2013 - Standars For Adolescents Health Services 9789241503594 - Eng

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accepta Save the Children,taUKbseconded
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2002, to contribute
bltoethe development of
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five WHO regions.
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and staff from
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r used the tool and contributed to its further
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iaalso did so.
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Chapter 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Annex 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Annex 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Making health services adolescent friendly iii
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table e UNFPA United Nations Population Fund
Abbreviations
UNICEF United Nations Childrens Fund

WHO
World Health Organization
iv Making health services adolescent friendly
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esthe public health rationale for making
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This Guidebook
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need to protect
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ehealth
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ec upon international experience, itais p
to adolescents.
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b
e
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s
totassess
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appropriate standards have beenc
achieved.
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attoethe Quality Assessment Guidebook: A guide to
to be a companion
acce The Guidebook is intended
i
r
p
o
r
p
apfor adolescent clients, which was published by the World Health Organization
assessing health
eservices
l
b
a
t
i
u
in 2009. These two guidebooks are part of a set of tools to standardize and scale up the coverage
ble eq(WHO)
of quality health services to adolescents, as described in another WHO publication: Strengthening the
Introduction
health sectors response to adolescent health and development.

The current publication is intended for national public health programme managers, and individuals
in organizations supporting their work. Its focus is on managers working in the government sector,
but it will be equally relevant to those working in nongovernmental organizations (NGOs) and in the
commercial sector.
Chapter 1 outlines the theoretical basis for actions to improve the quality of health service provision to
adolescents. It covers the following issues and themes:
The meaning of the terms adolescents, health and health services.
What adolescents need to grow and develop in good health.

The role of health service provision in contributing to the health and development of adolescents.
Main health problems of adolescents.
Whom adolescents typically turn to for help when they face health problems;
the factors that make it difficult for adolescents to obtain the health services they need.
Making health services adolescent friendly v
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Evidence
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describes
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uit
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6. What are the main health problems of adolescents?

7. When adolescents face health problems whom do they turn to for help?
8. What are the factors that make it difficult for adolescents to obtain the health services they need?
9. What do adolescents perceive as friendly health services?
10. What is currently being done to make health services adolescent-friendly?
11. What is the evidence of the effectiveness of actions to improve the provision and utilization of
health services (in relation to adolescents)?
12. What can be done to improve the quality of health service provision to adolescents?
13. What can be done to ensure that high quality health services reach all the adolescents who need them?
What do we mean by the term adolescents?

Adolescence, or the second decade of life, is a period in which an individual undergoes major physical
and psychological changes. Alongside this, there are enormous changes in social interactions and
relationships. It is a phase in an individuals life rather than a fixed time period; a phase in which an
1
individual is no longer a child but is not yet an adult.
1 The health of young people: A challenge and a promise. Geneva, World Health Organization, 1993.
Making health services adolescent friendly 1
Adolescence is a time of opportunity, but also one of risk. It presents a window of opportunity because
actions could be taken during this period to set the stage for healthy adulthood and to reduce the
likelihood of problems in the years that lie ahead (e.g. prevention of cardiovascular diseases of
adulthood through the development of healthy eating and exercising habits). At the same time, it is
a period of risk; a period when health problems that have serious immediate consequences can and
do occur (such as deaths resulting from road traffic injuries, and sexually transmitted infections and
unwanted pregnancies resulting from unprotected sexual activity); a period when problem behaviours
which could have serious adverse effects on health in the future (such as tobacco smoking and alcohol
consumption) are initiated.
Adolescents are a diverse group. For example, a boy of twelve is at a very different stage of personal
development than a boy of eighteen. Similarly, in addition to the obvious physical differences, he is
different in psychological and social terms from a girl of the same age. A boy of twelve who is fending for
himself on the street is likely to be growing and developing very differently from a boy of a similar age
who is growing up with a caring and financially secure family. Even two boys of the same age, growing
up in very similar circumstances, may grow and develop in different ways and time lines.
What do we mean by the term health?

WHOs constitution defines health as: a state of complete physical, mental and social well-being and
2
not merely the absence of disease or infirmity. This definition, which includes the absence of disease
or infirmity on the one hand and well-being on the other, is as relevant today as it was when it was
formulated in 1948.
What do adolescents need in order to grow and develop in

good health?
In 1995, WHO, in conjunction with the United Nations Childrens Fund (UNICEF) and the United
Nations Population Fund (UNFPA), agreed on a Common Agenda for Action in adolescent health
and development. This common agenda has the twin goals of promoting healthy development in
adolescents, and the prevention of and response to health problems if and when they arise. It calls for
the implementation of a package of interventions, tailored to meet the special needs and problems
of adolescents, which includes the provision of information and skills, the creation of a safe and
3
supportive environment, and the provision of health and counselling services.
A useful analogy is that of an 8 year-old girl who needs to cross the road every day to get to school. She
needs information and skills: on where to look, what to look for, when to walk across, and when not to
do so. She needs a safe and supportive environment: a pedestrian crossing, traffic lights that work or a
traffic warden in position, drivers who respect traffic rules or are punished if they do not do so. She may
also need health and counselling services, if she stumbles and falls, or is struck down by a vehicle.
2 Constitution of the World Health Organization. Geneva, World Health Organization, 1948.
3 WHO, UNFPA, UNICEF. Common agenda for action in adolescent health and development. Geneva, World Health
Organization, 1997.
2 Making health services adolescent friendly
Who needs to contribute to helping them grow and develop

in good health? What is the special contribution that health
workers and health services within this?
Many individuals and institutions have important contributions to make to the health and development
of adolescents. It may be useful to think of them in concentric circles of contact and influence. At the
centre is the adolescent himself or herself. Parents, siblings and close family members are in daily
contact with the adolescent and constitute the first circle. The second circle includes people in regular
contact with them such as their own friends, family friends, teachers, religious leaders and others. The
third circle includes musicians, film stars and sports figures who have a tremendous influence on them,
from afar. Finally in the fourth circle, politicians, journalists and bureaucrats, business magnates and
others affect their lives in small and big ways, through their words and deeds.
What do we mean by the term health services? And what is

the role of health services in contributing to the health and
development of adolescents?
By health services, we mean a service provided by a health worker to a patient aimed at preventing a
health problem, or detecting and treating one. It often includes the provision of information, advice and
counselling.
As indicated above, health workers are part of the list of players who need to contribute to the health
and development of adolescents. They have two complementary roles to play. Firstly, as service
providers, they have important contributions to make in helping well adolescents stay well, and in
helping ill adolescents get back to good health.
They do this through:
the provision of information, advice, counselling and clinical services aimed at promoting health and
preventing health problems and problem behaviours;
the diagnosis, detection and management of health problems and problem behaviours; and
referral to other health and social service providers, when necessary.
Health workers have another important role to play that of change agents in their communities.
They have credibility and influence in their communities and need to use this to help influential
community members take adolescent health seriously. They could make an invaluable contribution
in helping educators, religious leaders, political leaders and others understand the needs of
4
adolescents, and the importance of working together to meet these needs.
4 Programming for adolescent health and development. Report of a WHO/UNFPA/UNICEF study group on programming
for adolescent health. Geneva, World Health Organization, 1999.

What are the health problems that adolescents experience?

Many adolescents make the transition to adulthood in good health. Many others do not and may face
5,6
5 6
some of the health problems listed below: ,
injuries resulting from accidents or violence;

mental health problems;
problems resulting from substance use;
sexual and reproductive health problems (e.g. too-early pregnancy, mortality and morbidity during
pregnancy and child birth including due to unsafe abortion, sexually transmitted infections including
HIV, harmful traditional practices such as female genital mutilation, and sexual coercion);
problems resulting from under nutrition and over nutrition;
endemic diseases (e.g. tuberculosis and malaria).
Some of these health problems affect the individual during adolescence (e.g. a death caused by suicide
or interpersonal violence or from the consequences of an unsafe abortion). Others affect the individual
later in life (e.g. lung cancer resulting from tobacco use initiated during adolescence).
When adolescents have health-related concerns or are

experiencing health problems to whom do they turn for help? 7
As indicated above, most adolescents make the transition into adulthood in good health (although
some of them do not). Those adolescents who are well tend to see no good reason for visiting a health
facility. (In most developing countries, the system of periodic check-ups to monitor progress is limited
to children under the age of five, and to pregnant women). Those adolescents who fall ill with, for
example, commonly occurring conditions such as fevers, coughs and colds, may have no hesitation
in seeking care. On the other hand, they may be less willing to do so for more sensitive matters. For
example, a young woman may prefer to turn to her mother for advice and help, rather than to a nurse or
a doctor when she suffers from painful menstrual periods.
Not surprisingly, a key factor that influences adolescents health care-seeking behaviour is whether or
not the act of seeking health care could get them into trouble with their parents or guardians. If, as in
many cultures, social norms strongly forbid premarital sex, unmarried adolescents are likely to be wary
about seeking care even if they have a painful genital ulcer or a possible unwanted pregnancy. They
are likely to try to deal with the problem themselves, or with the help of friends or siblings whom they
can trust to keep their secrets. To ensure that no one around them comes to learn about their problem,
they tend to turn to service delivery points such as pharmacies and clinics at a safe distance from their
homes, as well as to service providers who are as keen as they are to maintain secrecy (such as those
who carry out abortions illegally).
5 Patton GC, Coffey C, Sawyer SM et al. Global patterns of mortality in young people. A systematic analysis of population
data. The Lancet, 2009, 374: 881892.

