BACKGROUND AND SIGNIFICANCE

In Nepal, adolescents (10-19 years) form 23.8% of the population1. Societal and cultural conditions make adolescents particu-

larly vulnerable to various sexual and reproductive health risks. Girls are under the pressure to get married early and subse-quently face the risk of early pregnancy and motherhood

2:

The median age at marriage among women between 25-49 years is 17.5 years. Childbearing begins early with almost one quarter of women giving birth by age 18 and nearly half by age 20. 17% of adolescent (15-19 years) are already mothers or pregnant with their first child.

OBJECTIVE

To improve the Sexual and Reproductive Health and Rights (SRHR) of adolescents through the introduction of adolescent-friendly services (AFS) in public health facilities in Nepal

which enhance access to as well as utilization and satisfaction of adolescents with SRH services incl. family planning.

PROGRAMME DESCRIPTION

Chronology of National ASRH Programme in Nepal Interventions - Supply side

Human Resource Development: Programmatic & technical orientations for district health manag-

ers, district level stakeholders, health service providers and health management operation and management committees (HFOMCs)

Organizational development: Introduction of standards for adolescent-friendly services

(AFS) and minor upgrading of health facility, e.g. provision with equipment, to ensure privacy and confidentiality in health facilities

Inclusion of adolescents in HFOMCs as invitee members

Cooperation and network development:

Reproductive Health Co-ordination Committees (RHCC) in districts and HFOMC improve the inclusion and meaningful participa-

tion of adolescents in their committees

Harmonization of inter and intra-sectoral activities targeted to ado-lescents

System development in policy field:

Development of a National ASRH Communication Strategy to drive forward age-appropriate and gender-sensitive behavior change communication interventions for adolescents

References: 1. Government of Nepal. Central Bureau of Statistics. National Population and Housing Census 2011; Vol 01, NHPC, Nov 2012. 2. Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc. 2012. Nepal Demographic and Health Survey 2011.

Kathmandu, Nepal: Ministry of Health and Population, New ERA, and ICF International, Calverton, Maryland. 3. WHO. Adolescent Friendly Health Services– An Agenda for Change. 2002.

Interventions - Demand side

Initiatives encouraged at local level to inform adolescents about the existence of AFS & to create a conducive environment for adoles-cents to use SRH services:

Referral of adolescents to AFS through lo-cal NGOs, schools and other social ser-vice providers

Age-appropriate IEC materials made available in schools and health facilities

Display in communities of a poster and cartoon booklet explicitly encouraging adolescents to use health services

2000

2009-10

2011

1998

1994

2010

2007

ASRH was included as one

component

National Reproductive Health

Strategy

First national document

addressing adolescents

National Adolescent Health

and Development Strategy

Pilot intervention con-

ducted in 26 health facili-

ties in 5 districts

Final Programme implementa-

tion guideline

National ASRH

Programme Scale up

Nepal showed commitment International Conference on

Population and Development

Goal: AFS in 1000 government HF by 2015 (Oct 13: 733)

Nepal Health Sector Pro-

gramme II

Operational guideline

on implementation

of ASRH Programme

Strong leadership in the MoHP to address adolescents’ SRHR -

ASRH issues mainstreamed into priority public health interventions -

an increase in financial investment

Improved capacity of district health managers and HFOMCs to re-

spond to adolescents’ health needs.

Improved capacity of health workers to provide adolescent - friendly

SRH services through the use of specific counselling tools and IEC

materials as well as an open and appreciative attitude.

Improved recording & reporting on adolescents’ service utilisation

Increased acceptance and utilization of SRH services in AFS by ado-

lescents

Increased efforts & funding of stakeholders for demand-side inter-

ventions are needed to strengthen awareness and demand of AFS.

RESULTS AND LESSONS LEARNT

Changes at output level after 18 months of implementation

Showed positive attitude of most health work-ers towards adolescents seeking SRH services incl. FP as well as improvement of capacity to deliver confidential quality services to youth.

Use of health services: Of all facilities, private clinic is attended by the majority of sick people (28%). Others are phar-

macy (25%), hospital/public health center (14%), sub-health post (8%), health post (8%), private hospital (5%) and

others (7%). But: More than half of the people in the mountains and hills consult government health facilities.3

Source of Family Planning (FP) Methods: 47% visit public health facilities to receive FP methods, followed by phar-

macy (32%), private health facility (11%) and health workers (10%). Public health facilities and pharmacy are the main

source of getting FP methods for all regions, zones and urban/rural areas.

Pre-natal care: 78% received some kind of pre-natal care: Of these, 84% from government health facilities.

Post-natal care: 19% receive postnatal care; 78% of those from government health facilities.

The private sector can deliver quality SRH services, however, national coverage of rural hill/mountain districts seems

only possible through the government system. The private sector has high potential for SRH demand-side interventions.

The role of the private sector in Nepal in providing (SRH) services

Mid-Term Evaluation

©Thomas L. Kelly

©Thomas L. Kelly

`I used to feel shy to provide services and hesita-

ted when males asked for contraceptives. I even

felt uncomfortable while counselling [...]. Now we

are counselling adolescents by showing them pos-

ters and pamphlets [...] demonstrating the use of

family planning methods, which was not the prac-

tice in the past. These are the differences that we

feel.´

(Health worker, Banke)

`They [health workers] provide us with both infor-

mation and services if we ask them. They give con-

doms and counselling services. They provide the

information secretly and maintain privacy.´

(Male participant peer ethnography, Banke)

`The availability of educational materials, the

adolescent-friendly sexual and reproductive health

related hoarding board outside, posters, pamph-

lets, and the availability of temporary contracepti-

on, medicine, treatment, counselling, and repro-

ductive health related services – although a sepa-

rate counselling room is not available, but coun-

selling services are given from the delivery room

[...] – all help in the implementation of this pro-

gramme.´

(Health Worker, Banke)

©Thomas L. Kelly

©Thomas L. Kelly

National Adolescent Sexual and Reproductive Health Programme

Providing Adolescent-Friendly Services in the Public Sector

Kathrin Schmitz, Nepali-German Health Sector Support Programme, Nepal