Dashboard Global Adolescent-Responsive Contraceptive Services – HIPs Adolescent and Youth-Friendly Health Services (AYFHS)

Philippines Toolkit: AYSRH Service Delivery

Adolescent and Youth-Friendly Health Services

(Source: ZFF).

This approach provides a guide on how to provide responsive sexual reproductive health (SRH) services to adolescents and young people in the Philippines as governed by the following directives, the Republic Act 10354 (also known as the Responsible Parenthood and Reproductive Health Act of 2012), the DOH Administrative Order 2013-0013 on the National Policy and Strategic Framework on Adolescent Health and Development, and other policies.

Adolescent and youth-friendly health services (AYFHS) must be offered in an environment where service providers are non-judgmental, unbiased, and considerate in their dealings with adolescents and youth, have competencies needed to deliver youth responsive SRH services, health facilities are equipped to provide adolescents and youth with services they need and commodities that they want in an appealing and friendly manner, adolescents are aware of where to obtain the services and community members are aware of the health service needs of different groups of adolescents and youth and support their provision. Given the unique developmental stage in which adolescents and youth are at, their meaningful participation is key. They must be involved in the planning, implementation, monitoring and evaluation of health services and decisions regarding their own care. In addition, the characteristics of the health facilities that young people visit are just as important as the service providers they meet and the choices available to them to make informed decisions.

IRR of RA 10354, Section 4.07 Access of Minors to Family Planning Services Any minor who consults at health care facilities shall be given age-appropriate counseling on responsible parenthood and reproductive health. Health care facilities shall dispense health products and perform procedures for family planning provided that in public health facilities, any of the following conditions are met:

(a) The minor presents written consent from a parent or guardian.

What are the benefits of AYFHS?

Facilitates adolescent and youth access to and satisfaction with services
Institutionalizes use of AYFHS standards in routine quality improvement/assurance supervisory visits
Delivers higher-quality SRH services to adolescents and youth
Empowers health providers to be advocates for adolescents and youth
Encourages future health-seeking behavior among adolescents and youth

How to implement

Step 1: Conduct a facility assessment against existing standards

The Department of Health (DOH) issued a memorandum to all regional directors and chiefs of hospitals on January 24, 2017 with an Adolescent Friendly Health Facility Standard Evaluation Tool. To encourage health facilities to achieve Level 3, there can be a recognition of facilities by DOH CHD/LGUs as initiated in 2019.

Department Memorandum 2017-0098: Adolescent-friendly Health Facility Evaluation Tool (Level 1, 2, 3 Criteria), wherein a health facility conducts a self-assessment to see if they are in compliance with the National Standards and then a validation is done at the next level to confirm recognition. For Level 2, the assessment is conducted jointly by the regional DOH office and province. To obtain Level 3, the facility must be validated by the national level AHD TWG – which comprises DOH, youth-led organizations, Department of Social Welfare and others.

The assessment/checklist was developed based on the national standards for the provision of adolescent and youth-friendly health services:

Standard 1: Adolescents in the catchment area of the facility are aware about the health services it provides and find the health facility easy to reach and obtain services from it (Accessible)
Standard 2: The services provided by health facilities to adolescents are in line with the accepted package of health services and provided on site or through referral linkages by well-trained staff effectively (Appropriate package of services and trained providers)
Standard 3: The health services are provided in ways that respect the rights of adolescents and their privacy and confidentiality. Adolescents find surroundings and procedures of the health facility appealing and acceptable (Facility characteristics)
Standard 4: An enabling environment exists in the community for adolescents to seek and utilize the health services that they need and for the health care providers to provide the needed services (Community support)

The key elements for operationalizing the standards include:

Ensuring privacy (audible and visual privacy)
Strengthening confidentiality
Enhancing capacities of healthcare providers
Health promotion and communication (behavior change)
Resource mobilization
Data gathering, documentation, monitoring, analysis and data use for decision-making

The LGU identifies and nominates facility(ies) to be an adolescent-friendly health facility (AFHF). Then, the facility completes Level 1 self-assessment. Based on the self-assessment, the facility looks at the gaps and resources that they need. They may draw up a formal or informal action plan which is then discussed with the office of health/health coordinator who can help support logistics, equipment, etc.

If desire to go from level 1 to level 3, then the facility will come up with a workplan and then ask for formal accreditation/validation team.

After validation, then they can be assessed for the next level of accreditation.

Tips for conducting the assessment:

Work with the facility quality assurance/improvement team to conduct the assessment.
Engage adolescents and youth in conducting the assessment. There’s no better way to ensure whether or not young people find your facility to be adolescent-friendly than engaging them in the process of defining what it would look like. It can be as simple as holding focus groups and running through the different criteria that matter to them when accessing facility-based services.