6 Gore F, Bloem PJN, Patton GC et al. Global burden of disease in young people aged 1024 years: a systematic analysis.
The Lancet, 2011, 377: 20932102.

7 Barker G, Olukoya A and Aggleton P. Young people, social support and help-seeking. International Journal of Adolescent
Medical Health, 2005, 17, 4:315336.
In many instances it is the adults surrounding an adolescent who decide whether or not health care
needs to be sought, and if so when and where it should be sought. This is generally true in case of
younger adolescents who are dependent on their parents. In some places, this is also true in case of
older adolescents. Studies in several south Asian countries suggest that decisions on care-seeking
during pregnancy and at the time of delivery, rest with husbands and mothers-in-law, rather than with
young wives.
What are the barriers that adolescents face in obtaining the

health services they need?
Some of the barriers that adolescents face in obtaining the health services they need also affect
children and adults; others are specific to adolescents. These barriers relate to the availability,
8
accessibility, acceptability and equity of health services.
Firstly, in many places, health services such as emergency contraception and safe abortion are simply
not available to anyone, either to adolescents or to adults.
Secondly, even where health services are available, adolescents may be unable to obtain them for a
variety of reasons restrictive laws and policies may prevent some health services from being provided
to some groups of adolescents (e.g. the provision of contraceptives to unmarried adolescents);
adolescents may not know where and when health services are provided; health facilities may be
located a long distance from where they live/study/work; or health services may be expensive and
beyond their reach). What this means is that the health services are not accessible to them.
Thirdly, health services may be delivered in a way that adolescents do not want to obtain them, even
if they can. One common reason for this is that they have to go to, and wait in, a place where they
could be seen by people they know. Other reasons are the fear that health workers will scold them, ask
them difficult questions, and put them through unpleasant procedures; or that health workers will not
maintain confidentiality. What this means is that the health services are not acceptable to them.
Finally, health services may be friendly to some adolescents, such as those from well-to-do families,
but may be decidedly unfriendly to others, such as young people living and working on the streets. In
other words, they may be available, accessible and acceptable but not necessarily equitable.
What do adolescents perceive as friendly health services?

Adolescents are a heterogeneous group. The expectations and preferences of different groups of
adolescents are understandably different.
It is interesting to note, however, that different groups of adolescents, from various parts of the world,
identify two key, common characteristics. They want to be treated with respect and to be sure that their
9
confidentiality is protected.
8 Adolescent-friendly health services: An agenda for change. Geneva, World Health Organization, 2003.
What is being done to make to make health services

adolescent friendly?
There is growing recognition of the need to overcome these barriers and to make it easier for
adolescents to obtain the health services they need. Initiatives are being undertaken in many countries
9
to help ensure that:
Health service providers are non judgemental and considerate in their dealings with adolescents;
and they have the competencies needed to deliver the right health services in the right way.
Health facilities are equipped to provide adolescents with the health services they need; and are
also appealing and friendly to adolescents.
Adolescents are aware of where they can obtain the health services they need, and are both able and
willing to do so when needed.
Community members are aware of the health-service needs of different groups of adolescents, and
support their provision.
NGOs are in the forefront of these efforts in most places, although in a growing number of countries,
government-run health facilities are also reorienting themselves in order to reach out to adolescents.
Initiatives are being undertaken in a variety of settings:
Hospitals;
Work places;
Public, private and NGO clinics;
Shopping centres;
Pharmacies;
Refugee camps;
Youth centres;
On the street.
Educational institutions;
Most of these initiatives are small in scale and of limited duration. However, there are a steadily growing
number of initiatives that have moved beyond the pilot or demonstration project stage to scale up
their operations to reach out to adolescents across an entire district, province or country.
Is there any evidence that efforts to make health services adolescent friendly can increase their
utilization by adolescents?
There is growing evidence for the effectiveness of some of these initiatives in improving the way health
services are provided, and in increasing their use by adolescents.
In 2006, WHO published a systematic review of the effectiveness of interventions to improve the use
10
of health services by adolescents in developing countries. This review identified twelve initiatives,
including one randomized controlled trial (Nigeria), six quasi-experimental studies (Bangladesh, China,
Madagascar, Mongolia, Uganda and Zimbabwe), two national programmes (Mozambique and South
Africa), and three projects (Ghana, Rwanda and Zimbabwe), which demonstrated that actions to make
health services user friendly and appealing had led to increases sometimes substantial in the use of
health services by adolescents.
9 Global Consultation on adolescent-friendly health services. A consensus statement. Geneva, World Health Organization, 2002.
10 Dick B, Ferguson J, Chandra-Mouli V, Brabin L et al. A review of the evidence for interventions to increase young peoples use of health
services in developing countries in Ross D, Dick B, J Ferguson (Eds.). Preventing HIV/AIDS in young people: A systematic review of the
evidence from developing countries. Geneva, World Health Organization, 2006.
These conclusions were reiterated in another review published in 2008, which concluded that: Enough
is known that a priority for the future is to ensure that each country, state and locality has a policy and
11
support to encourage provision of innovative and well-assessed youth-friendly health services.
What can be done to improve the quality of health service

