standards set clear goals. They make explicit the definition of quality required Required quality.

23. Standards-driven quality improvement 1. Standards set clear goals. They make explicit the definition of quality required Required quality. 2. Standards provide the basis for assessing the achievement of goals. They provide a clear reference against which quality can be assessed (& compared). Gap between required and actual quality. Actual quality.

24. Standards-driven quality improvement 1. Standards set clear goals. They make explicit the definition of quality required Required 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. Gap between required and actual quality. 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. Actual quality.

25. The Quality triangle. IMPROVE QUALITY MEASURE QUALITY Quality of Care DEFINE QUALITY

26. # 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 ? • By pressing for clarification on what proportion of the adolescents in a community need a specific health service. • By providing the basis for determining what proportion of them are in fact obtaining the health services they need.

27. Expanding the coverage of health services. ☻ ☻ ☻☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ 1. Clarifying what proportion of adolescents in a community need a specific health service.

28. Expanding the coverage of health services. ☻ ☻ ☻☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ 1. Clarifying what proportion of adolescents in a community need a specific health service. 2. Determining what proportion of these adolescents are in fact obtaining the health services they need. ☻ ☻ ☻☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻

29. Expanding the coverage of health services. ☻ ☻ ☻☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ 1. Clarifying what proportion of adolescents in a community need a specific health service. 2. Determining what proportion of these adolescents are in fact obtaining the health services they need. ☻ ☻ ☻☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻ ☻

30. # 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).

31. Providing directions • Providing methods & tools • Providing human & material support National 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 District level Local level Different but complementary actions at national, district & local levels.