Step 2: Ensure that health providers are trained in competencies in adolescent health care

At minimum, health providers should be familiar with the following topics:

Essential package for AYFHS
Value clarification and attitude transformation on adolescent and youth sexuality and provision of services such as contraception
Privacy and confidentiality
Characteristics of adolescent growth and development (including neurobiological, developmental and physical) which impact health

Work with the Reproductive Health focal person and facility in-charges to identify topics that meet staff’s learning needs and interests in adolescent and youth sexual and reproductive health (AYSRH).

In the effort to create a welcoming and accessible service delivery environment for adolescents, facility in-charges/managers need to plan for two distinct but reinforcing approaches:

Whole Site Orientation (WSO)

WSO is a cost-effective approach to orient all staff – clinical and non-clinical – on adolescent health and development issues and the benefits of AYSRH. This includes staff from all levels of the health facility, including boards of directors, senior managers, health care providers, barangay health workers, guards, receptionists, etc. Orientation sessions are “low-dose, high frequency” – that is, the sessions are shorter and spread out over many days to avoid taking staff away from their posts for long periods of time and avoid disruption to services. The sessions also take place at the facility itself. WSO ensures knowledgeable staff become the primary advocates for AYSRH and are able to direct, counsel and provide services appropriately.

See this agenda for an example of six sessions that can be added to an existing WSO.

Competency-Based Training

In contrast, training is aimed at improving specific clinical knowledge and skills of health care managers, administrators and providers to improve the delivery of clinical services to adolescents. The Department of Health (DOH) offers the following capacity strengthening training opportunities for health care providers:

Competency Training on Adolescent Health for Health Service Providers (Reference Material)
Adolescent Job Aid Training Manual
Adolescent Health Education and Practical Training (ADEPT) E-Learning Toolkit
Healthy Young Ones User Guide for Primary Healthcare Providers

Step 3: Reinforce training through supportive supervision and coaching

Identify adolescent SRH/FP trainers from those who has received training and are interested and have demonstrated skills to serve as mentors and coaches to other health care providers in their facility as well as nearby facilities.

Conduct coaching and mentorship sessions on regular basis to increase the number of competent skilled service providers within the facility who are able to offer FP services as well as to ensure quality assurance. These sessions can be part of supportive supervision. Ideally, they should start immediately post-training and then take place every month before they start tapering off to a more quarterly and on-demand basis according to quality improvement/assurance guidelines.

Capacity building does not end with a training but with the trained health care providers working in adolescent-friendly health facilities (AFHFs). Thus, the local government should invest in establishing AFHFs and in quality improvement of health centers, school clinics, counseling centers, and outreach services for adolescents.

Step 4: Provide systems to inform adolescents and youth on how to access and obtain SRH services

All facilities, but especially AFHFs, should consider posting signages with appropriate services available and operating hours, display the AFHS national standards like a charter, ensure barangay health workers (BHWs) and population volunteers are well-aware of AFHFs to refer to and use social media to reach adolescents and youth with information about SRH services. Health center physicians should make sure that BHWs and population volunteers receive AYSRH training and are part of WSO sessions, so that they understand the benefits of counseling and referring adolescents to the services that they need.

In addition, with support from the rural health midwife and DOH HRH, all BHWs and population volunteers should conduct a community mapping to develop a master listing of all women ages 10-49 with in their catchment area. This is a standard procedure across all LGUs. It is called the target client list (TCL).

This list will help BHWs and population volunteers to not only track pregnant women in the community, including young mothers, but also speak with parents and adolescents about AYSRH issues and provide referrals to services.

Other ways in which BHWs and population volunteers as well as youth influencers such as peer educators may generate demand for services include:

Serve as facilitators of intergenerational dialogues, including Usapan for Batang Ina and Batang Ama
Mobilize adolescents and youth for community health service days, like dedicated adolescent day at the AFHF or other facilities
Conduct other mobilization activities, such as neighborhood campaigns, indigenous events/festivals, engagement with community associations, and serve as guest speakers at key life events

Given the generation gap between BHWs and population volunteers and youth and the challenge that it may pose in ease of communication with each other, LGUs and facilities may want to pair student nurses or younger BHWs/population volunteers with older ones to serve as mentors. This way the older BHWs/population volunteers can speak with parents about AYSRH issues, while the younger ones speak with the adolescents. In addition, student nurses can always be contracted by health centers to serve as the administrator of social media channels associated with the health center to reach adolescents and youth with information about and referrals to SRH services.

To address potential capacity issues at AFHFs during dedicated adolescent days, the AFHF that is hosting the event should inform all nearby facilities, including private sector facilities, so that they are mobilized to also serve clients that day and, ideally, for free. In addition, the AFHF that is hosting the event may also pool health care providers from nearby cities for day if there are limited health care providers at the hosting facility. This can provide an opportunity for on-the-job training and coaching of health care providers.