provision to adolescents?
The starting point for any initiative aimed at improving the quality of health service provision to
adolescents is the national health policy and strategy developed by the ministry of health, which will
provide answers to five critical questions:
What health outcomes are being aimed for?
Among which group (or groups) of adolescents are these health outcomes being aimed for?
What is the place of health service provision to adolescents within an overall strategy to achieve
these health outcomes?
What is the package of health services to be provided, to achieve the health outcomes being aimed for?
Where (which type of health facility) and by whom (which type of health service provider) should
these health services be provided by?
Precise answers to these questions will provide a sound basis for developing a national strategy to
improve the quality of health service provision to adolescents.
It is important to build on what already exists. What this means is that efforts should be directed at
making existing service-delivery points intended to provide health services to all segments of the
population more friendly to adolescents, rather than on setting up new service-delivery points
exclusively intended for adolescents. Having said that, dedicated health service-delivery points and
outreach work could play a useful role in reaching marginalized and stigmatized groups of adolescents
(such as injection drug users), who may be reluctant to use a service-delivery point that is open to all.
Two complementary efforts are needed firstly, to make health-service provision friendly, so that
adolescents are more likely to be able and willing to obtain the health services they need; and
secondly, to ensure that the health services that adolescents need to stay healthy or to get back to good
health are in fact being provided, and are being provided in the right manner. In other words, efforts
must be made to increase both health service utilization and health service provision.
The WHO quality of care framework provides a useful guide to work on improving health service
12
provision and utilization. It brings together the complementary imperatives of, on the one hand,
making it easier for adolescents to obtain the health services they need and, on the other, providing
them with the health services they need in the right way.
The quality of care framework provides a useful working definition of adolescent-friendly health
services. To be considered adolescent friendly, health services should be accessible, acceptable,
13
equitable, appropriate and effective, as outlined below:
Accessible
Adolescents are able to obtain the health services that are available.
11 Tylee A, Haller DM, Graham T, Churchill R et al Youth-friendly primary-care services: how are we doing and what more needs to be
done. The Lancet, 2007, 369.
12 Quality of Care. A process for making strategic choices in health systems. Geneva, World Health Organization, 2006.
13 Quality Assessment Guidebook. A guide to assessing health services for adolescent clients. Geneva, World Health Organization, 2009.
Acceptable
Adolescents are willing to obtain the health services that are available.
Equitable
All adolescents, not just selected groups, are able to obtain the health services that are available.
Appropriate
The right health services (i.e. the ones they need) are provided to them
Effective
The right health services are provided in the right way, and make a positive contribution to their health.
It provides a useful way of organizing the characteristics that have been shown in research and in
programmatic experience to contribute to making health services adolescent friendly (see also Annex 1).
Specifying standards, i.e. statements of required quality,14 is a key first step. Once that is done actions
need to be taken to achieve those standards. A standards-driven quality improvement approach
enables this to be accomplished in the following three ways:
1. It helps set clear goals for different aspects of service-delivery point operations. For example, a
standard statement could specify what medicines (e.g. antibiotics) and supplies (e.g. needles and
syringes, cotton swabs and spirit to clean injection sites) need to be in place in a service-delivery point.
It could also specify the quantity of each of these medicines and supplies that need to be in place.
2. It provides the basis for assessing the achievement of goals. In relation to the example, the standard
statement provides a basis to assess whether in a particular service-delivery point, the specified medicines
and supplies are in place, and whether the specified quantities of these medicines and supplies are in place.
3. It provides an entry point for identifying why the goals were not achieved.
Based on this standards can help indicate what needs to be done, by when and by whom for the goals
to be achieved. In relation to the example, if antibiotics to treat sexually transmitted infections in
adolescents and adults are out of stock, the main reasons for this and actions to solve the problem
and to prevent it from occurring again in the future need to be identified. These actions may need
to be taken at the point service delivery, or they may need to be taken at other levels, for example
at the district or national level. Once these actions are put in place, the situation must be reviewed
periodically to determine whether specific problems recur.
Using these three complementary aspects defining quality, measuring quality and improving quality
ministries of health can put in place national initiatives to improve the quality of health service
15
provision to adolescents in order to achieve clearly defined health outcomes. This can be done as part
of wider initiatives to improve the quality of health services intended for all segments of the population.
14 E Necohea, D Bossemeyer. Standards based management and recognition. A practical approach for improving the performance and
quality of health services. Baltimore, Jhpiego, 2005.
15 R Massoud, K Askov, J Reinke et al. A modern paradigm for improving health care quality. Bethesda, Quality Assurance Project, 2001.
What can be done to ensure that high quality health services reach all the adolescents who need them?
Scaling up has been defined by WHO and ExpandNet as: Deliberate efforts to increase the impact of
successfully tested health innovations so as to benefit more people and to foster policy and programme
16
development on a lasting basis. Deliberate efforts are needed to reach out to all adolescents who
need health services.
17
Using the WHO nine-step approach to developing a scaling up strategy, a systematic process has been developed
for scale-up of health service provision to adolescents. The process begins with actions at the national level, which
are followed by subsequent actions at the state/district level and the health facility levels. The process is outlined in
18
the document titled: Strengthening the health sector response to adolescent health and development.
16 Practical guidance on scaling up health service innovations. Geneva, World Health Organization (with ExpandNet), 2009.
17 Nine steps to developing a scaling up strategy. Geneva, World Health Organization (with ExpandNet), 2010.
18 Strengthening the health sectors response to adolescent health and development. Geneva, World Health Organization, 2009.
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CHAPTER 2
What is the step?
Develop a clear understanding of the WHO approach to promoting adolescent health and to providing adolescents
with the health services they need, among key stakeholders involved in the national effort to strengthen health
service provision to adolescents.
What is the purpose of this step?
To ensure that key stakeholders involved in the national effort to strengthen health service provision to
adolescents have a clear understanding of WHOs approach to promoting adolescent health and to providing
adolescents with the health services they need. Key stakeholders may include officials from the ministry of health,
officials from influential national NGOs, academics, and representatives of international organizations.
What is the importance of this step?
The overall initiative is much more likely to move ahead if the key stakeholders have a shared understanding of
promoting adolescent health and of providing adolescents with the health services they need.
How could this step be taken?
In both formal and informal meetings with individuals, small groups or large groups, seek to understand the
perspectives of key stakeholders and to explain the WHO approach to promoting adolescent health and to
providing adolescents with the health services they need. (Please refer to Chapter 1).
Making health services adolescent friendly
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11
eptable
What is step 1?
Establish the basis for addressing adolescents within the national HIV/AIDS and/or RH policies and strategies.
To establish that this initiative is in line with national policies and strategies.
What is the importance of taking this step?
Firstly, in many countries there are individuals, groups and organizations who are uncomfortable with providing
adolescents sexual and reproductive health information and services. If there is resistance to the initiative from any
quarter, it would be helpful to show that it is entirely in line with national policies and strategies.
Secondly, grounding the initiative in national policies and strategies may make it more likely that it will receive both
moral and material support of decision-makers in the government and in international organizations.
Review the national HIV/AIDS and RH policy and strategy documents.
Hold one-to-one/small group discussions with officials responsible for the national HIV/AIDS and RH programmes.
Based on your findings, prepare a paper and table this for discussion in the process leading to the development of
the national quality standards for health service provision to adolescents. Some suggested questions to ask include:
(i) Does the national HIV/AIDS and/or RH policy/strategy identify adolescents as a population group to be
addressed?
(ii) Does the national HIV/AIDS or RH policy/strategy identify:- the magnitude of the problem(s) in adolescents (e.g.
the prevalence of HIV infection in males aged 1519 years among the general population);
the behaviours that contribute to the problem(s) in adolescents, (e.g. the prevalence of unprotected sexual activity
with multiple partners);
the factors influencing these behaviours in adolescents (e.g. low perception of the risk of HIV)?
(i) Does the national HIV/AIDS and/or RH policy/strategy include a component to prevent HIV/AIDS and RH
problems in adolescents?
What is step 2?
Establish the basis for the provision of health services to adolescents within the framework of the national HIV/AIDS
and/or RH policies/strategies.
To ensure that the national quality standards for health service provision to adolescents are formulated in line with
national policies and strategies.
Grounding the initiative in national policies and strategies will make it more likely that it will receive both the moral
and the material support of decision-makers in the government and in international organizations.
* Where national adolescent health policies and strategies address HIV and Sexual and Reproductive Health, they should be
reviewed.

Review the national HIV/AIDS and RH policy and strategy documents.
Hold one to-one/small group discussions with officials responsible for national HIV/AIDS and reproductive health
programmes.
Based on your findings, prepare a paper and table this for discussion in the consultancy process leading to the
formulation of the national quality standards.
To begin with, point to the sections of the national HIV/AIDS and/or reproductive health policies/strategies that identify the
need to provide sexual and reproductive health services to adolescents? Then, move on the following points.
(i) The population groups to be addressed.
(Note: Do the policy/strategy documents specify whether the health outcomes are being aimed for in all adolescents or
only in some groups of adolescents?).
(ii) The health outcomes being aimed for.
(Note: Do the policy/strategy documents specify what changes in the health status are being aimed for?).
(iii) The role of health service provision within a broader strategy.
(Note: Do the policy/strategy documents specify that health service provision is grounded in a broader strategy that
includes providing information and education to adolescents, providing them with counselling services, and making
their environment safer and more supportive?).
(iv) The package of health services to be provided.
(Note: Do the policy/strategy documents specify the package of preventive and curative health services that need to be
delivered at the primary and at various referral levels in order to contribute to the desired health outcomes?).
(v) The delivery of these health services where and by whom.
(Note: Do the policy/strategy documents specify where (i.e. from which health service delivery points) and by whom
(i.e. which health-service providers) the stipulated package of health services should be delivered ?).
(vi) A clear position on the authorization of adolescents to obtain the health services they need, and the requirement
for the consent of parents/guardians.
(Note: Do the policy/strategy documents clearly state whether all groups of adolescents are authorized to obtain the
stipulated package of health services; and whether they can do so autonomously i.e. without the consent of parents
or guardians).
Section III. Examine the programmatic implications of

applying the national quality standards
There are four steps in this section:
1. Develop a clear understanding of what a standards-driven initiative to improve the quality and
expand the coverage of health service provision to adolescents means in practice, and what it takes
to translate quality-standard statements into tangible improvements in quality and coverage at
health service delivery points, among key stakeholders involved in the national effort to strengthen
health service provision to adolescents.
2. Develop a good understanding of the current situation regarding the provision of health services to
adolescents, and their utilization by adolescents.
3. Gather experiences from within the country in applying quality improvement principles and
practices in public health programmes.
4. Identify the place of the unit driving of the national standards-driven initiative in the country; as
well as programmatic opportunities and challenges in applying them.
What is step 1?
Develop a clear understanding of what a standards-driven initiative to improve quality and expand the coverage of
health service provision to adolescents means in practice, and what it takes to translate quality-standard statements
into tangible improvements in quality and coverage at health service delivery points, among key stakeholders
involved in the national effort to strengthen health service provision to adolescents.
To seek to learn/understand from stakeholders:
(i) what problem do they want to solve and what gap do they want to fill through this national standards-driven
initiative to improve quality and expand coverage;
(ii) what results do they expect to achieve through this initiative.
To ensure that the key stakeholders clearly understand:
(i) what a standards-driven initiative to improve the quality and expand the coverage of health service provision
means in practice;
(ii) what efforts are required at the national and district levels to translate the quality standard statements into
tangible improvements in the quality of health service provision at health service delivery points.
It is important to ensure that the key stakeholders involved in the national effort to strengthen health service
provision to adolescents have a clear and shared understanding of the issues listed above. It is important that they
are fully aware that this effort requires concerted and complementary efforts at national, district and local levels.
Through formal and informal meetings with individuals, small or large groups, seek to understand the perspectives of
key stakeholders and to inform/explain to them WHOs viewpoints on this. Do this using the accompanying slide sets
and talking points.
What is step 2?
Develop a good understanding of the current situation regarding the provision of health services to adolescents, and
their utilization by adolescents.
To understand the current situation regarding:
(i) by whom and where health services are currently provided to adolescents;
(ii) barriers to the provision and utilization of health services by adolescents;
(iii) help-seeking and health care-seeking practices of adolescents;
(iv) initiatives that are under way in providing adolescents with the health services they need.
What is the importance of this step?
Firstly, a good understanding of the current situation will provide a solid basis for considering how the situation could
be improved, building on the areas of strength, and addressing gaps and areas of weakness. Secondly, it will send a
clear message that there is a systematic effort to draw upon, the lessons learned from within the country, in this area.
Through discussions with key informants in the ministry of health, NGOs, academic institutions and international
agencies, gather published papers and reports on:
(i) by whom and where health services are currently provided to adolescents;
(ii) barriers to the provision and utilization of health services by adolescents;
(iii) help-seeking and health care-seeking practices of adolescents;
(iv) initiatives that are under way in providing adolescents with the health services they need.
(Note: It is important to obtain the view points and perspectives of different groups of adolescents).
Identify individuals and organizations that are carrying out research and/or implementing programmes/projects on
If possible, bring together a small working group to prepare a working paper highlighting the lessons that could be
drawn from their work for scaling up health service provision to adolescents.
Identify possible individuals who could be involved in the formulation of the national quality standards
What is step 3?
Gather experiences from within the country in applying quality improvement principles and practices in public health
programmes.
To draw out the experiences gained from initiatives in the country that have worked to improve the quality of health
service provision and to increase health service utilization by any population group in order to achieve a clearly
defined health outcome.
There are three potential benefits of doing this. Firstly, it will help communicate the message that quality
improvement principles and practices are not foreign to the country. Secondly, it will help key stakeholders to
understand what the application of quality improvement principles and practices can achieve, and more importantly
what it takes to put and keep them in place. Thirdly, it will point to individuals and organizations from within the
country whose expertise could be drawn upon.
agencies, identify noteworthy initiatives that have applied quality improvement principles and practices in public
health work.
Gather published papers or reports that describe the process employed by these initiatives and the results they
achieved.
Identify individuals and organizations that are carrying out research and/or implementing programmes/projects on
If possible, bring together a small working group to prepare a working paper highlighting the lessons that could be
drawn from their work for scaling up health service provision to adolescents.
What is step 4?
Identify the place of the unit driving the national standards-driven initiative in the country; as well as programmatic
opportunities and challenges in applying them.
To identify the driver of the national standards-driven initiative, the strengths and weaknesses of the unit, and its
linkages with other units in the ministry of health.
To identify factors in the environment that could help or hinder the implementation of the initiative. For example,
a national effort to improve the quality of reproductive health services supported by UNFPA could be a potential
opportunity for a link with the initiative. However, the lack of willingness to engage health-service providers in the
private sector in public health programmes could hinder the ability of the initiative to work with a key group who
many groups of adolescents turn to.
Firstly, the national standards-driven initiative to improve the quality and expand the coverage of health service
provision to adolescents is much more likely to succeed if it has a driver with the authority, the technical capacity and
the resources needed to move the initiative forward.
Secondly, in moving the initiative forward it is important to be aware of potential opportunities and challenges in the
environment.
How could this step be taken ?
agencies, identify programmatic openings, prepare a working paper on:
(i) what are the strengths and weaknesses of the driver of the initiative, and what could be done to build on the
strengths and address the weaknesses;
(ii) the potential opportunities and challenges in implementing the initiative.
Section IV. Develop the national standards

There are two steps in this section:
1. Obtain the public support of the key stakeholders whose support is important for the national
standards-driven quality improvement to succeed.
2. Develop the national standards (and accompanying elements of a standards-driven quality
improvement initiative).
What is step 1?
Obtain the support of a wide range of stakeholders whose support is important for the national standards-driven
quality improvement initiative to succeed. In addition to individuals and organizations involved in the preparatory
work, this step should involve other community members such as political leaders, religious leaders, teachers
and officials from government departments other than health whose work affects adolescents/young people. It is
important to involve adolescents as well in the consultative process.
To present the conclusions and recommendations of the preparatory work that has been done (as described in
sections I, II and III) and to obtain further inputs.
To place in the public arena the fact that the national standards are to be developed and the ground work that has
been done to prepare for this.
For the initiative to succeed it is important to ensure that the wide range of stakeholders referred to above are fully
aware that national standards for health service provision to adolescents are being developed and comfortable with
the process for this. Secondly, they must be fully aware of the preparatory work that has been done and satisfied that
it is adequate. Thirdly, they need to believe that their perspectives have been listened to and taken on board.
Organize a consensus-building workshop bringing together a wide range of stakeholders.
(Note: It is important to involve adolescents in the consultative process. This could be done by having one or more
meetings in advance of the national consensus-building workshop. Adolescents selected by their peers could be
invited to participate in the consensus-building workshop.
What is step 2?
Develop the national standards (and accompanying elements of a standards-driven quality improvement initiative).
To define the key problems (i.e. the gap between required quality and actual quality) that the standards seek to
address.
For each problem:
(i) To formulate the standards (i.e. the desired quality to be achieved),
(ii) To identify the input, process and output criteria to achieve each standard (i.e. what needs to in place and what
needs to happen in and around at points of health service delivery for the standard to be achieved),
(iii) To identify the actions needed at national, district and local level to achieve each criteria,
(iv) To identify the indicators to verify the achievement of the criteria, and means of verifying them.
This step clearly outlines the objectives of the national initiative seeks to achieve, what needs to be done to achieve
these objectives, and what needs to be done to assess whether these objectives are being achieved.

A working group consisting of 810 persons should work together to draft the standards. Here is an indicative list of
working group members:
(i) 12 officials from the ministry of health at the national level;
(ii) 12 persons from influential NGOs;
(iii) 12 academics;
(iv) 12 representatives of international organizations.
The draft standards should be shared with key stakeholders involved in the national effort to strengthen health
service provision to adolescents.
The working group should meet, possibly more than once, to review the feedback that has been received, and work to
revise and finalize the standards.
(Note: The accompanying presentation entitled Developing standards and the accompanying document titled Generic
characteristics of adolescent-friendly health services within WHO-defined dimensions of quality, can be used to guide
the development of the standards and other elements).
Section V. Outline essential preparatory work at national

levels before the quality standards can be applied
There are four steps in this section:
1. Ensure that the draft standards and accompanying elements, are cleared by the relevant authorities
after being reviewed and revised, as needed.
2. Develop an implementation guide that outlines what district health management teams and
managers of health facilities need to do to ensure that the structure criteria accompanying each
standard statement are in place.
3. Develop a monitoring guide that outlines what and how district health management teams and
managers of health facilities need to track implementation.
4. Inform key stakeholders at the national level, who could help or hinder the implementation of the
initiative; explain to them what it aims to achieve and how it aims to do this.
What is step 1?
Ensure that the draft standards and accompanying elements are cleared by the relevant authorities after being
reviewed and revised, as needed.
To have the standards and accompanying endorsed by the relevant authorities, and thereby translating them into an
authoritative national document.
Official endorsement is required before the document can be disseminated and applied in order to improve the
quality of health services.
Actively follow up with the relevant authorities for official clearance. This will require responding to questions and
clarifying any lingering misconceptions.
What is step 2?
Develop an implementation guide that outlines what district health management teams and managers of health
facilities need to do to ensure that the structure criteria accompanying each standard statement are in place.

To provide clear guidance to district health management teams and managers of health facilities on what they need
to do to ensure that the \structure criteria accompanying each standard are put in place.
It is important to ensure that district health management teams and managers of heath facilities are clear as to what
they need to do to ensure that the structure criteria accompanying each standard are put in place. Without clear
guidance, it is likely that essential things may not be done.
Identify and engage an individual/organization with expertise in this area to prepare an implementation guide.
For example, structure criteria 4 (which accompanies standard 2 in the Tanzanian standards for youth-friendly
reproductive health services) states: Equipment, supplies and medicines will be constantly available. In this case,
the implementation guide needs to specify the range and quantities of equipment, supplies and medicines that
need to be place in each health facility.
What is step 3?
Develop a monitoring guide that outlines what and how district health management teams and managers of health
facilities need to track implementation.
To provide clear guidance to district health management teams and managers of health facilities on what and how
they need to check in order to verify that the required actions are being carried out.
It is important for district health management teams and managers of health facilities to be clear about what exactly
they need to check and how they should do this.
Identify and engage an individual/organization with the expertise in this area, to prepare a monitoring guide.
What is step 4?
Inform key stakeholders at the national level, who could help or hinder the implementation of the initiative; explain
to them what it aims to achieve and how it aims to do this.
To ensure that stakeholders do not oppose the initiative, and where relevant to draw upon their support in moving
forward.
Firstly, key stakeholders may have the power to kill the initiative themselves. Alternatively, they could contribute
to its decline by speaking about it in a negative manner. They may do this because they do not understand fully,
because they believe or may hear that it is not useful/feasible, or because they may feel excluded from
the consultative process contributing to the initiative. Secondly, they may be able to provide useful ideas and
suggestions to strengthen the initiative. Thirdly, they may be willing and able to support the initiative.
Identify the key stakeholders who need to be reached. Here is an indicative list:
(i) Within the ministry of health: the national HIV/AIDS programme, the national reproductive health programme,
and the primary health care unit;
(ii) The ministry of local government;
(iii) Key international organizations: within the United Nations system, bilateral agencies, international
organizations;
(iv) National NGOs.
Ideally, set up one-to-one meetings to explain the initiative, request ideas and suggestions for moving it forward.
Use an appropriate forum, such as a regular meetings of the national HIV/AIDS programme, to inform them about the
initiative and obtain their support for it.
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Workshop to develop national quality standards for