Step 5: Monitor and evaluate the standard of care delivered to adolescents at service delivery points

In order to deliver AYFHS, the Adolescent Health and Development Program (AHDP) is focusing on the different building blocks of the health system which are:

Health workforce
Facilities, logistics, and commodities
Services
Financing
Policy and governance
Strategic information and monitoring and evaluation (M&E)

Moreover, a focus on adolescent participation is also highlighted to ensure that adolescents are not only beneficiaries but are also partners and leaders in the design and implementation of AYFHS. Some of the key indicators of success are highlighted on this page.

Indicators for success

Indicator	Disaggregation	Data Source(s)
Number of health personnel trained in providing adolescent and youth-friendly health services Adolescent Job Aide (AJA) Adolescent Health Education and Practical Training (ADEPT) Health Young Ones Manual of Procedures (MOP)	Type of health personnel (doctor, nurse, midwife, peer educator)	Regional AHDP reports
Percentage of adolescent-friendly health facilities (AFHF) # of facilities (RHU and hospitals) that have Level 1, Level 2, or Level 3 AFHF certification Total # of facilities (RHU and DOH-retained hospitals)	Level of certification (Level 1, 2, 3) Type of facilities (RHU, DOH retained hospitals, teen centers, others)	Regional AHDP reports
Number of health facilities completing AYSRH whole site orientation		Facility/project report
Number of adolescents and youth provided contraception by method	10-14 15-19 20-24	Health center data/Facility register/FHSIS
Proportion of adolescents and youth clients who reported a positive experience when seeking services	10-14 15-19 20-24	Facility/project report/Regional AHDP reports
Number of health facilities with youth volunteers	Type of facilities (Rural Health Units or RHU, DOH retained hospitals, teen centers, others)	Facility/project report/Regional AHDP reports

Resources needed

Making any facility adolescent-friendly may require an initial injection of financial resources, including making adjustments to clinic layout to ensure young clients’ privacy.
Venue space for trainings and WSO, if necessary, because should use space in or outside the facility if possible
Whole site orientation and training material printing costs
Print copies of WHO’s Family Planning Handbook, 2018 Ed
Information, education and communication (IEC) materials Job aids, tools and guideline material printing
Refreshments and transportation costs for engaging youth

What’s the evidence?

A literature review on young people’s perspectives on health care revealed eight indicators central to their positive experience of care: accessibility of health care; staff attitude; communication; medical competency; guideline-driven care; age appropriate environments; youth involvement in health care; and health outcomes (Ambresin et al., 2013).
Another literature review on the evidence for improving adolescent access to and use of SRH services highlights that, in addition to quality clinical services, the most effective intervention is providing sexuality and life skills education and linking youth with educational and economic opportunities and supportive adults (Denno et al., 2015).
Evaluations show that competent health providers alone are not enough to increase youth access to SRH services (Chandra-Mouli et al., 2015; Dick et al., 2006). Approaches to scaling up services should use four complementary approaches:
- Providers are trained and supported to be nonjudgmental and friendly to adolescent clients
- Health facilities are welcoming and appealing
- Communication and outreach activities inform adolescents about services and encourage them to make use of services
- Community members are supportive of the importance of providing health services to adolescents

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Helpful Tips

Include youth as experts in health provider trainings; make an extra effort to include representatives from sub-populations such as younger adolescents, married youth, etc.
Link with training institutions that can provide ongoing and refresher trainings for staff.
Integrate family planning in the provision of other health services through supporting local government staff to conduct WSO sessions virtually to orient all staff – clinical and non-clinical – who are working in the health facility.
Strengthen community linkages by strengthening BHWs and population officers’ capacity to speak with adolescents and their parents about adolescent sexual reproductive health and contraceptive methods.
There is no one-size-fits-all-approach, which is why it is important to reach adolescents with SRH services at different stages of need. Often, youth are more concerned about the social and mental aspects of sexual and reproductive health, rather than clinical services. Therefore, partnering with specialized services for referrals is important.
Support pharmacies to provide proper family planning messages and to refer clients to health clinics as needed; provide short-acting contraception (e.g., pills, condoms).

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Challenges

Low reporting/compliance on utilization indicators. FHSIS can only capture service utilization indicators. And, there is a limited number of indicators in FHSIS so some indicators may need to be collected separately by the AHD program.
There have been different interpretations of checklist because the guidelines do not explicitly state the means for verification. As a result, the guidelines are being updated.
In addition, the checklist is a new process and quite dependent, at this time, on the provincial and regional TA structure.
Under RPRH law, minors (those under 18 years old) require consent from their parents or guardian to obtain a contraceptive method. As a result, WSO and engagement with parents via BHWs and population officers is critical.
Norms related to adolescents’ sexuality and reproductive health may be taboo. Health provider trainings should include reflections on these norms and the adverse health consequences they may have, particularly for young women.
When youth are placed in a position of commenting on adult health providers’ competencies, there may be a strong negative reaction. Health provider training should take this into consideration and raise awareness of the leadership role that youth have.