adolescent-friendly health services: Objectives, agenda and
facilitators guide
Objectives
To draft national quality standards and accompanying elements for providing health services to
adolescents.
Agenda
Days
1
9.00 to 10.30
11.00 to 12.30
14.00 to 15.30
16.00 to 17.30
Opening remarks
Identify the intended

beneficiaries
Define the health

outcomes to be
achieved
Define the health

services and healthrelated commodities
to be delivered
Identify the problem

statements to be
addressed
Formulate the quality standards
Introductions
Statement of
objectives of the
workshop
Explanation of working
methods to be used
2
Identify the health

service and healthrelated commodity
delivery points
Choose the set of criteria to be achieved for each

quality standard to be achieved
Identify the actions to be taken at national, district

and local levels for the criteria to be achieved
Specify ways and means of verifying the

achievement of the criteria
Outline the preparatory

work that needs to be
done at the national
level before the quality
standards can be
applied
Facilitators guide for sessions

1. Identify the intended beneficiaries
Ask the following questions:
a. What is the population segment (e.g. 1019 years) we want to
address? Why?
b. Within this, which population group do we want to focus on?
(E.g. those living and working on the street). Why?
Tips for the facilitator
Deal with the first question in plenary. Ask the group to name the
population segment to be addressed and the rationale for this.
Closing remarks
For the second question, split up the larger group into buzz groups of 3 people. Ask each group to
identify a maximum of two population groups and to provide the rationale for their choice. Ask each
buzz group to share their conclusions in plenary. Work with them to arrive at a list of around 5 specific
population groups.
2. Define the health outcomes to be achieved

Ask the following question:
2.1 What are the health outcomes we want to achieve?

Why?
Prepare copies of the following table in advance of the workshop.
Split up the larger group into buzz groups of 3 people. Ask each group to fill in the table. When they
are done, ask them to share their outputs in plenary. Work with them to arrive at a short list of health
outcomes to be addressed, using the criteria listed in the table. Stress that the longer the list is, the
more challenging this will be for implementation.
Health outcomes
How relevant is
this issue in my
country?
Can health workers make a

meaningful contribution to
addressing it?
(15)
(15)
(i) Healthy development:

To promote healthy development
To respond to development problems when they occur
(ii)Healthy nutrition:
To prevent under- and over-nutrition
To respond to under- and over-nutrition when they occur
(iii) Sexual and reproductive health:
To prevent unwanted pregnancy
To respond to unwanted pregnancy when it occurs
To support healthy pregnancy and to prevent problems during
pregnancy
To respond to problems when they occur during pregnancy
To prevent sexually transmitted infections (STI)
To respond to STI when they occur
To prevent HIV infection
To respond to HIV infection/HIV-related illnesses when they occur
To prevent sexual violence
Health outcomes
How relevant is
this issue in my
country?
Can health workers make a

meaningful contribution to
addressing it?
(15)
(15)
To respond to sexual violence when it occurs

(iv) Mental health:
To prevent mental health problems
To respond to mental health problems when they occur
(v) Substance use:
To prevent substance use
To respond to substance use problems when they occur
(vi) Injuries:
To prevent unintentional injuries
To respond to the physical and psychological consequences of
unintentional injuries when they occur
(vii) Injuries resulting from violence:
To prevent violence
To respond to the physical and psychological consequences of
violence when it occurs
(viii) Endemic diseases:
To prevent endemic diseases, such as malaria and dengue
To respond to them when they occur
(ix) Chronic conditions:
To respond to chronic conditions when they occur
3. Define the health services and commodities to be delivered to achieve these

health outcomes
3.1 What are the health services to be provided in relation to each of the health outcomes
above?

Depending on the size of the group, split them up into buzz groups of 3 people. Ask each group to
address some of the health outcomes. Ask them to share their outputs in plenary. Based on the
discussion revise and finalize the following table.
Health outcome to
be achieved
Information
provision
Counselling
provision
Clinical service
(promotive, preventive or curative)
Referral
4. Identify the health service and commodity

deliver points
Ask the following questions:
4.1 Where are the health services to be provided?

4.2 Where are the health-related commodities to be
provided?
Depending on the size of the group, split them up into buzz groups of 3 people. Ask each group to
address 12 delivery points, using the matrix below. Ask them to share their conclusions in plenary.
Based on the discussion, finalize the matrix below.
Health service/
health-related
commodity delivery
points
Groups of adolescents
who are likely to come in
or to be reached
The health services that could be

provided:
- Information provision;
The health-related
commodities that could
be provided
- Counselling provision;
- Clinical service provision;
- Referral.
A.
B.
C.
D.
E.
5. Identify the problem statements (the gap

between desired quality and actual quality)
How does each of the health service delivery points/health-related
commodity delivery points relate to the desired quality?
Task:
Identify key problems in the health service delivery points.
Do this exercise with the entire group. Ask participants to work
together to complete the following matrix. Once all the problem
statements are noted, ask the group to identify the five most
important ones (using the following two criteria):
a. the size of the gap between the actual and desired quality;
b. which of the gaps are most relevant to the groups of adolescents
we are concerned about?
Desired quality
Points of health service or health-related commodity
delivery:
provide the health services and the health-related
commodities that adolescents need (either-on the-spot
or through referral linkages)
enable adolescents to obtain the health services they
need
are appealing to adolescents
Health workers:
are non-judgemental and considerate in their dealings
with adolescents
deliver the services in the right way
Support staff:
are non-judgemental and considerate in their dealings
with adolescents
Community members support the provision of health
services to adolescents
Adolescents
are aware of what services are being provided
are (and feel) able and willing to obtain the health
services they need.
Actual quality
6. Formulate the quality standard statements

When we say that we want to improve the quality of these health
service delivery points, what exactly do we mean?
Task:
Formulate standard statements in relation to each of the main
problems identified. For each standard statement, define key words
and phrases in the statement.
Explain to the group that a standard is defined as a statement of required quality. In other words, it is a
precise description of what the situation will be like after the problem has been tackled and successfully addressed.
7. Choose the set of criteria to be achieved for

each quality standard to be achieved
What needs to be in place for the quality standard to be achieved?
Task:
Choose the criteria needed to achieve each standard. In other
words, identify what needs to be in place for each standard to be
achieved.
Lead the group through an example. In doing so, explain to the
group that there are three types of criteria:
i. Input criteria: The hardware that needs to be in place at
a health service-delivery point
Examples: A competent health worker; a notice board listing the
opening hours of a clinic.
ii. Process criteria: The way in which staff in the health service delivery point deal with
adolescent patients and with other community members.
Examples: Health workers manage adolescents as stated in the guidelines; support staff are welcoming
to adolescents.
iii. Output criteria: The desired effect on adolescent users of the health service delivery point
and on other community members.
Examples: Adolescents feel that health workers are concerned about their welfare; community
members are aware of what health services are being provided by the clinic.
Ask the group to brainstorm on possible criteria. Once this done, work with them to choose a short list
based on the following issues:
Potential impact (i.e. the potential impact of the criteria in contributing to the standard).
Feasibility (i.e. the feasibility of putting the criteria in place, in the local context).
Complementarity (i.e. how the set of criteria complement each other).
Stress that the criteria that they choose need to be ambitious but not overambitious, in line with
national laws and policies, and sensitive to the social and cultural norms.
Standard statement # 1
Criteria
Input criteria
Process criteria
(that correspond to the
input criteria)
Output
criteria
Potential
impact
Feasibility
Complementarity
1.
2.
3.
4.
5.
8. Identify the actions to be taken at national, district and local levels for the
criteria to be achieved
What needs to be done at the national, district and local levels to
ensure that health service provision meets the specified quality?
Task:
Identify the actions that need to be taken to achieve each of the
input criteria at the national, district and local levels.
Lead the group through an example. In doing so, explain to the group that they need to identify actions
that are required at the national, district and local levels. Stress that
they need to consider the complementary nature of these actions.
For example, a logo for the initiative will need to developed at the
national level; officials at the district level will need to provide
support to clinics in painting the logo on their notice boards; and
clinic managers will need to ensure that their notice boards are not
covered by unauthorised posters.
The actions that they identify just like the criteria they have chosen need to be:
ambitious but not overambitious;
in line with national laws and policies;
sensitive to the social and cultural norms.
Please note that they only need to identify actions for the input criteria.
Criteria
Input criteria
Process criteria
(that correspond to
the input criteria)
Local level
District level
National level
(i.e. health service

delivery point)
1.
2.
3.
4.
5.
9. Specify ways and means to verify the achievement of the criteria

How will we know that the elements contributing to
the quality of health service provision are in place?
Task:
For each criteria specify:
What data to gather in order to verify whether the criteria has
been achieved;
How to gather this data.
Lead the group through an example. In doing so, stress to the working group that for each item in the
list they need to consider the effort and the expense of the proposed actions. Encourage them to use
existing monitoring mechanisms as far as possible to reduce the cost and to increase the likelihood that
monitoring will in fact be done.
Note that this will need to be done for input, process and output criteria.
Criteria
What to verify?
How to verify?
Input criteria
1.
2.
3.
4.
5.
Process criteria:
1.
2.
Output criteria:
1.
2.
10. Outline the preparatory work that needs to be done at the national level before
the quality standards can be applied
What groundwork needs to be done in order for all these ideas can
be translated into reality?
Task:
List the preparatory work that needs to be done before
implementation can begin.
Do this exercise in plenary. Lead the group through a quick brainstorming session on what preparatory
work needs to be done. Once you have a 68 points on a flip chart, ask them to review each item and to
identify why it is important to do, using the following matrix:
What preparatory work needs to be done?
1.
2.
3.
4.
5.
6.
Why is this important?
7.
8.
9.
10.
Once the list has been completed, press the group to specify who will be responsible for each item and
to propose a date by when the task has to be carried out.
What preparatory work needs to be
done?
Who will be responsible for

carrying out this task?
When will this task be carried out?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
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30
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EQUITABLE: All adolescents, not just some groups of adolescents, are able to obtain the health services that are
available
Characteristics
Policies and procedures are in place that do not restrict the provision of health services.
Health care providers treat all adolescent clients with equal care and respect, regardless of status.
Support staff treat all adolescent clients with equal care and respect, regardless of status.
ACCESSIBLE: Adolescents are able to obtain the health services that are available
Characteristics
Policies and procedures are in place that ensure that health services are either free or affordable to adolescents.
Point of service delivery has convenient working hours.
Adolescents are well informed about the range of reproductive health services available and how to obtain them.
Community members understand the benefits that adolescents will gain by obtaining the health services they need,
and support their provision.
Some health services and health-related commodities are provided to adolescents in the community by selected
community members, outreach workers and adolescents themselves .
ACCEPTABLE: Adolescents are willing to obtain the health services that are available
Characteristics
Policies and procedures are in place that guarantee client confidentiality.

Point of service delivery ensures privacy.
Health care providers are non-judgmental, considerate, and easy to relate to.
Point of service delivery ensures consultations occur in a short waiting time, with or without an appointment, and
(where necessary) swift referral.
Point of service delivery has an appealing and clean environment.
Point of service delivery provides information and education through a variety of channels.
Adolescents are actively involved in designing, assessing and providing health services.
APPROPRIATE: he right health services (i.e. the ones they need) are provided to them
Characteristics
The required package of health care is provided to fulfil the needs of all adolescents either at the point of service
delivery or through referral linkages.
EFFECTIVE: The right health services are provided in the right way, and make a positive contribution to their health
Characteristics
Health care providers have the required competencies to work with adolescents and to provide them with the required
health services.
Health care providers use evidenced-based protocols and guidelines to provide health services.
Health care providers are able to dedicate sufficient time to deal effectively with their adolescent clients.
The point of service delivery has the required equipment, supplies, and basic services necessary to deliver the required
health services.
To improve the equity of services at the point of delivery:

1. Policies and procedures are in place to ensure that the provision of health
services is not restricted on any terms
(i) What does this mean?
There are no laws and policies that restrict the provision of health services by age, sex or any other
area of difference.
In many countries, as a result of existing laws and policies, the provision of some health services to
all or some groups of adolescents is unauthorized or even illegal. These restrictive laws and policies
are a serious obstacle to public health. They are also contrary to the United Nations Convention
on the Rights of the Child that says that young people have a right to life, development, and the
highest attainable standard of health and to facilities for the treatment of illness and rehabilitation
of health. (Article 24).
(ii) What does this mean?
Procedures are in place to ensure that no factor whether it be based on age, sex, social status,
cultural background, ethnic origin, disability or any other reason:
hinders the provision of health services to all or some groups of adolescents;
hinders the ability of all or some adolescents from obtaining health services.
In many places, existing procedures hinder the equitable provision of health services, and also of
adolescents experiences in obtaining them. Adolescents will not attend a point of service delivery
if they feel excluded or discriminated against in any way.
2. Health care providers treat all their adolescent patients with equal care and
respect, regardless of status
What does this mean?
Health care providers administer the same level of care and consideration to all adolescents
regardless of age, sex, social status, cultural background, ethnic origin, disability or any other
reason.
Being treated disrespectfully is a strong disincentive for adolescents to seek help. Being
treated equally will have a positive effect on adolescents, encouraging them to attend further
appointments and recommend the service to their peers.
3. Support staff treat all their adolescent patients with equal care and respect,
regardless of status
Support staff administer the same level of care and consideration to all adolescents regardless of
age, sex, social status, cultural background, ethnic origin, disability or any other reason.

Being treated disrespectfully is a strong disincentive for adolescents to seek help. Being
treated equally will have a positive effect on adolescents, encouraging them to attend further
appointments and recommend the service to their peers.
To improve the accessibility of services at point of health

service delivery
4. Policies and procedures are in place to ensure that health services are either
free or affordable to all adolescents
All adolescents are able to receive health services free of charge or are able to afford any charges
that might be in place.
This is particularly relevant in adolescents who are likely to have limited financial means of their
own. Adolescents who are dependent on their families may not want to add to the burden by
asking for money to pay for services. They may also be reluctant to disclose why they need to obtain
health services.
5. The point of health service delivery has convenient working hours

Health services are available to all adolescents during times of the day that are convenient to them.
Adolescents may find it difficult to obtain health services if the working hours coincide with times
when they are busy with study, work or other activities.
6. Adolescents are well informed about the range of health services available and
how to obtain them
Adolescents are aware of what health services are being provided, where they are provided, and
how to obtain them.
Informing adolescents about the range of health services available to them can help to encourage
usage of services.
7. Community members understand the benefits that adolescents will gain by

obtaining health services, and support their provision
Community members (including parents) are well informed about how the provision of health
services could help their adolescents. They support the provision of these services as well as their
use by adolescents.

Communities are likely to oppose the provision of health services to adolescents if they do not
understand or trust their value. Engaging community members in a respectful discussion and
working to create a shared understanding on this issue will help to ensure that the required health
services can be provided, and obtained, without opposition.
8. Some health services and health-related supplies are provided to adolescents

in the community by selected community members, by outreach workers and
by adolescents themselves
Efforts are under way to provide health services close to where adolescents are. Depending on the
situation, outreach workers, selected community members (e.g. sports coaches) and adolescents
themselves may be involved in this.
Adolescents may be reluctant to visit health facilities and other points of delivery. Some of them
may be unable to do so. Outreach workers, selected community members and adolescents
themselves can extend the reach of health services into the community. The provision of health
information and services by people they can easily relate to and in places they frequent may be
welcomed by adolescents.
To improve the acceptability of services at point of health

service delivery level
9. Policies and procedures are in place that guarantee client confidentiality
Policies and procedures are in place that maintain adolescent confidentiality at all times (except
where staff are obliged by legal requirements to report incidents such as sexual assaults, road
traffic accidents or gunshot wounds, to the relevant authorities).
Policies and procedures address:
registration information on the identify of the adolescent and the presenting issue are
gathered in confidence;
consultation confidentiality is maintained throughout the visit of the adolescent to the point of
delivery (i.e. before, during and after a consultation);
record-keeping case records are kept in a secure place, accessible only to authorized
personnel;
disclosure of information staff do not disclose any information given to or received from an
adolescent, to a third party (for example, family members, school teachers or employers) without
their consent.
Adolescents are very sensitive to privacy and confidentiality. Adolescents from around the world
say that concerns about lack of privacy and confidentiality discourage their use of health services.
10. The point of health service delivery ensures privacy

The point of service delivery is located in a place that ensures the privacy of adolescent users. It has a
layout that is designed to ensure privacy throughout an adolescents visit. This includes the point of
entry, the reception area, the waiting area, the examination area and the patient-record storage area.
Adolescents give high priority to privacy. They are more likely to obtain the health services they
need if they are confident that they will not be seen by anyone else, and that the privacy of their
records will be maintained.
11. Health care providers are non-judgemental, considerate and easy to relate to
Health care providers do not criticize their adolescent patients even if they do not approve of
their words and actions. They are considerate to their patients and reach out to them in a friendly
manner.
Health care providers do not need to abandon their own beliefs and values, but they must ensure
that these beliefs and values do not negatively influence the way in which they deal with their
adolescent patients. In addition, the ability to respond to adolescents with empathy and sensitivity
will contribute to the development of good communication and mutual respect.
Judgemental, inconsiderate and unfriendly behaviour will hinder communication. It is also likely to
turn adolescents away.
12. The point of health service delivery ensures consultations occur in a short waiting
time, with or without an appointment and (where necessary) swift referral
Adolescents are able to consult with health care providers at short notice, whether they have
a formal appointment or not. If their medical condition is such that they need to be referred
elsewhere, the referral appointment should also take place within a short timeframe.
Adolescents are more likely than adults to be deterred by long waiting times or by rigid
appointment-making policies. Having to wait for an appointment in advance could lead to a missed
appointment or seeking help from other possibly less effective or even harmful service providers
offering shorter waiting times.
13. The point of health service delivery has an appealing and clean environment
A point of health service delivery that is welcoming, attractive and clean.
Adolescents like adults may not want to go to a poorly maintained and dirty place.
14. The point of health service delivery provides information using a variety of
methods
Informational materials that are relevant to the health of adolescents provided by the point of
health service delivery are available in different formats (e.g. posters, booklets and leaflets). They
are presented in a familiar language, are easy to understand and are eye-catching.
Adolescents who visit the place may not know what they need to understand about the health
problems that could affect them. They may have received incorrect information from their peers or
other sources. They may have questions but may be embarrassed to ask their parents, teachers or
others.
15. Adolescents are actively involved in the assessment and provision of health
services
Adolescents are given the opportunity to share their experiences in obtaining health services, and
to express their needs and preferences. They are involved in certain appropriate aspects of health
service provision.
Involving adolescents in assessing service provision, and in actually participating in service
provision, can help make health services more sensitive and responsive to their needs.
The appropriateness of health services for adolescents is

best achieved if:
16. The health services required to fulfil the needs of all adolescents are provided
either at the point of delivery or through referral linkages
The health needs and problems of all adolescents are addressed by the health services provided
at the point of health service delivery, or through referral linkages. The services provided meet the
special needs of marginalized groups of adolescents, as well as those of the majority.
All adolescents should be able to obtain the health services that meet their needs either from one
point of health service delivery, or from a set of points that are linked together in a helpful manner.
The effectiveness of health services for adolescents is best

achieved if:
17. Health care providers have the required competencies
Health care providers have the required knowledge and skills to work with adolescents, and to
provide them with the required health services.

Health care providers need to be competent in working with adolescents in general, in the
adolescent-specific aspects of providing health promotion, preventive, curative and rehabilitative
services, as well as in interpersonal relations and communication.
18. Health care providers used evidence-based protocols and guidelines to provide
health services
Health service provision is based on protocols and guidelines that are technically sound and
of proven usefulness. Ideally they should be adapted to the requirements of the national/subnational situation and approved by the relevant authorities.
In using such tools, health care providers are assured of the best course of action in responding to
their adolescent patients.
19. Health care providers are able to devote adequate time to their patients
Health care providers are able to dedicate sufficient time to deal effectively with their adolescent
patients.
This is important for two reasons: firstly, adolescents may find it difficult to communicate, be shy
or frightened and may need extra time and encouragement to talk about their real concerns; and
secondly, because health care providers need adequate time to deal with their patients in an
effective manner.
20. Points of health service delivery have the necessary equipment, supplies and
basic services to deliver the required health services
Each point of health service delivery has the necessary equipment, supplies (including medicines)
and basic services (e.g. water and sanitation) needed to deliver essential health services.
Without the basic materials, health services cannot be provided effectively. The provision of health
services in such a context may even endanger the health of adolescents.
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District officials to
communicate laws
and policies to HSDP
managers.
Manager to work with

service providers and
support staff to ensure
that the procedures are
applied.
Actions to make HSDPs more equitable

Policies and
procedures are
in place that do
not restrict the
provision of health
services
Health care
providers treat
all adolescent
clients with equal
care and respect,
regardless of
status
National officials to review

laws and policies; and
modify existing ones where
they restrict the provision of
health services.
National officials to
communicate laws and
policies to relevant officials at
district level.
communicate the importance
of avoiding discrimination to
district officials.
ensure that preventing
discrimination is addressed
in training materials and in
handbooks. .
support the formulation
of procedures for HSDP
managers, in line with
these laws and policies.
communicate to
HSDP managers of the
importance of preventing
discrimination.
District officials to work

with HSDP managers
to identify groups of
adolescents who could be
discriminated against.
encourage HSDP
managers to be alert
to the occurrence of
discrimination and to take
corrective actions if and
when it does happen.
Support staff treat

all adolescent
clients with equal
care and respect,
regardless of
status
--
--

support staff to identify
groups of adolescents who
could be discriminated
against.
Manager to communicate
the importance of avoiding
discrimination.
Manager to be alert
to the occurrence of
discrimination and to take
corrective actions if and
when it does happen.
--
Actions to make HSDPs more accessible

Policies and
procedures are
in place that
ensure that health
services are either
free or affordable
to adolescents
The HSDP has

convenient
working hours
National officials to review

laws and policies; and modify
existing ones to ensure that
health services are free or
affordable to adolescents.
communicate laws and
policies to relevant officials at
district level.
of local actions (i.e.
modifying working hours to
meet the needs of specific
groups of adolescents) to
address this issue.
communicate laws
and policies to HSDP
managers.
support the formulation
of procedures for HSDP
managers, in line with
these laws and policies.
communicate the
importance of local
actions (i.e. modifying
working hours to meet the
needs of specific groups
of adolescents) to address
this issue, to HSDP
managers.

support staff to ensure
that the procedures are
applied.

support staff to determine
whether the working
hours could be modified
to take into account the
needs of specific groups of
adolescents.
Characteristics
services

national level

district level

(HSDP)
Adolescents are
well informed
about the range
of reproductive
health services
available and how
to obtain them
communicate the need for
district officials and HSDP
managers to take actions
to help inform adolescents
about the range of health
services that are be provided
at HSDP.
communicate what health
services are provided,
where and when they are
provided, and how much
they cost:
Manager to carry out the

following actions:
(i) in the mass media (where

possible);
(ii) in meetings with
representatives of other
sectors (e.g. education) and
civil society institutions (e.g.
NGOs);
(i) Put up a notice board

indicating what health
services are provided, when
they are provided, and how
much they cost;
(ii) Prepare a leaflet
indicating what health
services are provided, when
they are provided, and how
much they cost.
communicate the
importance of local
action (i.e. putting up a
notice board) to address
this issue, to HSDP
managers.
Community
members
understand the
benefits that
adolescents will
gain by obtaining
the health
services they
need, and support
their provision
communicate the rationale
for providing health
in the mass media, and in
meetings with national-level
representatives of other
sectors (e.g. education) and
civil society institutions (e.g.
religious bodies)
communicate the need
for district officials to
communicate this message
to
district-level representatives
of other sectors (e.g.
education) and civil society
institutions (e.g. NGOs).
communicate the rationale
for providing health
in meetings with districtlevel representatives
of other sectors (e.g.
education) and civil
society institutions (e.g.
NGOs).
Manager and staff

(including service
providers and support
staff) to identify key
institutions in the
catchment area of the
HSDP, and to meet with
heads of these institutions
to explain them, the
rationale for providing
health services to
adolescents.
Characteristics
services

national level

district level

(HSDP)
Some health
services and
health-related
commodities
are provided to
adolescents in
the community
by selected
community
members,
outreach workers
and adolescents
themselves
of reaching out to selected
groups of adolescents in the
community with selected
health services (e.g. some
aspects of antenatal care)
and commodities (e.g. iron
and folic acid tablets).
communicate the
importance of outreach
activities and/or
working with NGOs in
the community that
could engage selected
adults or adolescents to
provide health services
and commodities to
adolescents in the
community.
Manager to set aside some

time from selected staff
members for outreach
work.
Manager and staff to
identify NGOs which
could engage selected
adults and adolescents
to provide health services
and commodities to
adolescents in the
community.

with HSDP managers to
identify which groups
of adolescents to reach,
where to reach them, and
what health services and
commodities to reach
them with.
Actions to make HSDPs more acceptable

Policies and
procedures are
in place that
guarantee client
confidentiality
National officials to:

(i) clearly outline the events/
conditions service providers
are required to report to the
relevant authorities (such as
sexual assault, road traffic
accidents and gunshot
wounds);
(ii) communicate that in all
other circumstances, HSDP
managers, service providers
and support staff are required
to maintain the confidentiality
of their adolescent clients.
District officials to ensure

that HSDP managers are
aware of the national
policy on confidentiality
and the procedures to
translate these policies
into action.
Managers to work
with service providers
and support staff to
ensure that they are all
aware of the policies
and recommended
procedures.
communicate the
importance of applying
these procedures.
Managers to ensure
that the recommended
procedures are translated
into concrete actions
with clear designation of
responsibilities within the
HSDP.
communicate the
importance of ensuring
visual and auditory
privacy, and to support
managers in making
any modifications that
are needed to HSDPs to
ensure this.
Managers to work with

what could be done to
ensure both visual and
auditory privacy in the
HSDP, given the prevailing
resource constraints.
National officials to outline

clear procedures to be
followed in HSDP to ensure
that information about
clients is not disclosed to
third parties, and that client
records are held securely.
Point of service
delivery ensures
privacy
of actions to ensure visual
and auditory privacy during
registration and during
consultation with a service
provider.
Characteristics
services

national level

district level

(HSDP)
Health care
providers are
non-judgmental,
considerate, and
easy to relate to
of these attributes among
health care providers and
support staff.
District officials to conduct

workshops to orient/train
HSDP managers, health
care providers and support
staff.
ensure that these issues
are addressed in training
materials and in handbooks.
encourage HSDP
managers to support
health care providers and
support staff in being
non-judgemental and
considerate, and to relate
to their adolescents in
a friendly manner; and
where appropriate to take
corrective actions when
needed.
Managers to communicate
to health care providers
and support staff about
the importance of being
non-judgemental and
considerate, and to relate
to adolescent clients in a
friendly manner.
Point of service
delivery ensures
consultations
occur in a short
waiting time, with
or without an
appointment, and
(where necessary)
swift referral
of actions to keep waiting
times as short as possible
and to ensure that referral
mechanisms are in place and
function well.

with HSDP managers
in the district, to set
up/strengthen referral
mechanisms.
Point of service
delivery has an
appealing and
clean environment
of actions to make the
physical environment of
HSDPs appealing and clean.
encourage HSDP
managers to take the
needed actions to make
the physical environment
appealing and clean.

support staff to make the
physical environment of
the HSDP (e.g. to have
adequate and comfortable
seats in the waiting area)
and clean (e.g. to ensure
that the toilets are clean
and that drinking water
and is available).
Point of service
delivery provides
information
and education
through a variety
of channels
National officials to develop

informational/educational
materials and send them to
the districts.
arrange for the delivery of
informational/educational
materials obtained from
national officials or NGOs,
to HSDPs.
Managers to ensure that

educational/informational
materials are displayed/
distributed.
National officials to liaise

with NGOs working on
adolescent health issues
in the country to explore
whether the materials they
produce could be displayed/
disseminated to the districts.
Managers to be alert to
breaches of this, and to
take corrective actions.

what could be done to
keep waiting times as
short as possible.
support staff are aware
of, and apply, referral
mechanisms to providers
of health and social
services.
District officials to liaise

with NGOs working in their
district to explore whether
the materials they produce
could be displayed and
disseminated by HDSPs.
Even if no materials are

obtained from district
officials, managers to work
to ensure that clipping
from newspapers and
magazines, and handmade materials are
displayed.
Characteristics
services

national level

district level

(HSDP)
Adolescents are
actively involved
in designing,
assessing and
providing health
services
of involving adolescents in
designing, assessing and
providing health services.
encourage HSDP
managers to involve
adolescents in designing,
assessing and providing
health services.
Managers to work
and support staff to
identify and draw in
adolescents employed
by organizations working
with young people or
volunteers from the
community into the work
of the HSDP:
(i) by drawing upon their
ideas and suggestions in
designing health service
provision;
(ii) by involving them in
assessing and providing
health services.
Actions to ensure that the health services provided are appropriate

The required
package of health
care is provided
to fulfil the needs
of all adolescents
either at the point
of service delivery
or through referral
linkages
National officials to list the

health services that are to be
provided at each level (e.g.
primary level, secondary level
and referral level).

with HSDP managers
ensure that HSDPs provide
all the health services that
they are required to, and to
facilitate access to those
that they do not provide
with referral linkages.

HSDPs provide all the
health services they are
required to, and facilitate
access to those they do
not provide with referral
linkages to other HSDPs.
Actions to ensure that health services provided effectively

Health care
providers have
the required
competencies
to work with
adolescents and
to provide them
with the required
health services
National officials need to

develop teaching/learning
materials to build the
competencies of service
providers to deliver the
required based on a needs
assessment.
National officials to develop/
adapt a handy desk reference
tool for service providers.
National officials to set up
a system for supportive
supervision. (It would
be useful if that includes
elements of self assessment,
peer assessment, supervisor
assessment and external
assessment).
Health care
providers use
evidence-based
protocols and
guidelines to
provide health
services
National authorities to
develop evidence-based
protocols and guidelines.

with HSDP managers
to ensure that service
providers in the district
undergo training/
orientation.
Managers to ensure that:
District officials to supply

HSDP managers with desk
reference tools to service
providers.
(iii) self, peer and supervisor

assessments are carried out
in the context of supportive
supervision.
(i) service providers are

trained/oriented;
(ii) services providers have
desk reference tools;
District officials support

HSDP managers to put
in place self, peer and
supervisor assessment
systems; and to put
in place an external
assessment system.
--
--
National authorities to ensure

that these protocols and
guidelines are included in
teaching/learning materials
and desk reference tools.
Characteristics
services

national level

district level

(HSDP)
Health care
providers are
able to dedicate
sufficient time to
deal effectively
with their
adolescent clients
National authorities to
of this characteristic.
communicate the
importance of this
characteristic to HSDP
managers.

support staff to identify
how best to spread out
the clinics provided at the
HSDP and to deploy staff
in way that contribute in
spreading the patient load
through the working hours
of the HSDP.
The HSDP has

the required
equipment,
supplies, and
basic services
necessary to
deliver the
required health
services
District officials to support

HSDP managers to spread
out the clinics provided at
the HSDP (e.g. antenatal
clinic) and deploy staff in a
way that reduces crowding
in the waiting area and
pressure on service
providers to dispose of
patients quickly.
National officials to prepare
lists of equipment and
supplies that HSDPs need
to have to provide the
stipulated package of health
services.
National officials to send
these lists to district officials.
National officials to work
with district officials to
determine what equipment
and what stocks of supplies
are required to provide the
stipulated package of health
services; and to ensure that
they are sent out on in good
time.
District officials to give

HSDP managers the list of
equipment and supplies
that HSDPs need to have
to provide the stipulated
package of health
services.
with HSDP managers
to determine what
equipment and what
quantities of supplies are
required on a monthly/
quarterly basis.
with national officials to
obtain the equipment and
supplies required by the
district in good time.
Managers to encourage
service providers to devote
adequate time to each
patient.
Managers to have at-hand
lists of equipment and
supplies that are needed
to provide the stipulated
package of health
services.
support staff to put in
place a system to review if
the pieces of equipment
are in good order and that
the stocks of supplies are
adequate.
Managers to organize
regular servicing/repairs
of equipment and to
ensure that adequate
stocks of supplies are
maintained.
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For further information and publications please contact:
Department of Maternal, Child and Adolescent Health (MCA)

World Health Organization 20 Avenue Appia, 1211 Geneva 27, Switzerland
Tel +41 22 791-2668 Fax +4122 791-4853
Email: mca@who.int
Website: http://www.who.int/maternal_child_adolescent/

2013 - Standars For Adolescents Health Services 9789241503594 - Eng

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a

Making health services

Making health services

Making health services adolescent friendly iii

UNICEF United Nations Childrens Fund

World Health Organization

iv Making health services adolescent friendly

health sectors response to adolescent health and development.

What adolescents need to grow and develop in good health.

Making health services adolescent friendly v

vi Making health services adolescent friendly

6. What are the main health problems of adolescents?

What do we mean by the term adolescents?

Making health services adolescent friendly 1

What do we mean by the term health?

What do adolescents need in order to grow and develop in

2 Making health services adolescent friendly

Who needs to contribute to helping them grow and develop

What do we mean by the term health services? And what is

for adolescent health. Geneva, World Health Organization, 1999.

What are the health problems that adolescents experience?

injuries resulting from accidents or violence;

When adolescents have health-related concerns or are

data. The Lancet, 2009, 374: 881892.

The Lancet, 2011, 377: 20932102.

Medical Health, 2005, 17, 4:315336.

4 Making health services adolescent friendly

What are the barriers that adolescents face in obtaining the

What do adolescents perceive as friendly health services?

Making health services adolescent friendly 5

What is being done to make to make health services

Public, private and NGO clinics;

6 Making health services adolescent friendly

What can be done to improve the quality of health service

Making health services adolescent friendly 7

8 Making health services adolescent friendly

Making health services adolescent friendly 9

Making health services adolescent friendly

Review the national HIV/AIDS and RH policy and strategy documents.

Making health services adolescent friendly

How could this step be taken?

Section III. Examine the programmatic implications of

12 Making health services adolescent friendly

Making health services adolescent friendly 13

14 Making health services adolescent friendly

Section IV. Develop the national standards

Making health services adolescent friendly 15

How could this step be taken?

Section V. Outline essential preparatory work at national

16 Making health services adolescent friendly

What is the purpose of this step?

Making health services adolescent friendly

Workshop to develop national quality standards for

Identify the intended

Define the health

Define the health

Identify the problem

Formulate the quality standards

Identify the health

Choose the set of criteria to be achieved for each

Identify the actions to be taken at national, district

Specify ways and means of verifying the

Outline the preparatory